Need advice

[shubhac]

My cousin underwent a BCS for suspected CA-right breast in Jul 2014. Since the tumor tested positive, an oncosurgeon performed an MRM in the same month. The histopath report mentioned that one out of the 3 sentinel nodes showed presence of metastatic tumor. Staging was T1N1M0, the tumor was ER+/PR+, grade 3. Rest of the findings were - IDC with lobular growth pattern Mod RB score 3+3+2=8, desmoplasia, elastosis, microcalcification present, ductal carcinoma with EIC and criiniform type w/o necrosis. She was later given chemotherapy - dose dense Taxol protocol. The question is whether radiotherpay is necessary?

Thanks in advance.

[sumeet_shah Administrator]

I need to know following:

1. Was it the Oncosurgeon who did the sentinel node, during MRM? Since one was positive, did he complete the axillary clearance? What was the final number of nodes after MRM and how many were positive (On sentinel, one out of three were positive)

2. Did that positive node have PNE (Perinodal Extension)?

3. Were there any LVE (lymphovascular emboli) or PNI (Perineural invasion)?

4. You mentioned DUctal carcinoma with EIC. Just to confirm once more, EIC was present, right?

You can easily read the pathology report and you will get the answers there.

[roxboxfox RadiationOncologist]

I would agree with Sumeets first reaction, and agree that a complete Axillary Clearance is indicated in this situation, hence please ask your cousin whether were more Axillary nodes removed by the surgeon or not.

If not, and if there are plans for this by your oncologist to be covered by RADIOTHERAPY, the Surgical Oncologist needs to have a dialogue and clear communication in tumour board MDT discussion or over telephone.

COMING TO YOUR BASIC QUESTION:

YES. Radiotherapy is indicated. (irrespective of whether Axillary clearance is done or not).

The only caveat here is if by chance 4 or more nodes are positive, then a radiation Oncologist would also cover the lower neck.) so called SCF field) where a surgeon would not normally dissect (as this is the next echelon and area at risk).

---- whereas if no further clearance surgery is done.... a radiation oncologist would normally not treat the neck and just treat the chest wall and the Axilla... small perhaps 2-3% chance of missing it... but dont worry hope chemotherapy hopefully would tackle this risk....

... treating the Axilla with radiotherapy is a bit technically challenging and would require 3DCRT and significant effort at contouring and targeting the area at risk, and hence require expertise and knowledge about this.

Until recently patients with 1-3 lymph node positivity were classified as INTERMEDIATE risk Ca Breast, and the role of RAdiotherapy was debatable,

On 21st June 2014, there was a practice changing article published in Lancet which has changed management implications internationally amongst oncology thinkleaders.

Essentially, this IPD Meta-analysis showed that in women who had 1-3 positive nodes, postmastectomy radiotherapy reduced the recurrence rate by 32% and reduced the breast cancer mortality rate by 20%. The benefit was similar whether women had only 1 positive node or whether they had 2 or 3 positive nodes.

This so called Meta-analysis is LEVEL 1a evidence which is difficult to ignore, and despite the fact there are few ongoing clinical trials like SUPREMO which are currently still running to seek the answer to this same question, this publication is difficult to ignore and not advocate to patients.

My practice changed last year in JUNE 2014 with this publication, and i would certainly offer Adjuvant Chest Wall Radiotherapy to my patients.

PS: Please check if a Her 2 test has been done on the pathology specimen, as your cousin may merit further treatment with a wonder drug called HERCEPTIN if she is positive.

References:

1. medscape.com/viewarticle/82...

Original Lancet article

2. thelancet.com/journals/lanc...

Wish your cousin a quick and speedy recovery in her fight against Cancer.

Regards

Dr Rohit Malde MD, DNB, FRCR (UK)

Consultant Clinical & Radiation Oncologist

HCG - Dr Balabhai Nanavati Hospital

Vile Parle, Mumbai West

[shubhac in reply to roxboxfox]

Thanks, Drs. I am inquiring about axillary clearance. Regarding HER2+ status, it is negative, so trastuzumab is not indicated. The meta-analysis is definitely an eye opener. Thanks for this info.

[sumeet_shah Administrator in reply to roxboxfox]

Very well explained, roxboxfox. Thanks! You are really an asset to this forum.