How would you manage the axilla of a patient with a recurrent ipsilateral breast cancer treated with lumpectomy, sentinel node biopsy, and IORT?

Topics: Breast Cancer • Radiation Oncology

The patient is a woman in her 60s with a history of a grade 1 ER-positive, HER2 negative pT1bN0 invasive ductal carcinoma treated with lumpectomy, whole-breast RT and tamoxifen >10 years ago.

The patient has a new grade 3 ER-positive, HER2 negative cT1cN0 invasive ductal carcinoma in the same breast (but different location within the breast) and refuses mastectomy, so is treated on a clinical trial of breast-conserving surgery and sentinel node biopsy, followed by 50 kV IORT.

Pathology reveals 9 mm grade 3 primary, with negative margins, 1/1 sentinel lymph node with a micrometastasis (1.2 mm, without ENE).

Would you recommend axillary dissection for this patient? Axillary radiation? Appropriate systemic treatment based on Oncotype, with no further surgery or radiation to the axilla? MD Anderson Nomogram risk of non-sentinel lymph nodes is 19%.

Answer from: Radiation Oncologist at Academic Institution

Generally, I am unenthusiastic about reirradiation of breast cancer patients who've been treated with BCT. Even if one can avoid critical structures such as heart and lungs, brachial plexus, etc. Cosmesis is likely to be compromised, given sufficient length of follow-up. In this instance, presumably...

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Radiation Oncologist at Community Health Network
I would recommend ALND and no RT.

Answer from: Radiation Oncologist at Community Practice

There is a presumption also here that the patient had an axillary surgery at the original diagnosis > 10 years ago, as it was the standard of care. If this were the case one could question the merits of another axillary surgery on top of a previous AXLND vis-a-vis the risk of lymphedema. A microm...

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Radiation Oncologist at Vasek Polak Radiation Oncology
The patient had a negative sentinel node procedure...

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