In a young woman with large invasive breast carcinoma (case: pT3, lobular) s/p skin sparing mastectomy with positive anterior margin, what is the practical role for re-excision with or without PMRT?

- Related questions: -- Does re-excision typically change reconstruction options? -- In the setting of an "unidentifiable" margin, how do you consider the spectrum of a PMRT boost volume from whole chest wall boost to scar boost? - Other details of case: Age < 50 y/o, pre-menopausal, sentinel node biopsy with pN1mic (1 of 2 examined nodes), ER/PR-positive, Her2-negative, Grade 2, negative for LVSI, declined adjuvant chemotherapy, plan for adjuvant endocrine therapy +/- ovarian ablation, no germline mutations, no Oncotype score. Patient had immediate tissue expander with plan for delayed autologous reconstruction.

2 Answers

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Radiation Oncology · Varian Medical Systems/Allegheny health network

Answered on · Updated on

The case has many nuances.

Is the margin positive focal or diffuse? Can a surgeon confidently go back to excise positive? If not, would proceed with PMRT and boost quadrant where disease was present before surgery. Counsel the patient about reconstruction complications and the need for additional surgery because of that.

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Radiation Oncology · Allegheny Health Network, Pittsburgh

Answered on

I would discuss with the surgeon about the margin and whether it was a real positive margin. If so, and it can be localized, I do favor re-excision when possible.

In terms of reconstruction, if the reconstruction is subpectoral and the anterior margin, not commonly an issue. If prepectoral and anterior margin are involved, then usually a discussion with the breast surgeon and plastics about the impact of reconstruction, the need to remove/replace, localized removal of ADM, etc.

If the unidentifi...

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