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What evidence supports the use of high tangents for pN1mic breast cancer?

In my experience, high tangents are commonly used for patients with pN1mic disease, and occasionally for higher risk patients with pN0 disease. The recent ARO publication (Arbab et al.) on RT planning for residents endorsed this approach. However, I am not aware of any studies that have explicitly studied and validated this approach for pN1mic patients. In fact, pN1mic patients have generally been eligible for studies investigating comprehensive RNI: For example, pN1mic patients are eligible for the ongoing MA.39 trial which is randomizing patients between comprehensive RNI and no nodal irradiation. So it's not entirely clear to me how we know that only the low-axilla is at risk in patients with pN1mic disease, rather than the entire axilla being at risk suggesting that a more comprehensive RNI approach should be taken. Are there any trials that have actually defined outcomes using high tangents for pN1mic patients? Even better, are there any trials that have compared high tangents with a) no RNI (and shown superiority) or b) comprehensive RNI (and shown equivalence) in the pN1mic setting?
3 Answers
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Radiation Oncology · New York University School of Medicine
Answered on

This is a great question. To add to the excellent answers from @Dr. First Last and @Dr. First Last, here are some of my thoughts on this topic:

At the time of MA.20, the size of nodal metastasis was not routinely measured so it is unclear what percent of patients in MA.20, if any, had micrometastases...

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Radiation Oncology · Allegheny Health Network, Pittsburgh
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There are limited prospective or randomized data looking at only N1mic patients outside the IBCSG trial (Galimberti et al., PMID 23491275) and in that trial, RT was a bit heterogeneous (some got no RT, some IORT). The study does demonstrate the risk of additional nodes for patients with pN1mic disea...

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Radiation Oncology · Indiana University Health
Answered on

This is an interesting question, and another variation is pN1mi in the setting of patients who undergo mastectomy, where we do not usually consider high tangents and typically advocate for PMRT if there are additional risk factors.

I believe the addition of pN1mi for eligibility into MA.39 was off o...

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