Controversy of lymph node management in breast cancer in 2017

1st Case Pornwaree Trirussapanich, MD. Radiation oncology Unit Chulabhorn Hospital

History 37 year-old female, PE : mass 2 cm. at centre portion of Lt breast, no axillary node enlargement MMG: 1.79x1.88 cm. irregular shape hypoechoic nodule at L5

CT chest with contrast 10/6/2016 A 5.6x2.1 cm. enhancing mass in left breast A significant lymph node about 1.0 cm. in shortest axis and multiple enhance subcentrimeter lymph node at left axillary area, suspected lymph node metastasis A 5.6x2.1 cm. enhancing mass in left breast A significant lymph node about 1.0 cm. and multiple enhance subcentrimeter LN at Lt axillary area, suspected LN metastasis No IMC node enlargement

History S/P : Lt. MRM with TRAM with axillary node dissection Patho : IDCA gr 3 size 3.2x2.0x1.2 cm and satellite nodule 2.3x2.0x1.2 cm., Free margin. Pagetoid spreading cell to nipple LN 4/18 LN with ECE ER -ve, PR -ve, HER2/neu 3+, Ki67 50-60% Diagnosis : CA breast pT2N2M0

History S/P AC x 4  TH x 11 cycles During 11th TH : The patient developed dyspnea and desaturation Echocardiogram 30/12/2016 : LVEF 35% Dx cardiogenic pulmonary edema

Discussion Further management for this patient Target volume : Chest wall, SPC/whole axillar Internal mammillary node ? Radiation technique ?

Breast Cancer Case THASTRO Annual Meeting 10-11 March 2017 Chomporn Sitathanee, Radiation Oncology Unit Ramathibodi Hospital, Mahidol University

Case 1 CNB: R11-IDCA, R4-IDCA 37yo, 5 cm mass Rt breast MMG/US: mass 5x3.5x1.6 cm UOQ (R11-12), another 0.6x0.6 cm nodule at LIQ (R4) CNB: R11-IDCA, R4-IDCA

Case 1 Underwent skin-sparing mastectomy, SLNB, LD flap reconstruction Patho: IDCA grade 3, 4.3 cm at UOQ (R11), LVSI+, free margin (deep 1 mm), SLN-neg 0/4, intramammary LN (R4 lesion)+1 node (1.1 cm), ER+80% PR+20% HER2- Ki67+40%

Case 1 Questions: Staging  pT2N1M0; IIB Received adjuvant 4AC+4P  tam Questions: Prognostic significance of intra-mammary LN Is PMRT needed?, If so, what is the RT volume? Intramammary LN are considered axillary LN for purposes of N staging

Case 2 60yo, had excision of a benign lesion of the Rt breast 5y ago, developed Rt breast mass PE: ill-defined mass 3 cm just above old surgical scar & ?? another mass at UOQ

Case 2 MMG/US: new ill-defined mass at R12 2.7x1x1.5 cm just superior to scar, new nodule 0.8x0.9x0.7 cm at R11, Rt AN 0.6 cm with cortical thickening CNB: R12 & R11  IDCA FNA Rt AN: suboptimal material

Case 2 60yo, pT2N1M0 (IIB), mastectomy, no ALND Mastectomy & SLNB was performed, frozen section of SLN-neg (0/6) Patho: IDCA grade 1, 2.7 cm at UOQ, free margin (deep 1.5 cm), LVSI+, ER+90% PR+50%, HER2-, Ki67+20%, 1 SLN+ macromet, 1+ micromet  total+2/6 nodes, no ECE 60yo, pT2N1M0 (IIB), mastectomy, no ALND N1mi: >0.2mm but not more than 2 mm

Case 2 Further management? Any role of tumor biology on local RT? Complete ALND, if no additional AN+, no PMRT Complete ALND followed by PMRT no matter what PMRT cover chest wall, axilla, SPC, IMN? Any role of tumor biology on local RT?

Case 3 58yo postmen, Lt breast mass MMG/US: a spiculated 3-cm mass at L9 CNB: IDCA

Case 3 Underwent WE & SLNB Patho: IDCA grade 3 size 3 cm at IQ, free margin 3 mm, LVSI+, ER+70%, PR+40%, HER2-, Ki67+40% SLN+1/4, no ECE Receiving adjuvant chemo, AI planned

If HER2+ or triple neg, change management? Case 3 pT2N1M0; SLN+, no ALND, BCT RT technique? Standard tangents High tangents Tangents + SPC/axilla Tangents + SPC/axilla/IMN If HER2+ or triple neg, change management?

Case 4 43yo, Rt breast mass for 5mo MMG/US: ill-defined 4-cm mass at subareola-UIQ CNB: IDCA, FNA Rt AN: reactive hyperplasia

Case 4 Underwent MRM (multiple enlarged nonSLN) Patho: IDCA grade 3 size 6 cm at central-inner Q, free margin, LVSI+, AN+micromet 1/15n, ER+40%, PR+30%, HER2-, Ki67+70% OncotypeDx RS = 27 N1mi: >0.2mm but not more than 2 mm Intermediate risk score

Case 4 Questions: pT3N1miM0 stage IIIA, premen, Lum B-liked Received adjuvant chemo: 6FAC  tam Questions: PMRT volume; RNI? SPC+AN3, IMN?

Case Scenario Rachata Banlengchit, MD Faculty of medicine, chiangmai university Annual THASTRO Meeting Centara Hotel, Udonthani 11 March 2017

History Case 55-yr old female Presented with left breast mass 1 year PE: mass 5 cm at 12 o’clock of left breast no axillary LN or SPC LN enlargement

Investigations Mammogram - Irregular hypoechoic solid mass extending to retroareolar region at 12 o’clock Lt.breast 1 cm from nipple, measuring 3.2 x 2.5 x 4 cm - BIRADS V

Investigations W/U metastasis CXR - unremarkable Bone scan - no evidence of bone metastasis Liver U/S - unremarkable

S/P Lt. simple mastectomy with SLND Patho : invasive ductal carcinoma size 5.1 cm, N1H1 LVSI -ve , PNI -ve margin free SLND 0/6 ER 3+ve, PR 3+ve, C-erbB2 1+

S/P FAC 6 cycles Imp. Lt CA Breast pT3pN0M0 S/P Lt simple mastectomy with SLND S/P FAC 6 cycle

What is the appropriate further management. 1. Radiotherapy or not. 2 What is the appropriate further management ? 1. Radiotherapy or not ? 2. Radiation field ?

What is the next proper management ? If this patient had received neoadjuvant chemotherapy and the pathological report showed pCR What is the next proper management ?