1. Controversy of lymph node management in breast cancer in 2017

2. 1st Case Pornwaree Trirussapanich, MD. Radiation oncology Unit
Chulabhorn Hospital

3. 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

4. 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

5. 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+, Ki %
Diagnosis : CA breast pT2N2M0

6. 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

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

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

9. 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

10. 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%

11. 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

12. 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

13. 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

14. 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

15. 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?

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

17. 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

18. 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?

19. 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

20. 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

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

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

23. 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

24. 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

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

26. 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+

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

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

29. 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 ?