I would be very uneasy about not having adjuvant nodal irradiation. She would have been eligible for the Danish and Canadian trials that show a survival improvement. The trial result tells us about axillary surgery, but nothing about axillary radiotherapy. Clearly the previous assumptions about 'good'/'bad' or 'adequate'/'inadequate' axillary surgery are incorrect. Either 2 nodes is enough, or axillary dissection just tells you about risk of further axillary disease. It also seems to suggest that another 10-14 LNs is insufficient to greatly affect the risk.

Maybe we were wrong all along and nodes are now irrelevant except as a marker of metastatic risk?

Was sent to us for adjuvant radiation, my teaching was that this lady needs complete axillary ln dissection however things have changed and our breast surgeons do not do it anymore. This publication is an excellent example.
This study is published in full paper form and is ready to be discussed.
http://jama.ama-assn.org/content/305/6/569.full.pdf+html

Please feel free to discuss and tell us how your breast team is handling this issue.

The two articles have analysed the toxicity in a cohort given trastuzumab concurrently with RT. The first study is particularly pertinent for your patient. While skin and esophageal toxicity were not significantly increased, but the cardiac function is reduced more. So I would exercise caution if doing IMN radiation. Radiation pneumonitis is not significantly increased either. In addition this interesting rat model study also suggests there is little increase in late radiation pneumonitis. It is important to stress here that the first study was having a retrospective design for RT data collection. The 2nd study did not allow use of IMN (2% received it though) and though prospective was not designed to answer the question of increase/decrease toxicity with use of trastuzumab and herceptin.

However there are several pertinent issues that the authors of the 1st article pointed out with respect to concurrent use of Trastuzumab and RT in breast cancer patient with IMN reported by shaffer et al in a letter to the editor. The letter is available here and gives a nice highlight of the pertinent issues with shaffer's study which did show no increase in cardiotoxicity with the use of Trastuzumab concurrent with RT.

I can't comment on omission of Chemotherapy though. As I mentioned, only hormonal therapy may be suffice. The jury can be out for omission of anthracyclines perhaps in view of their cardiac toxicity.

Arguments AGAINST radiation delivery

1) Age of the patient.
2) Clear margins
3) ER+. Some people may advocate adjuvant hormonal therapy alone.
4) Co-morbidities.

Arguments FOR Radiation AND Systemic Therapy:

1) She has a single node positivity in the Axilla along with adverse histopathological features:
a) Lymphvascular Invasion,
b) Grade III tumor
c) Perineural Invasion.
d) She has been operated twice; for recurrence pointing towards aggressiveness although we don't know what the initial HPR has been.
e) KPS 80.

In view of her age, it can be argued that breast cancer MAY NOT be the competing cause of death. However, keeping the adverse issues in mind, I would strongly argue for a clear cut case of systemic therapy AND Radiation to chest wall.

I am assuming that there is no ECE in the dissected axillary node which would in any case bolster my argument for systemic therapy AND radiation. I would then follow it up with hormonal therapy.

The main reason for advocating radiation here is the results from Danish Post Menopausal trial. Although there did not seem to be any benefit in patients having 1-3 positive nodes but if you look carefully, the median number of nodes dissected was about 7. It has been shown in subsequent studies that the less number of nodes taken out for staging is perhaps an indicator for higher nodal positivity which otherwise has not been taken out.

Further, the loco-regional relapse rates in patients in the Danish study with nodal positivity and post operative radiation was about 4% indicating a benefit of radiation than those who did not get any adjuvant therapy (relapse rates around 15%).

To give XRT or not is again matter of debate which has not been settled; SUPREMO Trial results would give us a CLEAR CUT answer!