I have a case coming up, recurrent ca-breast , Chest wall recurrence along with systemic disease. Our tumor board has asked us if we can do something for her, may be palliative surface mould for our patient. Havn't seen the patient yet.

Nikhilesh

However there is no long term follow up nor any metion of late radiation sequaela. There is more experience of re-irradiation by external beam but that is essentially is a palliative setting with mean doses of 20 to 30 Gy.

In a more radical scenario,the largest series i could find in the post mastectomy irradiated chest wall setting was:

1. http://www.ncbi.nlm.nih.gov/pubmed/17869019

The median follow-up from the second RT course was too short (just 1 year) Four patients developed late Grade 3 or 4 toxicity out of 81. However, 25 patients had follow-up >20 months, and no late Grade 3 or 4 toxicities were noted. Interesting,but its difficult to get the actual incidence of late damage from this publication.

The incidence of late damage will of course be proportional to the dose of radiotherapy making its use beyond 50 Gy probably unfeasible for a normally cautious oncologist, even if a localised volume to the chest wall is re-irradiated. But to be very honest for Andrew it could be SKY IS the LIMIT. What have you got to lose … rib fractures, soft tissue necrosis …. are these really serious to give you nightmares

And its upto a radiation oncologist to believe in his magic treatment, whether would 50 Gy do the job and give this lady a 50% or 80% chance of being free from local relapse. I m sure nobody other than Andrew himself will understand this equation of higher the dose, higher the chance of local control but equally distressing would be the chance of soft tisse necrosis and late damage.

I have to see Andrew sitting with this patient, going through a graph and telling the patient, look lady what do you want.
You want 40 % chance of local control with 30 % chance of late damage
or 60% chance of local control with 50% chance of late damage
or a 80% chance of local control with 70% chance of late damage.
Common lady, its your choice at the end of the day.

Sorry, Andrew just pulling your leg, those figures are just arbitrary and not real, so others please dont take these for granted since they are just from me.

This earlier publication , http://www.ncbi.nlm.nih.gov/pubmed/9342443?dopt=Abstract

makes me believe that evetually this patient would have a systemic relapse if she is fortunate to have had a good local control.
But we are always optimistic, hence 10 y OS = 30% is the best realistic estimate you could have for this patient with isolated local relapse.

Such a fuss about this positive margin , microscopic disease which we cant even see, but can be a matter of life or death for this 52 y old lady.

1. My preferred Option: Discuss this with Plastic Oncosurgeon or Thoracic Surgeon for further curative resection as this lady is too young (52 yrs).
Let the surgeoon know that median survival forthese patients is 5.6 years and 10 y OS = 30% which is reasonable.
http://www.ncbi.nlm.nih.gov/pubmed/9342443?dopt=Abstract

2. Re-irradiation: The equation between Cure Vs Complication would tilt more towards the latter.
i personally dont think you could safely achieve this.
You need at least 60 Gy minimum for this microscopic disease.
You could use electrons (with bolus) or kV.
Its highly likely this treatment may result in soft tissue necrosis and/or osteoradionecrosis of ribs which could be as high as 40-60%.

And of course you could ask your plastic Surgeon or Thoracic Surgeon to get you out of that mess in may be 2011 or 2012 with some chest wall reconstruction procedure.

3. Observe

(Many times we ve seen, patients have positive margin, however on further resection there is no e/o residual cancer.

I would re-check her ER, PR and Her-2 receptor status on the current resection and consider any systemic therapy along those lines if necessary.

Now presents with local chest wall mass. We saw her post resection of the mass by surgeon. + deep margin . Surgeon believes can not remove it by resection.

Re-staging—> No Metastasis.

1. What would be your treatment options?
2. If RT? How to deliver to give least chance of XRT necrosis?
3. What is the chance of soft tissue XRT induced necrosis?
4. If happens what would be the treatment options?