In postmenopausal T4aN3 M0 ladies with supraclav Ln at presentation,post NACT MRM staging ypT2N1M0 ,supraclav recurrence during RT ,should RT continue?Would this still be considered a local recurrence?
An infectious disease during treatment in any patient-chicken pox,herpes,TBetc-how long should the treatment break be - end of infectious period,immediately after taking all due precaution(example with HIV),or after completion of treatment for the infectious disease.
Hi Hari
Can you give some more details regarding your patient - age, performance status, surgical path including hormonal status, metaststic workup, what NACT, how many fractions of RT received etc.
As far as infectious diseases are concerned - it depends on which site is being treated and whether the infection itself affects RT delivery and tolerance. The issue also is of ho this patient puts others on the unit at risk. I don;t think there are any universal solutions - you have to make a decision on an individual basis.
dear hari
if the portals are correct and few fractions have been treated and you see a recurrence at supraclav, then essentially it is a palliative situation. you can d what ever you wan to do . change the fractionation and stop treatment for chest wall, or stop RT altogether. It doesnt matter.
Coming to infection I agree with indranil. There can not be a general guideline.
60 year old postmenopausal,T4a with supraclav and axillary LNs,CECT chest and abdomen-negative for mets.treated with CAFx3#s with disappearance of the supraclav and local disease becoming operable.MRM done-final HP-IDC-GdIII.ypT2N1,ER+,PR-,HER2neu-,received further 3 # CAF upto 25 Jan.reported to me after 4 weeks of completion of chemo.started RT after CT scan which is clear.developed supraclav LN within 01 week.My question is why does it become palliative.(PS-I have stopped RT and referred to med oncologist .I have just expressed my misgivings here).
Hi
I am not an expert in breast at all (so don't pay too much attention to it) - but my first impression here was that this lady has had a transient response in her SC node from chemo perhaps the node which had become smaller is starting to grow back. I am not sure I would call it a distant met or progression on RT because enough RT dose has not been delivered and the response to second line chemo may be shortlived too. Not sure if there is any evidence on this particular situation, but I would have had great misgivings about aborting RT too. I would be tempted (maybe wrongly so) to consider RT boost to the SCLN or surgery in SCLN if the patient was inclined towards radical treatment and current staging did not show other mets. I don't know the best systemic approach here in terms of hormones vs. further chemo etc.
hi
the fact that she has relapsed so soon after chemo is not a good sign but i dont think this all ''palliative''. (she has had only 1 week of RT) If the systemic staging is clear i'll encourage you to continue with RT. Make sure this lump is adequately covered and may need to use the skin bolus for build up if its too superficial and do push the total dose to tolerance of brachial plexus.
question comes wht you do after RT completion - most debatable i think … personally i'll offer further chemo only if she progreses.
in my practice i would have offered this patient taxane based chemo to start with and provided she was responding would have carried on to complete full chemotherapy schedule before definative surgery rather than having a break after 3 cycles.
The rapid recurrence after chemo is an indicator of the general effectiveness of chemo against macroscopic disease. This further reinforces the need for the RT to the SCF/axilla and chest wall. Attention does need to be paid to the node to make sure that it is getting TD.
As for brachial plexus tolerance, the impact of recurrence is a high chance of brachial plexopathy so I would be ignoring it. The brachial plexopathy rate from treatment is low (<5-10%). Later on if she is alive to worry about the side effect, you should remember - she IS alive.
There is nothing for the MO to say about treatment at this point. Further chemo now is unlikely to have an impact. RT is likely (>80%) to achieve a CR in this situation. After the end of the RT, he may want to give more chemo but that's a data free zone as far as I know. So I'd make it disappear and then wait for recurrence also.
I would not have stopped/ suspended RT in this scenario.
I would have treated the chest wall with 40 Gy/ 15 # / 3 weeks OR 50Gy / 25 # whichever ppl are comfortable.
(Refer to UK- START Trial)
The SCLN should be treated with cobalt or 6 MV (whatever is available at your centre) with at least 50 Gy / 25 # / 5 weeks and after this i would add an electron boost to Palpable GTV or that visualised on CT-Sim giving 3 cm margin to make your PTV. This electron boost would be 10 Gy / 5 # / 1 week.
Of course please ensure that this node is not underdosed when using photons and add bolus if need be.
Total dose of 60 Gy is a good enough tumoricidal dose, which is close to the TD 5/5 for Brachial Plexopathy, but of course with electrons i dont expect the full 100% (10 Gy) to go to the Brachial plexus, so i would quote the incidence of Brachial plexopathy around 2-3 % to this pt. (this needs to be consented and documented, which is most impt)
As mentioned by Sid, after this Definitive RT (not pall RT), the question of further chemo remains controversial, and i would agree by the view to re-stage with CT scan Neck/Chest/Abdo/Pelvis 2-3 months Post RT to determine need for further Chemo, which of course as mentioned by Indranil would be Taxane based.
Some enthusiasts may get a PET scan done at her first follow up.
Some may simple relax and re-assure her and treat her when she relapses clinically.
Meanwhile since she is ER+ve, and postmenopausal i would start her on LETROZOLE if she is not been started.
As this lady had supraclavicular node at presentation, she should have undergone supraclavicuar clearance even though SC nodes were not palpable post chmeotherapy. Because complete pathological CR is seen in only 10-25%.
Now as she is already on RT better to ontinue RT as suggested above with dose escalation upto 60Gy. Start her on letroz as she is ER+ve.
Do a PET scan at 2 months. If the disease is present and localised to SCF then consider surgical resection.
If there is extensive disease with distant mets then palliative chemotherapy.
At present no much role of chemotherapy