This is an interesting case scenario.
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!
sayan paul, 30 Nov 2010 17:59