Breast is the worst: another, another case!

[elementaryschooleconomics]

wait and see what systemic therapy does, or just go ahead and start?

I agree with @TheWallnerus re: potential dose.

Young and healthy otherwise? I would just treat now. While she might respond to systemic therapy, she might not, and I wouldn't want to lose the window.

Obviously, IMRT/VMAT might get fought by insurance. You could consider DCA supplemented by static field(s) for a 3D plan that won't get you thrown in eviCore jail.

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[TheWallnerus]

wait and see what systemic therapy does, or just go ahead and start?

I think I would start. Some people will want to do 25 to 30/5 on this and that's not wrong either of course. EDIT: if IMRT is denied and you do a P2P, record the P2P and post it on the internet if the P2P is denied.

 

[mheat3]

wait and see what systemic therapy does, or just go ahead and start?

Given her symptoms I'd start RT and allow systemic to be given as well (assuming she is in good shape).

 

[elementaryschooleconomics]

 

[Palex80]

I'd start treating. How many lines of antihormonal treatment has she had? Are there any left?

 

[Ray D. Ayshun]

I'd start treating. How many lines of antihormonal treatment has she had? Are there any left?

She's only had anastrozole. This is her initial presentation as metastatic.

 

[Palex80]

She's only had anastrozole. This is her initial presentation as metastatic.

Well that gives her several options for systemic treatment and chemotherapy will certainly not be the next line. Thus:
a) her prognosis is not bad and b) interaction with systemic treatment will not be much of an issue.
I'd treat now with a palliative dose. 10 x 3 Gy or 5 x 5 Gy or whatever...

 

[Ray D. Ayshun]

Thanks all. Sorry to interrupt forum flow with clinical question. Wanted to see if anyone could talk me out of treating now.

 

[TheWallnerus]

Thanks all. Sorry to interrupt forum flow with clinical question. Wanted to see if anyone could talk me out of treating now.

A patient like this could be alive for a looong time from now so it will be best to be as anal retentive about dose spillage as possible for the not hugely unlikely moment you may need to re irradiate the spot in the future. In other words, go way below normal constraints as much as possible is kind of my philosophy in a case like this. Healthy brain cells really help QOL.

 

[SneakyBooger]

Thanks all. Sorry to interrupt forum flow with clinical question. Wanted to see if anyone could talk me out of treating now.

On the other hand...

I would probably see what systemic does.

If doesn't respond to systemic it likely won't matter what you give right now anyway.

But, as others have said, treating now is also reasonable.

IMO, whichever path you choose there are arguments to support each.

 

[Ray D. Ayshun]

On the other hand...

I would probably see what systemic does.

If doesn't respond to systemic it likely won't matter what you give right now anyway.

But, as others have said, treating now is also reasonable.

IMO, whichever path you choose there are arguments to support each.

Thanks. It's bothering her now, as it should given the imaging appearance. My concern is hair loss/temporal lobe irradiation, as she works full time, is active etc. This basically popped up about 14 months after stopping anastrozole, so I think there's hope to get it back under control on a reasonable timeline. Nonetheless, she's coming in for a sim today.

 

[evilbooyaa]

Thanks. It's bothering her now, as it should given the imaging appearance. My concern is hair loss/temporal lobe irradiation, as she works full time, is active etc. This basically popped up about 14 months after stopping anastrozole, so I think there's hope to get it back under control on a reasonable timeline. Nonetheless, she's coming in for a sim today.

Hair loss will be temporary. Temporal lobe will be fine with 30/10 or 37.5/15 or even 25-30/5 given basically abutment of brain.

 

[Neuronix]

Returning to my breast dumpster. Saw this patient. Very healthy 65 yo with recurrent/metastatic hormone receptor positive lobular carcinoma involving mediastinal nodes and multiple bones. Referred to me for pain in the right temporal bone with this imaging:
View attachment 351003
CSF negative. If I'm ultimately forced to treat this, preference would be IMRT, though a palliative dose. Wondering others thoughts, and what the trigger would be to treat as she has yet to start systemic therapy.

20/5 or 30/10 my preference. Would argue for IMRT to stay off lacrimal gland. Would contour some other stuff too like lenses and hippocampi though they shouldn't get much dose.