is PMRT needed for this patient?

[TheWallnerus]

So upper inner quadrant change anything for people? I suspect sentinel nodes weren't mapped?

Her risk of bone marrow involvement is greater than the risk of IMN involvement here... so *shocker* no

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[SneakyBooger]

For different reasons I was looking at this paper, which also applies here:

View attachment 354531

I think we understand a lot less than people would have us believe we do in this space, regarding what/how to irradiate, and what specific anatomical regions drive patterns of failure.

Sounds like another win for IMRT in this space.

 

[Ray D. Ayshun]

Her risk of bone marrow involvement is greater than the risk of IMN involvement here... so *shocker* no

dare i ask: Is there ever a case where this isnt the case in the absence of a positive IMN biopsy?

 

[TheWallnerus]

dare i ask: Is there ever a case where this isnt the case in the absence of a positive IMN biopsy?

nice comeback!

 

[elementaryschooleconomics]

View attachment 354570

* I don't actually believe this, but internet memes crack me up so I was feeling creative.

20 years ago I came to SDN to learn how to get into medical school.

Now I come to learn new memes.

 

[taserlaser]

dare i ask: Is there ever a case where this isnt the case in the absence of a positive IMN biopsy?

Ugh I have someone now that had auto recon and plastics biopsied the IMN. Shocker, it is positive. Also didn’t want chemo, and pretty sure after talking to her doesn’t want RT. Whelp, least she’s on Tam…

 

[communitydoc13]

Her risk of bone marrow involvement is greater than the risk of IMN involvement here... so *shocker* no

Don't worry about those dormant ER+ bone marrow mets. Nobody know WTF they mean or to do with them.

Looking at post mastectomy BC Trial, clearly that XRT working some magic in patients who almost certainly had dormant bone marrow mets. Amazing how we stop following our breast cancer patients hard come 5 years when ER+ recurrences almost monotonic going forward past that.

Breast cancer dormancy: need for clinically relevant models to address current gaps in knowledge - npj Breast Cancer

Breast cancer is the most commonly diagnosed cancer in the USA. Although advances in treatment over the past several decades have significantly improved the outlook for this disease, most women who are diagnosed with estrogen receptor positive disease remain at risk of metastatic relapse for the...

www.nature.com

 

[TheWallnerus]

Looking at post mastectomy BC Trial, clearly that XRT working some magic in patients who almost certainly had dormant bone marrow mets

I think this is so provocative yet seldom talked about. The "magic" may truly be an abscopal effect. That is to say, as counterintuitive as it seems, irradiating just a percent of the subclinical/microscopic disease in a breast cancer patient's body may illicit a response in the unirradiated cells.

And this explains why we will never see OS benefits from RNI machinations or differing styles thereof in most breast cancers. Locoregional therapy can be too sloppy and hurt survival, but it can be as fancy as you'd like and the returns rapidly diminish. Again confirming Fisher:

This trial had an enormous influence on how radiation oncologistssurgeons and clinicians perceived the behavior of breast cancer; it convinced them, once and for all, that nuances in locoregional therapy were unlikely to have a substantial influence on ultimate survival and that patients succumbed to the disease not because of inattention to radiotherapeuticoperative detail but rather because micrometastases were present at the time of the initial irradiationoperation. This provided the biologic rationale for the evolution of clinical trials that evaluated not only additional reduction in the extent of locoregional therapy, but also, more importantly, the use of adjuvant systemic therapy.

 

[Palex80]

Her risk of bone marrow involvement is greater than the risk of IMN involvement here... so *shocker* no

Well, following that logic, perhaps we should stop irradiating pelvic nodes in cT3 cN0 rectal cancer. The risk of microscopic positive pelvic nodes (beyond the mesorectum) is likely lower than that of microscopic liver metastases...

 

[taserlaser]

I think this is so provocative yet seldom talked about. The "magic" may truly be an abscopal effect. That is to say, as counterintuitive as it seems, irradiating just a percent of the subclinical/microscopic disease in a breast cancer patient's body may illicit a response in the unirradiated cells.

And this explains why we will never see OS benefits from RNI machinations or differing styles thereof in most breast cancers. Locoregional therapy can be too sloppy and hurt survival, but it can be as fancy as you'd like and the returns rapidly diminish. Again confirming Fisher:

This trial had an enormous influence on how radiation oncologistssurgeons and clinicians perceived the behavior of breast cancer; it convinced them, once and for all, that nuances in locoregional therapy were unlikely to have a substantial influence on ultimate survival and that patients succumbed to the disease not because of inattention to radiotherapeuticoperative detail but rather because micrometastases were present at the time of the initial irradiationoperation. This provided the biologic rationale for the evolution of clinical trials that evaluated not only additional reduction in the extent of locoregional therapy, but also, more importantly, the use of adjuvant systemic therapy.

There was some interesting Danish work on CD8+ t-cells and PMRT effect at ESTRO. We have just started to breach the surface with our understanding of immunoRT effects I think

 

[OTN]

There was some interesting Danish work on CD8+ t-cells and PMRT effect at ESTRO. We have just started to breach the surface with our understanding of immunoRT effects I think

We've just started to breach the surface because YET AGAIN academic radoncs are 10 years behind.

 

[TheWallnerus]

There was some interesting Danish work on CD8+ t-cells and PMRT effect at ESTRO. We have just started to breach the surface with our understanding of immunoRT effects I think

Here you go. VERY cool results IMHO and I have considered this for a long time thanks to Formenti. Now, it will actually mean (if we base PMRT on CD8+ findings) a little less PMRT utilization, but such is life! The stratification for PMRT effect seems to be more pronounced for CD8+ status than it does for LN status; keep in mind EORTC 22922/MA20 showed no OS benefit to RNI, yet here we have a near doubling of OS using PMRT based on CD8+ at 20y with a p<0.00001. (NB: CD8+ cells are cytotoxic T cells if you recall from med school immuno.)

"The findings may indicate that RT triggers a local immune response that induces a systemic effect, which improves survival through eradication of distant tumor deposits."

 

[communitydoc13]

Wallnerus can run his CD8+ and LN positive CW vs. RNI trial as a next step. Include intact breast.

 

[Ray D. Ayshun]

For those of you doing chest wall only for +sm, are you treating the primary plan to 40/15 or 50/25?

 

[deleted1111261]

For those of you doing chest wall only for +sm, are you treating the primary plan to 40/15 or 50/25?

40/15

It is terrible how well they tolerate that

And for regional nodes, too.

Early pandemic, did everyone in 4 weeks (including CW boost) and thought I’d never go back.

 

[thecarbonionangle]

I hear from colleagues that once you start doing your three field breasts with hypofrac you just simply never go back.

 

[jondunn]

I hear from colleagues that once you start doing your three field breasts with hypofrac you just simply never go back.

Truth.

 

[evilbooyaa]

For those of you doing chest wall only for +sm, are you treating the primary plan to 40/15 or 50/25?

Good question. Haven't done one quite recently, but don't see a great reason to not do 40/15, but would consider reasonable to do conventional.

I hear from colleagues that once you start doing your three field breasts with hypofrac you just simply never go back.

It certainly will be the future, I am personally not a fan of low numbers from START doing RNI or the chinese trial where they did electrons for the CW. It's probably fine as long as you do the match line properly and don't double dose at the brachial plexus. Good thing I don't treat a lot of breast anyways...

 

[thecarbonionangle]

even if you do single/double iso the chance of the constant overlap is likely quite low. Furthermore, there is natural “feathering” which happens with daily set up between CW and SCV fields. Chinese data should be enough. I agree this is the way and future