This case raises many issues
1.at age 39, should we obtain a BRCA gene?
2.frequency of triple positive breast
3.should BRAC be positive should with push for bilateral Mastectomy and Bilateral Oophorectomy
4.should BRCA be positive, what are the proximity genes to look at?
5.what is the frequency of lymphedema post RT
6.Is AC-T the best chemotherapy regimen
7. should T be weekly even though Herceptin is not offered?
8.What is the role of PET in helping decide ALND Vs RT
but first thing first
For Node-Positive Breast Cancer, Axillary Radiation Is Best
Of the patients with positive lymph nodes, 744 went on to receive ALND and 681 received axillary radiotherapy.
Radiotherapy (50 Gy in 25 fractions of 2 Gy, 5 days a week) was started within 12 weeks of surgery, and directed at 3 levels of the axilla and the medial part of the supraclavicular fossa, Dr. Rutgers explained. Levels I and II of the axilla were mandatory and level III was optional.
There were no significant differences in between the radiotherapy and surgery groups at baseline. Median age was 55 to 56 years, and 38% to 42% of the patients were premenopausal. Median tumor size was 17 to 18 mm, and 75% of patients had grade 2 or 3 cancer.
In the cohort, 82% underwent breast conservation and the remainder underwent mastectomy; 90% received systemic treatments. A median of 2 sentinel nodes were removed from each woman.
For patients who received axillary clearance, the sentinel node was the only positive node in 67%; 33% had further node involvement and 8% had 4 or more positive nodes.
After 5 years of follow-up, the axillary recurrence rate was "extremely low" in the surgery and radiotherapy groups (0.54% vs 1.03%), Dr. Rutgers reported.
Because "this was far below what we anticipated, the trial was underpowered for a noninferiority comparison," he explained.
There were no significant differences between the surgery and radiotherapy groups in disease-free survival (86.9% vs 82.7%; P = .1788) or overall survival (93.3% vs 92.5%; P = .3386).
However, 5 years after therapy, the rate of lymphedema in the surgery group was twice that of the radiotherapy group (28% vs 14%).
"The AMAROS trial provides very important evidence that the kind of regional nodal treatment used after a positive sentinel node biopsy will not substantially affect the risk for subsequent regional nodal failure, rates of metastasis-free breast-cancer-specific, or overall survival in most patients," Dr. Recht told Medscape Medical News.
He explained that a more important question than whether to choose radiotherapy is which type to choose.
"Is axillary radiotherapy better at preventing regional nodal failure than just irradiating the breast, which includes the lower portion of the axilla in many individuals?" he asked.
Dr. Recht said that previous studies that compared breast radiotherapy with ALND — such as the"
"The guideline updates three recommendations based on evidence from randomized controlled trials:
• Women without sentinel lymph node (SLN) metastases should not receive axillary lymph node dissection (ALND).
• Most women with 1 to 2 metastatic SLNs planning to receive breast conserving surgery with whole breast radiotherapy should not undergo ALND.
• Women with SLN metastases who will receive mastectomy may be offered ALND.
The guideline updates two groups of recommendations based on cohort studies and/or informal consensus:
• Women with operable breast cancer and multicentric tumors, and/or DCIS who will have mastectomy, and/or had prior breast and/or axillary surgery, and/or had preoperative/neoadjuvant systemic therapy may be offered sentinel lymph node biopsy (SNB).
• Women who have large or locally advanced invasive breast cancers (tumor size T3/T4), and/or inflammatory breast cancer, and/or DCIS, when breast-conserving surgery is planned, and/or are pregnant should not receive SNB.
The ASCO committee noted that in some cases, evidence was insufficient to update previous recommendations."