Should I have radiotherapy to the supraclavicular fossa - 1259606

aya1471
Posts:7

Hi. I was diagnosed with primary breast cancer in January 2013 - with a 4 cm tumour, lymph node involvement and dcis. Lymph nodes were diagnosed with fine needle aspirant. I had neo adjuvant chemo (ec and taxol - 4 cycles of each) wide local excision and level 1 axillary clearance. My pathology report showed only 2mm of invasive cancer left. And no cancer in the lymph nodes. So in having radiotherapy - the royal marsden in London did not plan to give radiotherapy to the supraclavicular fossa. They did not mention this but I queried it and they said it was my choice. As I had neoadjuvant chemo it's impossible to know how many lymph nodes were involved. The policy is if you have 4 or more nodes they offer scf. With ppl in my situation it's not routinely offered. Should I have it? Risks appear to be lymphodemia, nerve damage (1% risk) , slightly mor lung tissue exposed. Are there risks to the oesphogus or thyroid?? My risk of a recurrence, in the scf is low (around 3-5%), is there any evidence to help me make this decision?? I understand the us is launching trials on how to treat those who present node positive and convert to node negative. Thanks my cancer was left sided and her 2 positive - I'm receiving herceptin.

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Reply # - October 2, 2013, 03:09 PM

aya1471
Posts: 7

Thanks - I should add I'm 36 years old. Current radiotherapy plan is to the whole breast not to axilla.
I'm really interested in potential side effects of supraclavicular radiation. My onc says risks to thyroid and oesphogus are soo small they don't mention but that doesn't tally up with my research....also is it possible to make a guess at how many lymph nodes I had affected? Onc says not possible as can't see ultrasounds retrospectively - so they're going by reports. He said one or two but the reports say several enlarged nodes and few nodes....so that's confused me.

Reply # - October 2, 2013, 04:43 PM

carrigallen
Posts: 194

It seems like you have had a great response to intensive preoperative chemotherapy, so it sounds like you have a lot to celebrate - congratulations!
I'll defer a definitive response to the breast oncology faculty, but I had one question that may help clarify: which specific lymph nodes, if any, were enlarged originally? (axillary, internal mammary or supraclavicular lymph nodes?) Usually ultrasound reports will comment on the size, number, features, and location of abnormal lymph nodes. Depending on the size and number of lymph nodes, there is evidence to support adjuvant radiation to involved areas. The adverse effects to axillary radiation depend also on how extensive of a lymph node sampling you had during surgery. I don't think that modern conformal radiation techniques commonly cause esophageal or thyroid toxicity when directed to axilla or supraclavicular fossa for adjuvant intent. Hope this helps.

Reply # - October 2, 2013, 04:51 PM

dr cianfrocca
Posts: 49

In general, the optimal approach to radiation therapy after neoadjuvant chemotherapy, particularly when it is successful is unclear. As Dr Creelan indicated, it would depend somewhat on which nodes were involved. I encourage you to discuss the risks/benefits in detail with a radiation oncologist and if you are still uncomfortable, a second opinion is a good idea.

Dr Cianfrocca

Reply # - October 2, 2013, 11:47 PM

aya1471
Posts: 7

Thank for Dr Creelan and Cr Cianfrocca.

I've always assumed it was the axillary nodes that were englarged. I was diagnosed at a different hospital to what I was treated at - and although I have my medical records from my treating hospital and includes imaging made at diagnosis - it doesn't seem to include the ultrasound reports from when originally diagnosed. I'll chase the original hospital and see if I can get more information.

On the axilla - the surgery was only level 1 clearance. I've already started radiotherapy - had 5 fractions - and currently not receiving radiotherapy to the axilla or supraclavicular fossa. I'm comfortable with not have radiotherapy to my axilla as I believe the surgery was sufficient. The question on SCF only came up on Monday - and the team have said I can have my rads extended to cover this.

Thanks

Reply # - October 3, 2013, 05:17 AM

aya1471
Posts: 7

Hi - So it is only lyphm nodes in the axilla which were enlarged. After my fine needle aspirant - the ultrasound report before chemo said:

“several abnormal enlarged lymph nodes seen in the left axilla with a maximal cortical thickness of 5mm”

and the CT/Chest/Abdo/Pelvis Scan - said "there are several prominent left axillary lymph nodes, the three largest measuring approximately 1.2x0.8cm in size but these are suspicious of probable malignant involvement."

Would this suggest I had quiet a few (e,g more than 4) nodes involved - or do you think the fine needle aspirant could have resulted in disturbing the area and making more look enlarged.

I know need to talk to my doctor - but I've already quizzed them twice and I'm not getting much luck in getting hold of them....

Reply # - October 3, 2013, 09:05 AM

catdander
Posts:

aya, It's impossible to knew exactly how many "several" means in a rad report, or how exactly it connects with "the 3 largest" except to assume the obvious which is there are 4 or more. Imaging reports are often vague sounding in this way since the doctor writing the report isn't seeing patients, the interpretation is left to the onc seeing the patient.

I'll ask Dr. Cianfrocca to address your FNA question.

I hope that helps,
Janine
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Reply # - October 3, 2013, 09:13 AM

dr cianfrocca
Posts: 49

FNAs can cause some inflammation but I doubt it caused the changes you mentioned. Janine is correct, it really is up to your treating oncologists to interpret the results of your imaging and decide whether you had complete axillary surgery and then make radiation recommendations based on that. It really isn't appropriate for me to make specific treatment recommendations.
All the best,
Dr Cianfrocca

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