Neoadjuvant chemotherapy

HER2-positive breast cancer

Post-mastectomy radiation therapy (PMRT)

Sentinel node biopsy

Axillary dissection

Tumor board discussion

Multifocal breast cancer

Breast MRI

Surgical planning error

Lymphedema risk

Radiation complications

NSABP B-51 trial

Residual disease after neoadjuvant therapy

Expander reconstruction and radiation

Hypofractionated radiation

Internal mammary node radiation

Genetic mutations and breast cancer (e.g., BRCA, CHEK2)

Radiation therapy and implants

Proton vs. photon therapy

Cosmetic outcomes after breast reconstruction

Radiation oncology decision-making

📚 General Topics:
Case Presentation:

43-year-old female surgeon with HER2-positive, ER-low breast cancer

Multifocal disease with 1.5 cm primary tumor and abnormal lymph node

Strong family history, BRCA negative

Diagnostic Workup:

Screening MRI showing multifocal disease

Biopsies confirming invasive ductal carcinoma and nodal involvement

Treatment Course:

Neoadjuvant AC + paclitaxel/trastuzumab

Bilateral mastectomy with expander placement

Sentinel node biopsy error (biopsied node not retrieved)

Second axillary surgery to retrieve clipped node

Post-Surgical Pathology:

Pathologic response in node; residual breast disease (max 5 mm)

No lymphovascular invasion; negative margins

Radiation Therapy Decision-Making:

Patient hesitant due to limited arm mobility post-surgery

Concern for career-ending lymphedema

B-51 trial implications and controversy in adjuvant RT after neoadjuvant chemo

Multidisciplinary Team Dynamics:

Discrepancy in treatment advice across institutions

Emphasis on clear communication and planning

Clinical Trial Data Discussion:

NSABP B-51 trial findings (presented, not yet published)

Discussion of subgroup outcomes, mastectomy vs. lumpectomy relevance

Limitations of current data and lack of subgroup stratification

Technical Considerations:

Radiation planning with expander implants

Use of hypofractionation

Contraindications to proton therapy

Bolus application and field targeting

Ethical and Practical Concerns:

Informed consent regarding treatment risks and benefits

Balancing long-term benefit with short-term functional loss

The challenge of interpreting and communicating evolving trial data

Additional Questions Raised:

Radiation approaches for patients refusing surgery post-chemotherapy

Partial breast irradiation in mutation carriers (e.g., CHEK2, BRCA)