International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationsFactors associated with regional nodal failure in patients with early stage breast cancer with 0–3 positive axillary nodes following tangential irradiation alone
Introduction
The optimal treatment of regional nodes in the setting of breast-conserving surgery and radiation after early stage breast cancer is unknown. Recent randomized trials have suggested that for patients treated with adjuvant systemic therapy, the addition of postmastectomy radiation substantially reduces the risk of regional nodal failure (RNF) 1, 2, 3. However, in the larger Danish trials, the extent of axillary dissection was more limited than commonly used in the United States. As a result, a median of 7 nodes were removed, and a substantial rate of axillary recurrence was seen in the unirradiated patients. Therefore, it is unclear if regional nodal irradiation in patients who have undergone an adequate axillary dissection with negative or 1–3 involved nodes would have a substantial impact on the risk of RNF. Moreover, the benefits of regional nodal irradiation must be balanced against the potential toxicities of such treatment, which include increased risks of radiation pneumonitis (4), brachial plexopathy (5), arm edema (6), long-term cardiac toxicity 7, 8, match line fibrosis (9), and second tumors 10, 11.
Until now, it has been our policy to recommend regional nodal irradiation only to patients with four or more positive nodes because of these concerns regarding toxicities. However, given the results of the randomized studies of postmastectomy radiotherapy, we decided that this question needed to be readdressed. The purpose of this study was to determine the risk of RNF in patients with 0–3 positive axillary lymph nodes treated with breast-conserving surgery, axillary dissection, and tangential radiation fields without nodal irradiation and with or without systemic therapy. We also examined whether particular clinical or pathologic factors were associated with an increased risk of RNF following such treatment.
Section snippets
Methods and materials
From July 1968 to December 1987, 2140 patients without a history of a prior malignancy (except nonmelanoma skin cancer or in situ carcinoma of the cervix) were treated at the Joint Center for Radiation Therapy (JCRT) for Stage I or II invasive breast carcinoma. Patients who presented with synchronous bilateral primary tumors or who had had prior cancer in the opposite breast were excluded from this group. For patients later developing a contralateral tumor, only the first side treated was
Results
By 8 years of follow-up, 86 patients (13%) had a local recurrence as the site of first failure, 123 (18%) had a distant or opposite breast recurrence, 34 (5%) died without recurrence, and 421 (61%) had no evidence of disease (Table 1). RNF was the first site of failure within 8 years for 27 patients (3.9%, exact Poisson 95% confidence interval of 2.65% to 5.5%) (Table 1).
Eight of the 27 patients with RNFs had simultaneous distant metastases and 19 did not (Table 3). Of the 19 patients who
Discussion
This study reports the 8-year crude incidence of regional nodal failure among patients with early stage breast cancer and 0–3 involved axillary nodes treated with breast-conserving surgery, axillary dissection, and tangential radiation without nodal irradiation. In our total cohort, the incidence of regional nodal failure for each specific regional nodal site was 2% or less. The internal mammary nodes were a less common site of failure than the axilla or supraclavicular/infraclavicular fossa
References (21)
- et al.
Post-operative radiotherapy in high-risk postmenopausal breast cancer patients given adjuvant tamoxifenDanish Breast Cancer Cooperative Group DBCG 82c randomised trial
Lancet
(1999) - et al.
Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer
Int J Radiat Oncol Biol Phys
(1992) - et al.
Edema of the arm as a function of the extent of axillary surgery in patients with stage I and II breast cancer treated with primary radiotherapy
Int J Radiat Oncol Biol Phys
(1986) - et al.
Cardiovascular mortality in a randomized trial of adjuvant radiation versus surgery alone in primary breast cancer
Int J Radiat Oncol Biol Phys
(1992) - et al.
Frequency, sites of relapse, and outcome of regional node failures following conservative surgery and radiation for early breast cancer
Int J Radiat Oncol Biol Phys
(1989) - et al.
The impact of extracapsular axillary nodal extension (ECE) with and without irradiation on patterns of failure and survival from breast cancer (Abstr)
Int J Radiat Oncol Biol Phys
(1996) - et al.
Regional nodal management patterns of failure following conservative surgery and radiation therapy for stage I and II breast cancer
Int J Radiat Oncol Biol Phys
(1993) - et al.
Post-operative radiotherapy in high-risk pre-menopausal women with breast cancer who receive adjuvant chemotherapy
N Engl J Med
(1997) - et al.
Adjuvant radiotherapy and chemotherapy in node-positive pre-menopausal women with breast cancer
N Engl J Med
(1997) - et al.
Radiation pneumonitis in breast cancer patients treated with conservative surgery and radiation therapy
Int J Radiat Oncol Biol Phys
(1991)
Cited by (87)
Role of internal mammary node radiation as a part of modern breast cancer radiation therapy: A systematic review
2016, International Journal of Radiation Oncology Biology PhysicsBreast Cancer: Stages I-II
2015, Clinical Radiation OncologyThe Cambridge post-mastectomy radiotherapy (C-PMRT) index: A practical tool for patient selection
2014, Radiotherapy and OncologyRadiotherapy After Mastectomy
2013, Surgical Oncology Clinics of North America
- 1
Dr. Galper is the recipient of a Health Services Research Fellowship from the Agency for Health Care Policy and Research.