Treatment of breast carcinoma in patients with clinically negative axillary lymph nodes using radiotherapy versus axillary dissection

Axillary radiotherapy: an alternative treatment option for adjuvant axillary management of breast cancer

Axillary lymph node dissection is standard management of axilla in invasive breast cancer. Radiotherapy also is important in local treatment. It is controversial as to whether axillary radiotherapy can displace axillary lymph node dissection. We performed a meta-analysis comparing axillary radiotherapy with axillary dissection. No significant difference was observed for disease free survival and overall survival between the radiation group and the dissection group. There was also no significant difference in either the axillary recurrence or the local recurrence between the two groups. But the axillary relapse rate in the radiation group was higher than in the surgery group at five-year follow-up while the local recurrence rate in the surgery group was higher than in the radiation group. A subgroup analysis showed that the difference in the axillary recurrence rate (RR = 0.20, P = 0.01) and local recurrence rate (RR = 4.7, P = 0.01) mainly appeared in the clinical node-positive subgroup. The edema rate in the surgery group was higher than in the radiation group (RR = 2.08, 95%: 1.71–2.54, P < 0.0001). We concluded that radiotherapy may be an alternative treatment option for adjuvant management of the axilla in selected sub-groups of patients.

Is regional nodes radiotherapy an alternative to surgery?

Sentinel node biopsy (SN) in breast cancer treatment was introduced in the mid-1990s in order to be able to stage patients before decision of definitive surgery. Since then, both the pathological examinations of the SN and the systemic adjuvant treatment have improved and cause new challenges in the correct decision making regarding whether or not to radically treat the axilla in case of a positive SN. In SN positive patients, current St. Gallen guidelines support no completion ALND (axillary lymph node dissection) in clinically node-negative patients with 1-2 macrometastatic sentinel nodes operated with breast conservation and receiving tangential field adjuvant radiotherapy (RT). ALND is being questioned due to increased morbidity compared with SN biopsy alone, and to limited long term benefit on disease free survival in selected patients. An alternative to ALND is treating the axilla with nodal RT although this treatment is mostly used as adjuvant treatment after ALND in high risk patients. Few studies have investigated the benefit of nodal RT compared to ALND, and no consensus has yet been reached. Clinical decision making regarding treating the axilla should be based on relevant data, and in this review studies aiming at deciding whether or not and how the axilla should be treated in SN positive patients will be discussed. Furthermore treatment choice will be discussed, since besides ALND, both breast irradiation and nodal irradiation might cure residual disease after SN. Also the issue of improved systemic adjuvant treatment will be discussed in relation to eventually no regional axillary treatment.

Omission of axillary lymph node dissection for clinically node negative early-stage breast cancer patients

BACKGROUND

For clinically node negative (N0) breast cancer patients, sentinel node (SN) biopsy (SNB) is a standard technique and complete axillary lymph node dissection (ALND) remains the standard treatment when the SN is positive. However, the American College of Surgeons Oncology Group Z0011 trial and the International Breast Cancer Study Group 23-01 trial showed that SNB without ALND can offer excellent regional control and equal survival compared with ALND for limited macrometastatic and micrometastatic SN involvement, respectively. We retrospectively evaluated axillary control rates in clinically N0 patients who had no axillary surgical treatment.

METHODS

Data on 158 patients who underwent breast-conserving therapy without any axillary surgical procedure between 1994 and 2010 were extracted. The last follow-up was on May 2013, and the overall median follow-up period was 119.0 months.

RESULTS

Of all 158 patients, 10 (6.3 %) and 3 (1.9 %) developed locoregional and axillary recurrences, respectively. The 10-year locoregional and axillary recurrence rates were 5.8 and 2.1 %, respectively. The 5- and 10-year overall survival rates were 94.0 and 84.8 %, respectively. Cases with axillary recurrence tended to have common risk factors for recurrence.

CONCLUSION

Even if SNB and ALND were omitted, local and regional recurrence rates were very low among clinically N0 patients and were at the same levels shown in recent trials. This suggests that at least ALND might be safely avoided in clinically N0 patients without any obvious risk factors regardless of axillary nodal status after SNB.

Axillary Irradiation with High Tangent Fields for Clinically Node-Negative Breast Cancer: Can 3-D Conformal Radiotherapy with a Field-in-Field Technique Better Control the Axilla?

BACKGROUND

The target volume for postoperative breast irradiation is the remaining breast tissue, and the axillary region is not an intentional target volume.

PATIENTS AND METHODS

Between 2001 and 2009, eligible women with pT1-2cN0/pN0(sn) breast cancer underwent breast-conserving therapy without axillary dissection. Treatment outcomes between 2 radiotherapy planning groups, high tangent fields with 2-dimensional (2-D) simulation-based planning and 3-dimensional (3-D) computed tomography-based planning with a field-in-field technique, were compared. The correlating factors for axillary failure were also calculated.

RESULTS

In total, 678 patients were eligible. As of May 2009, the median follow-up times for the 2-D (n = 346) and 3-D (n = 332) groups were 94 and 52 months, respectively. Patient characteristics were balanced, except for a younger population in the 2-D group and more lymphovascular invasion in the 3-D group. On multivariate analysis, 2-D planning was the only risk factor for axillary failure. In the 2-D and 3-D groups, the 5-year cumulative incidences of axillary failure were 8 (3.1%) and 1 (0.3%) (log-rank p = 0.009), respectively. The respective 5-year overall survival rates were 97.4 and 98.4% (p = 0.4).

CONCLUSION

High tangent irradiation with 3-D planning improved axillary control compared to that with 2-D planning, suggesting that optimizing axillary dose distribution may impact outcomes.

Optimal treatment of the axilla after positive sentinel lymph node biopsy in early invasive breast cancer. Early results of the OTOASOR trial

Introduction: Sentinel lymph node biopsy alone has become an acceptable alternative to elective axillary lymph node dissection in patients with clinically node-negative early-stage breast cancer. Approximately 70 percent of the patients undergoing breast surgery develop side effects caused by the axillary lymph node dissection (axillary pain, shoulder stiffness, lymphedema and paresthesias). Aim: The current standard treatment is to perform completion axillary lymph node dissection in patients with positive sentinel lymph node biopsy. However, randomized clinical trials of axillary dissection versus axillary irradiation failed to show survival differences between the two types of axillary treatment. The National Institute of Oncology, Budapest conducted a single centre randomized clinical study. The OTOASOR (Optimal Treatment of the Axilla – Surgery or Radiotherapy) trial compares completion axillary lymph node dissection to axillary nodal irradiation in patients with sentinel lymph node-positive primary invasive breast cancer. Method: Patients with primary invasive breast cancer (clinically lymph node negative and less than or equal to 3 cm in size) were randomized before surgery for completion axillary lymph node dissection (arm A–standard treatment) or axillary nodal irradiation (arm B–investigational treatment). Sentinel lymph node biopsy was performed by the radio-guided method. The use of blue-dye was optional. Sentinel lymph nodes were investigated with serial sectioning at 0.5 mm levels by haematoxylin and eosin staining. In the investigational treatment arm patients received 50Gy axillary nodal irradiation instead of completion axillary lymph node dissection. Adjuvant treatment was recommended and patients were followed up according to the actual institutional guidelines. Results: Between August 2002 and June 2009, 2106 patients were randomized for completion axillary lymph node dissection (1054 patients) or axillary nodal irradiation (1052 patients). The two arms were well balanced according to the majority of main prognostic factors. Sentinel lymph node was identified in 2073 patients (98.4%) and was positive in 526 patients (25.4%). Fifty-two sentinel lymph node-positive patients were excluded from the study (protocol violation, patient’s preference). Out of the remaining 474 patients, 244 underwent completion axillary lymph node dissection and 230 received axillary nodal irradiation according to randomization. The mean length of follow-up to the first event and the mean total length of follow-up were 41.9 and 43.3 months, respectively, and there were no significant differences between the two arms. There was no significant difference in axillary recurrence between the two arms (0.82% in arm A and 1.3% in arm B). There was also no significant difference in terms of overall survival between the arms at the early stage follow-up. Conclusions: The authors conclude that after a mean follow-up of more than 40 months axillary nodal irradiation may control the disease in the axilla as effectively as completion axillary lymph node dissection and there was also no difference in terms of overall survival. Orv. Hetil., 154(49), 1934–1942.

Outcomes of clinically node-negative breast cancer without axillary dissection: can preserved axilla be safely treated with radiation after a positive sentinel node biopsy?

PURPOSE

We analyzed whether axillary nodal irradiation could control clinically node-negative disease, including those patients with a positive sentinel lymph node biopsy (SLNB), most of whom received regional nodal irradiation. We also evaluated toxicity profiles that resulted from nodal irradiation.

PATIENTS AND METHODS

From 1988 to 2011, 2107 patients with cT1-T2N0M0 breast cancer underwent breast conservation therapy in the absence of axillary dissection: nx group (n = 1548), without any axillary surgery; the sn(-) group (n = 518), with a negative SLNB; and sn(+) group (n = 104), with a positive SLNB.

RESULTS

The median follow-up times were 88, 56, and 55 months for the nx, sn(-), and sn(+) groups, respectively. The nx group had more risk factors than did the other 2 groups in terms of age, grade, or T stage. Ninety-eight percent of the sn(-)group received only tangent irradiation, and 100% and 83% of the sn(+) and nx group, respectively, received additional regional nodal irradiation. The 5-year cumulative incidences of axillary failure and regional nodal failure were 34, 3, and 0 (2.7%, 0.7%, and 0%; P = .02, log-rank test) and 57, 4, and 0 (4.4, 1%, and 0; P = .04), respectively. Overall survival rates in 5 years were 96.4%, 98.9%, and 97.6% (P = .03), respectively. Symptomatic but transient radiation pneumonitis developed in 31, 16, and 6 (2.0%, 3.1%, and 5.7%). Mild arm edema was observed in 1, 4, and 0 (0.06%, 0.8%, and 0%) in the nx, sn(-), sn(+) groups, respectively.

CONCLUSIONS

Treatment without axillary dissection showed excellent outcomes with negligible toxicity for patients with clinically node negative, including those with a positive SLNB. Regional nodal irradiation after a positive SLNB is a reasonable alternative to axillary dissection.

The role of surgery in the management of older women with breast cancer

Standard treatment for early breast cancer usually involves multi-modality treatment with a combination of surgery and one or more adjuvant therapies. These may include chemotherapy, radiotherapy, endocrine therapy and Trastuzumab. The treatment schedule for an individual patient may be complex, prolonged and associated with significant morbidity. The benefits of such regimens are clear to see in the improving mortality statistics for this breast cancer. However, such protocols may not appropriate for all women. Older women (over 70 years) have increasing rates of co-morbidities, reduced life expectancy and generally have more favourable breast cancer disease biology. Competing causes of death mean that they are less likely to die of their breast cancer, stage for stage, than a younger woman. In addition, their tolerance to some of the therapies is reduced which increases treatment related morbidity and reduces the risk to benefit ratio. It may therefore be appropriate to modify treatment protocols in selected older women. This should be done in consultation with the multi-disciplinary team with input from specialists in Medicine for the Elderly. The views and wishes of the patient should be respected during these discussions. This article reviews these issues.

Radiation therapy after breast-conserving surgery

The authors critically reviewed previous articles concerning the significance of breast irradiation following breast-conserving surgery in terms of the following subject items: indications for breast-conserving therapy, the significance and complications of breast irradiation, the timing of the start of breast irradiation, the significance of boost irradiation, the potential improvement of survival with systemic therapy plus breast irradiation, the significance of axillary dissection, indications and the significance of regional nodal irradiation, accelerated hypofractionated radiotherapy, omission of breast irradiation in low-risk patients, and future directions. In addition, our previously reported results of breast irradiation following breast-conserving surgery at the Keio University Hospital are outlined. Our newly developed tangential irradiation technique directed to the axilla and a recently introduced three-dimensional simulation technique for radiotherapy treatment planning are also presented.