Postoperative periclavicular radiotherapy in breast cancer patients with 1–3 positive axillary lymph nodes

Effect of post-mastectomy radiation therapy on survival in breast cancer with lymph nodes micrometastases: a meta-analysis and systematic review

Background

Axillary management of patients with early-stage breast cancer (ESBC) has evolved, especially with the implementation of precision radiotherapy techniques that have resulted in a significant reduction in treatment-related toxicities, but it is unclear whether post-mastectomy radiotherapy (PMRT) improves survival outcomes in breast cancer with lymph nodes micrometastases (BCLNMM, that is T0, T1 ~2NmiM0). Our study is to systematically evaluate the effect of PMRT on survival in breast cancer with lymph nodes micrometastases.

Methods

A literature search was performed for randomized controlled trials (RCTs) or retrospective studies related to PMRT versus non-post-mastectomy radiotherapy (non-PMRT) in the adjuvant treatment of ESBC in PubMed, Cochrane Library, Embase, CNKI and other databases. R package meta software was used to perform meta-analyses with hazard ratio (HR). Newcastle Ottawa scale was selected for quality assessment. The review was prospectively registered on PROSPERO (CRD42024562444).

Results

10 relevant studies were screened, all of which were retrospective studies. The difference in overall survival (OS) was not statistically significant (HR = 0.92, 95%CI: 0.81 ~ 1.04; Z = 1.35, P = 0.177). The difference in breast cancer-specific survival (BCSS) between the PMRT group and the non-PMRT group was not statistically significant HR = 1.18, 95%CI: 0.94 ~ 1.48; Z = 1.41, P =0.160). The difference in disease-free survival (DFS) was statistically significant (HR = 0.47, 95%CI: 0.23 ~ 1.00; Z = 1.96, P =0.049). The difference in local recurrence free survival (LRRFS) was also not statistically significant (HR = 0.50, 95%CI: 0.11 ~ 2.26, P = 0.190). The difference in distant-metastasis free survival (DMFS) was not statistically significant (HR = 0.54, 95%CI: 0.22 ~ 1.35, P = 0.356).

Conclusions

Despite the tendency of PMRT in BCLNMM to improve DFS, OS, BCSS, LRRFS, and DMFS showed no benefit, therefore, PMRT should be used with caution in BCLNMM.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024562444.

Regional nodal irradiation in pT1-2N1 breast cancer patients treated with breast-conserving surgery and whole breast irradiation

Purpose

To evaluate the necessity of regional nodal irradiation (RNI) for pT1-2N1 breast cancer patients treated with breast-conserving surgery and radiotherapy, we compared clinical outcomes of patients treated with and without RNI.

Materials and Methods

We retrospectively analyzed the data of 214 pT1-2N1 breast cancer patients treated with breast-conserving surgery and whole breast irradiation from 2007–2016. There were 142 (66.4%), 51 (23.85%), and 21 (9.8%) patients with one, two, and three positive lymph nodes, respectively. Thirty-six patients (16.8%) underwent RNI. Adjuvant chemotherapy, endocrine therapy, and anti-HER2 therapy were given to 91.6%, 79.0%, and 15.0% patients, respectively. The most common chemotherapy regimen was anthracycline + cyclophosphamide, followed by taxane (76.5%). The median follow-up was 64 months (range, 6 to 147 months). Patients were propensity matched 1:2 into RNI and no-RNI groups.

Results

Two patients experienced locoregional recurrences simultaneously with distant metastases, ten patients developed distant metastases, and one patient died. Before matching, the 5-year actuarial locoregional control (LRC), distant metastasis-free survival (DMFS), and overall survival (OS) rates in the RNI and no-RNI groups were 100.0% and 99.4% (p = 0.629), 94.1% and 96.0% (p = 0.676), and 100.0% and 99.4% (p = 0.658), respectively. After matching, the 5-year LRC, DMFS, and OS were 98.3% and 100.0% (p = 0.455), 96.6% and 93.9% (p = 0.557), and 100.0% and 100.0% (p > 0.999) in the RNI and no-RNI groups, respectively. No clinicopathologic or treatment-related factors were significantly associated with LRC, DMFS, or OS.

Conclusion

Adding RNI did not show superior LRC, DMFS, or OS in pT1-2N1 breast cancer patients.

Outcomes in Patients with pT1-T2, pN0-N1 Breast Cancer After Conservative Surgery and Whole-breast Radiotherapy

AIM

To evaluate locoregional recurrence, overall survival, disease-free survival and prognostic influence of the number of positive lymph nodes and other variables in breast cancer treatment.

PATIENTS AND METHODS

A total of 377 patients with pT1-T2, pN0-N1 invasive breast carcinoma treated from 2005 to 2013 were retrospectively evaluated. Patients underwent conservative surgery followed by whole-breast radiotherapy. Clavicular region irradiation was not performed.

RESULTS

With a median follow-up of 4 years, locoregional recurrence rate was 3.4% (nodal recurrence=1.06%). Expression of progesterone receptors was significantly associated with better disease-free survival, tumor size (T>2 cm) with poorer disease-free survival, locoregional recurrence and poorer overall survival; the presence of three nodal metastases was related to significantly poorer overall survival (p=0.024).

CONCLUSION

Whole-breast adjuvant radiotherapy without nodal irradiation after breast-conserving surgery led to low rate of locoregional recurrence and high rates of overall survival and disease-free survival in patients with pT1-T2 pN0-N1 breast cancer.

Predictive Value of Molecular Subtyping for Locoregional Recurrence in Early-Stage Breast Cancer with N1 without Postmastectomy Radiotherapy

PURPOSE

This study was designed to investigate the relationship between molecular subtype and locoregional recurrence (LRR) in patients with early-stage breast cancer with 1-3 positive axillary lymph nodes (ALNs) and improve the individualized indications for postmastectomy radiotherapy (PMRT).

METHODS

The records of 701 patients with pT1-2N1M0 breast cancer who did not undergo PMRT were retrospectively analyzed. Tumors were subclassified as follows: luminal A, luminal B, human epidermal growth factor receptor 2 (HER2)-enriched, and basal-like subtypes. Multivariate Cox analysis was used to determine the risk of LRR associated with the different subtypes and to adjust for clinicopathologic factors.

RESULTS

Luminal A, luminal B, HER2-enriched, and basal-like subtypes accounted for 51.2%, 28.0%, 8.1%, and 12.7% of cases, respectively. The median follow-up duration was 67 months (range, 9-156 months). Univariate analysis revealed that, compared with the luminal A subtype, the HER2-enriched and basal-like subtypes were associated with significantly higher 5-year LRR rates (5.6% vs. 21.6% and vs.15.7% respectively; p=0.002 each), lower 5-year LRR-free survival (LRFS) rates (90.6% vs. 73.8% and 78.5%, respectively; p=0.001 each), and poorer 5-year breast cancer-specific survival (BCSS) rates (93.7% vs. 82.2% [p=0.002] and 84.9% [p=0.001], respectively). Multivariate analysis revealed that the HER2-enriched and basal-like subtypes, age ≤35 years, a medial tumor, and pT2 stage were poor prognostic factors for LRR and LRFS; furthermore, 2 to 3 positive ALNs represented an independent prognostic factor affecting LRR. The 10-year LRR rates of patients with 0, 1, 2, 3, and 4 risk factors were 1.0%, 6.9%, 14.3%, 30.4%, and 54.3%, respectively (p<0.001); the 10-year BCSS rates were 86.6%, 88.5%, 84.4%, 79.7%, and 38.8%, respectively (p<0.001).

CONCLUSION

Molecular subtyping allows for individualized evaluation of LRR risk in patients with pT1-2N1M0 breast cancer. PMRT should be recommended for patients with ≥3 LRR risk factors.

Supraclavicular and infraclavicular lymph node delineation in breast cancer patients: a proposal deriving from a comparative study

AIMS AND BACKGROUND

Current advances in radiotherapy for breast cancer require knowledge of the anatomy of irradiated areas to minimize geographic miss and spare organs at risk. This study aimed at defining a contouring approach for supraclavicular (SC) and infraclavicular (IC) nodes after mastectomy or conservative surgery in patients with breast cancer.

METHODS AND STUDY DESIGN

In 15 patients, SC and IC nodes were contoured on computed tomography slices according to Madu et al and Dijkema et al. After analyzing relapse sites, as reported by Reed et al, our approach was defined. The 3 methods were compared in all patients, quantifying differences in contours by percentage overlap (PO).

RESULTS

In our approach, SC node delineation is similar to Madu et al in the ventral and medial landmarks, but includes the lateral SC nodes described by Dijkema et al. The lateral landmarks are the scalenus anterior and medius muscle lateral border and the clavicle. Dorsal boundaries are the scalenus anterior and medius muscle ventral and lateral surfaces and the subclavian artery ventral border. In IC node delineation, major differences emerged in cranial and dorsal limits which, in our approach, are the pectoralis minor muscle upper edge and the subclavian axillary artery ventral side. Our mean and median volumes and POs were between the other 2 methods.

CONCLUSIONS

This study contributes to standardizing draining node contouring, so as to reduce variability and minimize geographic miss.

Influence of surgical margins on the outcome of breast cancer patients: a retrospective analysis

OBJECTIVE

Breast-conserving surgery has become the preferred treatment for early breast cancer. Yet the question of what constitutes a 'safe margin', in terms of impact on patient outcome, remains unanswered. Our aim was to address this knowledge gap by determining the prevalence of positive and narrow margins after breast-conserving surgery, and evaluating how margin status impacted local recurrence and overall survival.

MATERIALS AND METHODS

We collected data about all women who underwent breast-conserving cancer surgery in our department between 2002 and 2011, focusing on patient and tumor characteristics, the distance from the tumor to the surgical margin, therapies administered, and outcome (measured in terms of local recurrence and overall survival). Data were analyzed by R (version 3.0.1), considering p < 0.05 as significant. Multivariate analyses were also performed.

RESULTS

Of 1,192 women who received breast-conserving surgery, 264 were considered for widening; 111 of these patients had positive margins and 153 narrow (where narrow was defined as less than 5 mm). Widening was performed for 38 % of these patients (99/264) and mastectomy for 27 % (70/264), while 36 % (95/264) had no further surgery and were simply followed-up. Our multivariate analysis confirmed that local tumor recurrence and overall survival were not significantly influenced by margin status, either at initial surgery, or (for those patients with initially positive margins) at secondary margin-widening surgery. However, the following were found to be significantly correlated with local recurrence: tumor multifocality, high expression of Ki-67/Mib-1, comedo-like necrosis, and non-axillary lymph node positivity (p < 0.05).

CONCLUSIONS

We found the status of resection margins and the management of infiltrated or narrow margins to have no significant influence on local tumor recurrence rates or on overall patient survival. Instead, biological factors connected with tumor aggressiveness seem to play the most important role in breast cancer prognosis, independent of surgical radicality.

Benefit of post-mastectomy radiotherapy of the supra-/infraclavicular lymphatic drainage area in breast cancer patients

BACKGROUND

This study investigated the survival benefit of radiotherapy (RT) of the supra- and infraclavicular lymphatic drainage area in Chinese women with T1-2N1M0 breast cancer receiving mastectomy.

METHODS

A total of 593 cases were retrospectively reviewed from 1998 to 2007. The relationship between supra- or infraclavicular fossa relapse (SCFR) and post-operative RT at the supra-/infraclavicular lymphatic drainage area was evaluated.

RESULTS

The majority of patients (532/593; 89. 8%) received no RT while 61 patients received RT. The median follow-up was 85 months. Among patients without RT, 54 (10. 2%) developed recurrence in the chest wall or ipsilateral SCFR. However, none of the 61 patients who underwent RT demonstrated SCFR. One patient who received RT (1. 6%) experienced recurrence in the chest wall. Univariate analysis revealed that age and molecular subtype (both P < 0. 05) were two prognostic factors related to supraclavicular and infraclavicular fossa relapse-free survival (SFRFS). Multivariate analysis revealed that only Her-2 positive status (P = 0. 011) was an independent predictor of SFRFS. RT had no influence on distant metastasis (P = 0. 328) or overall survival (P = 0. 541). SCFR significantly affected probability of distant metastasis (P < 0. 001) and overall survival (P < 0. 001).

CONCLUSION

Although RT was not significantly associated with SFRFS, postoperative RT was significantly associated with a lower locoregional (i. e. , supraclavicular/infraclavicular and chest wall) recurrence rate. SCFR significantly influenced distant metastasis-free survival, which significantly influenced the overall survival of T1- 2N1M0 breast cancer patients after mastectomy. Thus, prophylactic RT is recommended in T1-2N1M0 breast cancer patients, especially those who have Her-2 positive lesions.

Outcome of a phase II prospective study on partial breast irradiation with interstitial multi-catheter high-dose-rate brachytherapy

BACKGROUND AND PURPOSE

Partial breast irradiation (PBI) is an alternative to whole-breast irradiation after breast-conserving surgery in selected patients. Until the results of randomized phase III studies are available, phase II studies inform about PBI. We report the 5 year results of a phase II prospective study with PBI using interstitial multi-catheter high-dose-rate brachytherapy (ClinicalTrials.gov Identifier: NCT00499057).

METHODS

Hundred patients received PBI (4 Gy, twice a day for 4 days, until 32 Gy). Inclusion criteria were: age ≥ 40years, infiltrating carcinoma without lobular histology, ductal in situ carcinoma, tumor size ≤ 2.5 cm, negative surgical margins and axillary lymph nodes.

RESULTS

At a median follow-up of 60 months late toxicity occurred in 25 patients; the 5-year probability of freedom from late toxicity was 72.6% (95% CI: 63.7-81.7). Tamoxifen was the only significant risk factor for late toxicity. Cosmetic results, judged by physicians and patients, were good/excellent in 98 patients. Three local relapses (1 true, 2 elsewhere) and 1 regional relapse occurred. The 5-year probability of local or regional relapse-free survival was 97.7% (95% CI: 91.1-99.4) and 99.0% (95% CI: 92.9-99.8), respectively.

CONCLUSION

PBI with interstitial multi-catheter brachytherapy is associated with low relapse and late toxicity rates.

The effects of ECE on the benefits of PMRT for breast cancer patients with positive axillary nodes

BACKGROUND

The purpose of the present study was to retrospectively evaluate the effects of extracapsular extension (ECE) on the benefits of post-mastectomy radiation therapy (PMRT) for groups of patients with varying numbers of positive axillary nodes (1-3, 4-9 and ≥10 positive axillary nodes).

METHODS

A total of 1220 axillary node-positive patients who had received mastectomy were involved in this study. Patients were grouped as 'Radio + /ECE + ', 'Radio-/ECE + ', 'Radio + /ECE-' or 'Radio-/ECE-' according to status of ECE and whether receiving PMRT or not, and were evaluated in terms of local region relapse (LRR) rate. The 5-year and 10-year Kaplan-Meier disease-free survival and overall survival (OS) rates were analyzed.

RESULTS

ECE-positive differed from ECE-negative groups with statistical significance for all comparisons in favor of the ECE-negative group: 5-year locoregional failure-free survival (LRFFS) (82.69% vs 91.83%, P < 0.001), 10-year LRFFS (75.39% vs 90.02%, P < 0.001); 5-year OS (52.12% vs 74.46%, P < 0.001), 10-year OS (35.17% vs 67.63%, P < 0.001). There were no significant effects of ECE on the benefits of PMRT for patients with 1-3 (P = 0.5720), ≥10(P = 0.0614) positive axillary nodes. However, for the group of patients with 4-9 positive axillary nodes, ECE status had a significant effect on the benefits of PMRT with respect to 5-year and 10-year LRFFS (P < 0.05).

CONCLUSION

In our study, regardless of the ECE status, PMRT didn't significantly improve the LRFFS for patients with 1-3 or ≥10 positive axillary nodes. However, for patients with 4-9 positive axillary nodes, ECE could be an important criterion to consider when deciding whether to receive PMRT.