Selective avoidance of lymphatic radiotherapy in the conservative management of early breast cancer

Tangential vs. defined radiotherapy in early breast cancer treatment without axillary lymph node dissection: a comparative study

PURPOSE

Recent studies have demonstrated low regional recurrence rates in early-stage breast cancer omitting axillary lymph node dissection (ALND) in patients who have positive nodes in sentinel lymph node dissection (SLND). This finding has triggered an active discussion about the effect of radiotherapy within this approach. The purpose of this study was to analyze the dose distribution in the axilla in standard tangential radiotherapy (SRT) for breast cancer and the effects on normal tissue exposure when anatomic level I-III axillary lymph node areas are included in the tangential radiotherapy field configuration.

PATIENTS AND METHODS

We prospectively analyzed the dosimetric treatment plans from 51 consecutive women with early-stage breast cancer undergoing radiotherapy. We compared and analyzed the SRT and the defined radiotherapy (DRT) methods for each patient. The clinical target volume (CTV) of SRT included the breast tissue without specific contouring of lymph node areas, whereas the CTV of DRT included the level I-III lymph node areas.

RESULTS

We evaluated the dose given in SRT covering the axillary lymph node areas of level I-III as contoured in DRT. The mean VD95% of the entire level I-III lymph node area in SRT was 50.28% (range, 37.31-63.24%), VD45 Gy was 70.1% (54.8-85.4%), and VD40 Gy was 83.5% (72.3-94.8%). A significant difference was observed between lung dose and heart toxicity in SRT vs. DRT. The V20 Gy and V30 Gy of the right and the left lung in DRT were significantly higher in DRT than in SRT (p<0.001). The mean heart dose in SRT was significantly lower (3.93 vs. 4.72 Gy, p=0.005).

CONCLUSION

We demonstrated a relevant dose exposure of the axilla in SRT that should substantially reduce local recurrences. Furthermore, we demonstrated a significant increase in lung and heart exposure when including the axillary lymph nodes regions in the tangential radiotherapy field set-up.

Axillary Irradiation as an Imperative Alternative to Axillary Dissection in Clinically Lymph Node-Negative but Sentinel Node-Positive Breast Cancer Patients?

At the moment, positive sentinel lymph node dissection (SLND) of the axilla is followed by axillary lymph node dissection (ALND) as standard of care. Recent data proves that omitting ALND after positive SLND in clinically lymph node-negative early stage breast cancer patients is feasible with low recurrence rates. The well known effect of radiotherapy to destroy occult tumor cells highly contributes to these results as a large extent of level I and II lymph nodes are unavoidably included in standard tangential radiation treatment fields. Reviewing the up to date published data on axillary lymph node treatment with radiotherapy, we hypothesize that full dosage coverage of level I and II of the axilla in early stage breast cancer will improve outcome and should be further evaluated.

Dosimetry and field matching for radiotherapy to the breast and supraclavicular fossa

PURPOSE

Early breast cancer radiotherapy aims for local disease control and reduced recurrence. Treatment is directed to breast or chest wall alone using tangential fields, or includes regional lymph nodes with a separate anterior field. The complex geometry of this region necessitates matching adjacent radiation fields in three-dimensions. Potential exists for overdosage or underdosage and cosmetic results may be compromised if fields are not accurately aligned.

METHODS AND MATERIALS

A study of dosimetry across the match line region using different techniques, as reported in the multicentre START Trial Quality Assurance programme, was undertaken. A custom-made anthropomorphic phantom assessed dose distribution in three-dimensions using film dosimetry.

RESULTS

Methods with varying degrees of complexity were employed for field matching. Techniques combined half beam blocking and machine rotations to achieve geometric alignment. Asymmetric beam matching allowed use of a single isocentre technique. Where field matching was not undertaken a gap between tangential and nodal fields was employed. Results demonstrated differences between techniques and variations for similar techniques in different centres. Geometric alignment techniques produced more homogenous dose distributions in the match region than gap techniques or those techniques not correcting for field divergence.

CONCLUSIONS

Field matching techniques during the START trial varied between centres. Film dosimetry used in conjunction with a breast-shaped phantom provided relative dose information. The study highlighted difficulties in matching treatment fields to achieve homogenous dose distribution through the region of the match plane and the degree of inhomogeneity as a consequence of a gap between treatment fields.

Matching supraclavicular fields to the extent of axillary surgery in women prescribed radiotherapy for early stage carcinoma of the breast

AIMS

To determine (1) if the lower border of a standard anterior radiotherapy field to the supraclavicular fossa matches the upper limit of level II/III axillary dissection; and (2) whether standard lung blocks in patients prescribed axillary radiotherapy shield target axillary tissue in women with breast cancer.

MATERIALS AND METHODS

Between 1999 and 2001, 30 women with breast cancer undergoing level II/III axillary dissection had titanium clips placed to define the upper and medial limits of surgery. At radiotherapy planning, a supraclavicular fossa field similar to that described in the UK START trial protocol was simulated, with head twist applied to position the inferior field border (50% isodose) 1 cm below and parallel to the lower border of the clavicle. The field position was recorded on X-ray film. The location of the most superior axillary clip was measured in relation to this inferior field border on the X-ray film. The location of the most medial clip was measured in relation to the lung/chest wall interface.

RESULTS

The median distance between the most superior clip and the inferior border of the supraclavicular field was 3.6 cm (0.8-6.9 cm), representing significant underlap in all cases. In addition, five out of 30 (17%) patients had surgical clips over 2.0 cm medial to the lung/chest wall interface, suggesting that medial lymph nodes in an undissected axilla would be shielded by standard lung blocks in patients prescribed axillary radiotherapy.

CONCLUSION

Current standard radiation fields to the supraclavicular fossa, as applied in this study, leave apical axillary lymph nodes untreated in a high proportion of patients. Standard lung shielding, as applied in this study to patients simulated for axillary radiotherapy, protect medial axillary lymph nodes in a few patients. A change in practice is recommended.

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

BACKGROUND

The role of axillary lymph node dissection (AxD) for patients with breast carcinoma who have clinically negative lymph nodes (cN0) and undergo breast-conserving therapy has been controversial. If patients do not undergo AxD, then it is uncertain whether specific lymph node irradiation should be given. The authors compared the results obtained from patients w ho underwent AxD with the results from patients who received axillary irradiation (AxR) using one of two radiotherapy techniques.

METHODS

Patients with T1-T2cN0 breast carcinoma were treated from 1983 to 2002 with either AxD (80 patients) or AxR (1134 patients received tangential-field [2-field] irradiation, and 303 patients received 3-field irradiation). The median follow-up was 161 months for the AxD group and 66 months for the AxR group (55 months for patients who received tangential-field irradiation, and 122 months for patients who received 3-field irradiation).

RESULTS

One patient in the AxD group and 35 patients in the AxR group had axillary recurrences. The 10-year cumulative axillary recurrence rates were 1.3% and 4.6% for the AxD group and the AxR group, respectively (P = 0.21). For patients with T1 tumors, the 10-year overall survival rates for the two groups were 94.7% and 92.7%, respectively (P = 0.34); and, for patients with T2 tumors, the 10-year overall survival rates were 92.5% and 89.1%, respectively (P = 0.34). In the AxR group, the 5-year axillary recurrence rates were 2.5% for patients who received tangential-field irradiation and 1.7% for patients who received 3-field irradiation (P = 0.18), and the 5-year regional recurrence rates for the two groups were 4.8% and 2.4%, respectively (P = 0.048). On multivariate analysis, positive lymphovascular invasion, outer tumor location, and larger tumor size were significant risk factors for regional failure.

CONCLUSIONS

For patients with cN0 breast carcinoma, AxD and AxR yielded the same overall survival rates. Most patients can be treated safely with tangential-field irradiation alone. Patients who are at increased risk of regional failure may benefit from three-field irradiation.

Breast cancer: improving outcome following adjuvant radiotherapy

In the treatment of early breast cancer adjuvant irradiation improves local control following both mastectomy and breast-conserving surgery. For women at high risk of relapse it also increases survival. Breast radiotherapy is usually given using simple planning techniques and serious morbidity is unusual. The greatest concern following adjuvant breast irradiation is of an increase in cardiovascular mortality after 15-20 years. New techniques of breast irradiation including conformal radiotherapy and intensity-modulated radiotherapy (IMRT) have been shown to reduce cardiac and lung irradiation. In addition, improved dosimetry within the breast may improve both local control and cosmesis. To replace current radiotherapy techniques with those requiring more complex planning would demand an increase in resources including both machinery and staff. In this review we outline the indications and benefits of breast radiotherapy along with the planning process. Technical advances are discussed within the context of improving outcome at a time of limited national resources.

T1-T2 Breast Cancer with Four or More Positive Axillary Lymph Nodes: Adjuvant Locoregional Radiotherapy with High-Dose or Standard-Dose Chemotherapy. Results of an Observational Study

Aim and background

The aim of this study was to investigate the efficacy of postoperative locoregional radiotherapy in patients with T1-T2 breast cancer and four or more positive axillary lymph nodes submitted to mastectomy or breast-conserving surgery followed by standard-dose or high-dose adjuvant chemotherapy. The incidence of locoregional relapses and the survival correlated with the number of positive nodes were recorded for each treatment arm.

Patients and methods

From August 1992 to August 1999 86 breast cancer patients (median age, 54 years, T1-T2, N+ >4) submitted to surgery were treated. Sixty-three patients received standard-dose chemotherapy while 23 patients with 10 or more positive nodes received high-dose chemotherapy. After four courses of standard-dose anthracycline-based chemotherapy peripheral blood stem cells were mobilized with cyclophosphamide (7g/m2) and G-CSF (10-16 μg/kg/day/sc). High-dose chemotherapy consisted of etoposide 1000 mg/m2, thiotepa 500 mg/m2 and carboplatin 800 mg/m2. Hormone receptor-positive patients underwent hormone therapy. Following chemotherapy all 86 patients were given conventional radiotherapy to the breast or the chest wall and the supraclavicular fossa. The high-dose subgroup received radiotherapy to the internal mammary nodes ± axilla. Results: The median follow-up from the start of radiotherapy was 36.5 months. Locoregional relapses occurred in nine patients (10.4%); in four of them they were isolated (4.6%). Local relapses were four (4.6%) and regional relapses six (6.9%). Twenty-five patients (29%) had distant metastases. The five-year and eight-year overall actuarial survival rates were 82.6% ± 4.8 and 60.1% ± 8.8, respectively. No statistical differences were found when the number of positive nodes or the type of treatment of N+ 10 patients was included in the analysis.

Conclusions

Breast cancer patients with four or more positive axillary lymph nodes are at high risk of developing locoregional and distant relapses. The results reported here demonstrate the efficacy of radiotherapy in the reduction of locoregional failure; no differences in survival and locoregional control in relation to treatment arm and number of positive nodes were found.

Evaluation of novel modified tangential irradiation technique for breast cancer patients using dose–volume histograms

PURPOSE

We have previously reported that entire axillary lymph node regions could be irradiated by the modified tangential irradiation technique (MTIT). In this study, MTIT was compared with a conventional irradiation technique (CTIT) using dose-volume histograms to verify how adequately MTIT covers the breast and axillary lymph node region and the extent to which it involves the lung and heart.

METHODS AND MATERIALS

Forty-four patients with early-stage breast cancer were treated by lumpectomy, axillary dissection, and postoperative radiotherapy. Twenty-two patients were treated with MTIT and 22 with CTIT. In 25 patients, the breast tumor was on the left and in 19 on the right. During axillary dissection, surgical clips were left as markers at the border of the axillary lymph node region. MTIT was planned by setting the dorsal edge of the radiation field on a lateral-view simulator film at the dorsal edge of the humeral head and the cranial edge of the radiation field at the caudal edge of the humeral head. CTIT was planned to ensure radiation of the breast tissue without considering the axillary region. In this study, all patients underwent computed tomography, and the CT data were transmitted on-line to a radiotherapy planning system, in which the dose-distribution computed tomography images and dose-volume histograms were calculated by defining the breast, axillary region (levels I, II, and III), lung, and heart region.

RESULTS

Dose-volume histogram analysis demonstrated that breast tissue was radiated with an 86.5-100% volume (median 96.5%) by MTIT and an 83-100% volume (median, 95%) by CTIT at >95% of the isocenter dose. The axillary lymph node regions at Levels I, II, and III were irradiated with 84-100% (median, 94.5%), 59-100% (median, 89%), and 70-100% (median, 89.5%) volumes, respectively, by MTIT and with 2-84% (median, 38%), 0-53% (median, 15%), and 0-31% (median, 0%) volumes, respectively, by CTIT at >70% of the isocenter dose. The ipsilateral lung was irradiated with a 5-22% volume (median, 11.5%) by MTIT and 5-15% volume (median 9%) by CTIT at >90% of the isocenter dose. In all 25 left-sided breast cancer patients, the volumes irradiated with an 80% isocenter dose were <30 cm(3).

CONCLUSION

The results of our study demonstrated that the breast tissue was sufficiently irradiated with both CTIT and MTIT planning, the axillary lymph node areas irradiated by MTIT were much wider than those irradiated by CTIT at all levels, and the lung and heart volumes irradiated by MTIT were small.

Are the axillary lymph nodes treated by standard tangent breast fields?

BACKGROUND AND OBJECTIVES

With the increasing use of sentinel lymph node biopsy, a growing proportion of women with early-stage invasive breast cancer are undergoing breast conserving surgery without a formal axillary lymph node dissection. A frequent question raised is whether the level I-II axillary lymph nodes are treated with standard breast tangent fields. In an attempt to answer this question, surgical clips placed at the time of the level I-II axillary lymph node dissection were used as a surrogate for the location of the nodes and the simulator films for tangent fields of 45 patients were analyzed.

METHODS

Study criteria were as follows: five or more clips placed in the axilla, and all clips and the humeral head visualized on the medial tangent film. Clips were scored as "in" or "out" of the tangent field, as defined by the delineator wires. All technical parameters were analyzed to determine whether any reproducible techniques would consistently include all of the clips and, hypothetically, the axillary nodes at levels I and II.

RESULTS

All clips were included in the medial tangent breast radiation field in only 38% (17 of 45) of cases.

CONCLUSIONS

The standard, two-field tangent breast fields do not reliably encompass the all level I-II axillary lymph nodes as defined by this study, but some of the nodes were treated in all 45 cases.

Observation of the breast cancer patient with a tumor-positive sentinel node: implications of the ACOSOG Z0011 trial

Axillary lymph node status has been the most important prognostic factor for breast cancer throughout the past century. During the past decade, intraoperative lymphatic mapping with sentinel lymph node dissection (SLND) has been investigated as an alternative staging modality. This technique may be as accurate as ALND, and certainly is less invasive. Adjuvant treatment recommendations, which historically were made on the basis of lymph node status alone, now take into account primary tumor features, molecular markers, and patient characteristics. This evolution of current treatment patterns is driven in part by the diminishing size of tumors, the simultaneous decrease in the presence of axillary metastases, and a better understanding of tumor-specific risk factors. How do these trends affect the interpretation of a tumor-positive sentinel node (SN)? Can an axilla with a positive SN be observed? Should it be observed? This review examines the implications of a positive SN in the context of smaller tumor size, decreased nodal disease, and increased reliance on alternative prognostic factors for treatment decisions. The historical data comparing ALND to no ALND in clinically node-negative patients is reviewed and discussed in the context of observation for a positive SN. These are the issues underlying the ACOSOG Z0010 and Z0011 trials.

An audit of indications and techniques for supraclavicular fossa irradiation in early breast cancer in the United Kingdom

This article describes an audit of the indications and techniques used by clinical oncologists in the United Kingdom (UK) in the delivery of adjuvant radiotherapy to the supraclavicular fossa (SCF) in patients with early breast cancer. A postal questionnaire was sent to one consultant clinical oncologist in each UK radiotherapy centre in November 1999. These were the same individuals listed in the Maher Committee Report as providing breast cancer services. Forty-one out of 51 completed forms were returned. The results show significant variation in the indications for SCF irradiation and for the definition of the radiotherapy target volume. We discuss the possible basis for the variations found in the audit. There was broad agreement on technique, in particular on the need for matching the tangential and SCF fields and maintaining patient position between fields, factors that are likely to minimize serious morbidity, including brachial plexus injury.

Omitting axillary surgery for low-risk breast cancer patients--a Swedish prospective cohort study

The effects of mammography screening are a decrease in the sizes of tumours and a shift in stage. Very few small breast cancers (< or = 10 mm) have lymph node metastases when screening-detected, the rate being as low as 7%. Axillary clearance is not necessary for all such small tumours. A Swedish prospective cohort study, scheduled for 1500 patients, is being launched, where axillary surgery is omitted for screening-detected breast cancers of < or = 10 mm showing Elston grade I or II/and/or S-phase < or = 10%. Axillary surgery, with the associated disadvantages, will not be performed in 970 women out of 1000 expecting an axillary recurrence rate of 3%. Nordic breast cancer centres are welcome to join the study, which has already recruited around 500 patients.

Adjuvant radiotherapy in breast cancer--the treatment of lymph node areas

Adjuvant radiotherapy decreases the risk of locoregional recurrences threefold, according to the results of many randomized trials and overviews. In patients treated with total mastectomy, the risk of local recurrence is mainly related to the number of involved axillary nodes, i.e. about 25%, 35% and 55% at 10 years when 1-3, 4-9 and 10 or more nodes are involved, respectively. In contrast, at 10 years, less than 15% of patients with negative axillary nodes relapse locally. The effect of adjuvant radiotherapy on distant metastases and overall survival is a controversial issue. On the one hand, recent results are compatible with the existence of a mechanism of secondary dissemination generated from locoregional tumor nests. The beneficial effect of radiotherapy can be observed whether with or without adjuvant systemic treatment. On the other hand, a deleterious late toxic effect, mainly cardiac, has also been shown. The importance of improvements in radiation techniques and quality assurance to obtain a positive balance in terms of overall survival is emphasized.

The relationship between lymphatic vessell invasion, tumor size, and pathologic nodal status: can we predict who can avoid a third field in the absence of axillary dissection?

PURPOSE

Tangential (2-field) radiation therapy to the breast and lower axilla is typically used in our institution for treating patients with early-stage breast cancer who have 0-3 positive axillary nodes, as determined by axillary dissection, whereas a third supraclavicular/axillary field is added for patients with 4 or more positive nodes. However, dissection may result in complications and added expense. We, therefore, assessed whether clinical or pathologic factors of the primary tumor could reliably predict, in the absence of an axillary dissection, which patients with clinically negative axillary nodes have such limited pathologic nodal involvement that they might be effectively treated with only tangential fields. This would eliminate both the complications of axillary dissection and the added complexity and potential morbidity of a supraclavicular/axillary field.

METHODS AND MATERIALS

In this study, 722 women with clinical Stage I or II unilateral invasive breast cancer of infiltrating ductal histology, with clinically negative axillary nodes, at least 6 lymph nodes recovered on axillary dissection, and central pathology review were treated with breast-conserving therapy from 1968 to 1987. Pathologic nodal status was assessed in relation to clinical T stage, the presence of lymphatic vessel invasion (LVI), age, histologic grade, and the location of the primary tumor.

RESULTS

LVI, T stage, and tumor location were each significantly correlated with nodal status on univariate analysis. Ninety-seven percent of LVI-negative patients had 0-3 positive axillary nodes compared to 87% of LVI-positive patients. There was no association between T stage and extent of axillary involvement within LVI-negative and LVI-positive subgroups. In a logistic regression model, only LVI remained a significant predictor of having 4 or more positive nodes, although tumor size was of borderline significance. The odds ratio for LVI (positive vs. negative) as a predictor of having 4 or more positive nodes was 3.9 (95% CI, 2.0-7.6).

CONCLUSION

For patients with clinical T1-2, N0, infiltrating ductal carcinomas, the presence of LVI is predictive of having 4 or more positive axillary nodes. Only 3% of patients with clinical T1-2, N0, LVI-negative breast cancers had 4 or more positive nodes on axillary dissection. Such patients may be reasonable candidates for treatment with tangential radiation fields in the absence of axillary dissection.

Regional node failure in patients with four or more positive lymph nodes submitted to conservative surgery followed by radiotherapy to the breast

A retrospective analysis was conducted to evaluate the incidence of nodal failure in a subgroup of patients who had T1-T2 breast cancer and four or more positive nodes. Sixty-four 5 patients ranging in age from 29 to 73 years (median, 51) received conservative surgery followed by radiotherapy to the breast between November 1980 and May 1995. Adjuvant chemotherapy was administered to 56 patients, 27 of whom were also treated with tamoxifen, which was used alone in 5 patients. Three patients received no adjuvant treatment. Sixty-two patients are evaluable for regional node failure. There were 10 nodal failures, 4 in the axillary and 6 in the supraclavicular regions, in 9 patients, at a median of 56.5 and 27 months, respectively. There was no internal mammary node failure. Median follow-up was 72.6 months. The 10-year probability of developing axillary and supraclavicular failure is 13.9 +/- 7.7% and 10.5 +/- 4.1%, respectively. Prognosis was better for patients with axillary and breast recurrence and worse when relapse was in the supraclavicular region. On the basis of our results and data already published in premenopausal patients, we believe that radiotherapy to the supraclavicular region should be considered in patients with four or more positive axillary nodes, after a complete dissection.

Adjuvant Radiation after Modified Radical Mastectomy for Breast Cancer Fails to Prolong Survival

Recent literature has reported improved local disease control and overall survival in premenopausal node-positive (stage II, and HI) breast cancer patients undergoing modified radical mastectomy (MRM) using radiation therapy (RT) combined with chemotherapy. To assess the efficacy of postoperative RT in our own community, we analyzed all patients undergoing MRM for carcinoma utilizing an extensive database from the three major teaching hospitals in Tulsa, OK, between 1965 and 1993. A total of 5257 patients underwent MRM during this time period. One hundred thirty-seven patients were excluded for insufficient data or because they were found to be at stage IV, leaving a total study population of 5125. Overall survival (OS), overall mean survival (MS), disease-free survival (DFS), and locoregional DFS (LRDFS) were analyzed for all patients and were further analyzed according to stage, lymph node involvement, and menopausal status. Median follow-up was 103 months. Statistical analysis was performed using Kaplan-Meier and t-tests. The DFS at 10 years was 65 per cent in the RT group and 80 per cent in the patients who did not receive RT ( P = 0.00). No improved DFS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. Similarly, the LRDFS at 10 years was 91 per cent in the RT group and 96 per cent in the patients who did not receive RT ( P = 0.00). No improved LRDFS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. The overall MS was 97 months in the RT group and 104 months in the patients who did not receive RT ( P = 0.00). Comparisons of overall MS rates revealed apparent survival benefits from RT in the premenopausal node-negative group, postmenopausal one to four-positive-node group, and all stage I patients. This apparent survival advantage was not confirmed by Kaplan-Meier curves of OS. No other overall MS differences were detected according to stage, lymph node, or menopausal status. Using Kaplan-Meier survival curves, the OS in the RT group at 10 years was 46 per cent, and 63 per cent in the patients who did not receive RT ( P = 0.00). No improved OS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. These findings from a large breast cancer database failed to demonstrate any meaningful benefit from RT after MRM and serve to further question the efficacy of this treatment modality in postmastectomy breast cancer patients.

Internal mammary node relapse following breast conservation: a case for reirradiation

Internal mammary node involvement in early breast cancer is a prognostic factor of uncertain significance. This paper addresses isolated regional recurrence at this site following breast conservation radiotherapy. A case is presented of a woman who developed an internal mammary recurrence after lumpectomy and breast irradiation. This recurrence was diagnosed as a bone metastasis, a common mistake which may lead to suboptimal management. The true incidence of regional recurrences in the internal mammary nodes has been underestimated and their clinical significance has not been appreciated. Salvage procedures for local control and long-term cure are likely to be successful if the diagnosis is made before distant metastases have occurred and a lengthy period has elapsed since initial treatment was given. The role of reirradiation should be considered as the tissues at this site will generally tolerate a second course of radical radiotherapy given more than 10 years after the first.

Selective avoidance of lymphatic radiotherapy in the conservative management of women with early breast cancer

BACKGROUND AND PURPOSE

Until recently, elective treatment of the lymphatic pathways in women with early invasive breast cancer was assumed to impact on quality of life rather than on overall survival. In a multidisciplinary breast clinic these considerations underpinned a policy of observation of the lymphatic pathways if axillary lymph nodes were not palpably enlarged and if recommendations for adjuvant systemic therapy did not depend on knowledge of pathological node status. This paper evaluates the long-term outcome of the observation policy in terms of lymphatic morbidity due to cancer recurrence.

MATERIAL AND METHODS

Seven hundred and fifty-nine patients with operable breast cancer and suitable for breast conserving surgery were seen between January 1984 and December 1994. Of these, 291 (38.3%) were recommended a policy of observation to the lymphatic pathways. The case records of these patients were reviewed to record regional relapse patterns and morbidity.

RESULTS

At a median follow up of 60 months, 32/291 (11%) patients suffered ipsilateral lymphatic relapse at some stage prior to death or last follow up, representing a 22% actuarial 10-year risk of lymphatic relapse. Metastases coincided with, or preceded, lymphatic relapse in 8/32 (25%) patients. Eighteen out of 32 (56%) patients suffered symptoms of lymphatic relapse prior to death or last follow up, despite subsequent surgery, radiotherapy and/or systemic therapies. The absolute risk of symptomatic ipsilateral lymphatic relapse in the observation group was 18/291 (6.2%), representing an actuarial 10-year risk of 17%.

CONCLUSION

A policy of observation on the axilla with deferred treatment of lymphatic relapse has benefited 273/291 (94%) patients, but at the expense of cancer-related regional morbidity in 18 (6%) patients. We conclude that the cancer-related morbidity suffered by a minority of patients and the strengthening evidence of an overall survival benefit conferred by elective local-regional therapy favours a policy of elective treatment of the lymphatic pathways in the routine setting.

Postmastectomy radiotherapy: randomized trials

Postmastectomy radiotherapy decreases threefold the risk of locoregional recurrences according to the results of many randomized trials and overviews. This risk is mainly related to the number of involved axillary nodes (ie, about 25%, 35%, and 55% at 10 years when 1 to 3, 4 to 9, and 10 or more nodes are involved). In contrast, at 10 years, fewer than 15% of patients with negative axillary nodes relapse locally. The effect of postmastectomy radiotherapy on distant metastases and overall survival is a controversial issue. On the one hand, results are compatible with the existence of a mechanism of secondary dissemination generated from locoregional tumor nests. The beneficial effect of radiotherapy may be observed in the absence or presence of adjuvant systemic treatment. On the other hand, a deleterious late toxic, mainly cardiac, effect of radiation has also been shown. This point emphasizes the importance of radiation technique and quality to obtain a positive balance in terms of overall survival.

Lymphatic relapse in women with early breast cancer: a difficult management problem

The aim of this study was to review the ability to control symptoms of regional lymphatic relapse in women with early breast cancer. A retrospective study was made of 759 consecutive women presenting with stage 1 or 2 breast cancer treated by breast conserving surgery and radiotherapy between June 1984 and December 1994, 291 (38.3%) of whom were managed by a policy of observation on the lymphatic pathways. Patterns of lymphatic relapse, relapse management and morbidity caused by recurrent malignancy were reviewed from the case notes. The overall rate of relapse in the ipsilateral axilla and/or supraclavicular fossa was 76/759 (10%) at any time prior to death or last follow-up. 34 of 65 patients who relapsed in the axilla did so despite prior axillary surgery and/or radiotherapy. 41 of 76 patients with regional recurrence presented with symptoms, including lymphoedema, arm pain or sensory motor changes. These symptoms were poorly controlled by palliative surgery, radiotherapy or systemic therapy in 23 cases, including 12 who progressed to arm paralysis. Symptomatic control of patients with regional lymphatic relapse can be very difficult, even in women under regular surveillance in a multidisciplinary breast cancer clinic.

Axillary lymph node involvement in stage III breast cancer: treatment implications

BACKGROUND AND OBJECTIVES

The introduction of multimodal therapy has improved the prognosis in stage III breast cancer. A knowledge of the likely axillary lymph node status at presentation is important, both to plan surgical therapy to the axilla and to establish the effect of induction therapy on the axillary nodes.

METHODS

The study involved a chart review of 114 patients with stage III breast cancer who were treated by modified radical mastectomy without prior systemic therapy. A standard method was used for axillary dissection and numbers and levels of pathologically involved lymph nodes were recorded. The incidence of lymph node metastases was correlated with tumour size, grade, and clinical T stage. The accuracy of clinical axillary staging and the relationship between level III invasion and the number of level I and II nodes invaded was also assessed.

RESULTS

Overall, 96 of 114 (84%) patients had axillary nodal metastases, and 37 of 114 (32%) patients had level III metastases. Eighteen of 43 tumours (42%) 30 mm or less had level III metastases and 27% of larger tumours had level III metastases (6/25 31-49-mm tumours, and 12/42 50+-mm tumours). Of 98 gradable cancers, only 1 out of 10 well-differentiated tumours had level III metastases, but the rate in moderately and poorly differentiated tumours was 36% (19/53) and 37% (13/35), respectively. Clinical node staging was unreliable. A group of patients with a low likelihood of level III metastases who might benefit from an axillary procedure less than level III dissection could not be identified preoperatively.

CONCLUSIONS

Patients with stage III breast cancer have a high incidence of level III axillary lymph node metastases. A subgroup with a low incidence of level III metastases could not be identified in this study. Until axillary downstaging has been convincingly demonstrated with induction therapy, a less than complete axillary procedure may leave the patient at high risk of axillary relapse.

The importance of local-regional radiotherapy with conventional or high-dose chemotherapy in the management of breast cancer patients with > or = 10 positive axillary nodes

PURPOSE

To assess the effect of local-regional radiotherapy (RT) on the outcome of breast cancer patients with > or = 10 positive axillary lymph nodes who have received modern conventional or high-dose systemic therapy.

METHODS AND MATERIALS

A total of 55 women with local-regionally confined breast cancer involving 10 or more axillary nodes were treated between October 1983 and January 1996. Local-regional therapy consisted of modified radical mastectomy in 39 and breast-conserving surgery in 16. Postoperative radiotherapy was given to 44 of the 55 patients. Radiotherapy consisted of tangential fields to the chest wall or intact breast to a median dose of 50.40 Gy. A total of 86% (38 of 44) received regional nodal irradiation as follows: 35 patients received RT to the supraclavicular (SC) region and axillary midplane to a median dose of 50.40 Gy and 46.20 Gy, respectively; 3 patients received RT to the SC region without inclusion of the axilla to a median dose of 50. 40 Gy. All patients received adjuvant standard-dose systemic chemotherapy, 9 of whom received additional intensification chemotherapy followed by autologous bone-marrow transplant (ABMT) or peripheral blood stem-cell transplant (PBSC). Twenty-five patients received adjuvant tamoxifen.

RESULTS

With a median follow-up of 30 months, the crude overall survival (OS) and disease-free survival (DFS) for the entire group were 67% and 53%, respectively. On univariate analysis of various clinical, pathological, and therapy-related features, radiotherapy emerged as the most important factor influencing the relapse rate. The addition of RT was significantly associated with an improved DFS (p = 0.003), specifically by prolonging the time to disease progression. The median time to failure was 61 months and 12.5 months with and without RT, respectively. Patients receiving RT also appeared to survive longer; however, the groups were not statistically different (p = 0.10). Analysis of the patterns of failure showed local-regional recurrence (LRR) as the first site of failure in 12 (22%) of 55 and distant failure in 20 (36%) of 55. Univariate results revealed both radiotherapy and tamoxifen to be significantly associated with decreased LRR rates (p = 0.0001 and p = 0.03, respectively); only RT remained independently significant on multivariate analysis.

CONCLUSION

Local-regional radiotherapy is an essential component of the management of breast cancer patients with extensive nodal involvement, despite the use of contemporary adjuvant chemotherapy including high-dose regimens with autologous rescue. In addition to the expected improvement in LRR, radiotherapy is also associated with significantly prolonged DFS and a trend for improvement in OS.

An update on radiation therapy in breast cancer

Radiation therapy plays an important role in the management of both invasive and noninvasive breast cancer. During the last 20 years, the availability of radiation therapy has made it possible to test the feasibility and safety of breast preservation after the diagnosis of early-stage breast cancer. This article summarizes some of the ongoing controversies concerning the use of radiation therapy in the multidisciplinary management of breast cancer.

Modern trends in breast cancer therapy: towards less lymphoedema?

AIMS

To review from the evidence, with special reference to axillary node management, whether the incidence of lymphoedema following breast cancer treatment is falling in modern breast practice.

CONCLUSIONS

The incidence of lymphoedema does seem to be reducing with modern approaches to breast cancer management. Axillary treatment seems to determine its development but more studies looking specifically at this problem are needed.

The role of regional nodal irradiation in the management of patients with early-stage breast cancer treated with breast-conserving therapy

PURPOSE

To determine the incidence of regional nodal failure (RNF) and indications for regional nodal irradiation (RNI) in patients with Stage I and II breast cancer treated with breast-conserving therapy (BCT).

METHODS AND MATERIALS

Four hundred fifty-six patients with Stage I/II breast cancer were treated with BCT at William Beaumont Hospital. All patients underwent excisional biopsy and 288 (63%) were reexcised. A Level I/II ipsilateral axillary lymph node dissection was performed on 431 patients (95%). Pathologically involved nodes were found in 106 (23%) cases (69 with one to three nodes and 37 with > or = four nodes involved). All patients received whole breast irradiation (median dose 50 Gy) and 415 (91%) were boosted to the tumor bed (median total dose 60.4 Gy). Three hundred and sixty (79%) patients received breast alone irradiation and 96 (21%) also received RNI. The median axilla/supraclavicular fossa dose was 50 Gy.

RESULTS

With a median follow-up of 83 months, 15 patients developed a RNF for a 5- and 8-year actuarial rate of 3 and 4%, respectively. The 5- and 8-year actuarial rates of axillary failure (AF) were 0.7 and 1.0%, respectively. The incidence of RNF or AF was not affected by the use of RNI in N0 or N1 patients with one to three positive nodes. Only in patients with four or more positive nodes was there a trend towards improved regional control with RNI (p = 0.09). However, patient numbers were extremely small, and this improvement was limited to a reduction in the rate of failure in the supraclavicular fossa (SCF) (20 vs. 0%, p = 0.04). Multiple clinical, pathologic, and treatment related factors were analyzed for an association with AF. On univariate analysis, AF was associated with the number of lymph nodes excised (p < 0.0001) estrogen receptor status (p = 0.0016), and pathologic node status (p = 0.0021).

CONCLUSIONS

Regional nodal failure as the first site of failure is uncommon in patients with early-stage breast cancer treated with BCT with < or = three positive lymph nodes and appears unaffected by RNI. For patients with four or more positive lymph nodes, a trend towards improved RNF was noted with RNI, primarily in the SCF. However, patient numbers were extremely small in all subsets analyzed. Additional studies are needed to further define the need for RNI in these patients and help determine other factors associated with RNF.

Treatment outcome after tangential radiation therapy without axillary dissection in patients with early-stage breast cancer and clinically negative axillary nodes

PURPOSE

To determine the risk of nodal failure in patients with early-stage invasive breast cancer with clinically negative axillary lymph nodes treated with two-field tangential breast irradiation alone, without axillary lymph node dissection or use of a third nodal field.

METHODS AND MATERIALS

Between 1988 and 1993, 986 evaluable women with clinical Stage I or II invasive breast cancer were treated with breast-conserving surgery and radiation therapy. Of these, 92 patients with clinically negative nodes received tangential breast irradiation (median dose, 45 Gy) followed by a boost, without axillary dissection. The median age was 69 years (range, 49-87). Eighty-three percent had T1 tumors. Fifty-three patients received tamoxifen, 1 received chemotherapy, and 2 patients received both. Median follow-up time for the 79 survivors was 50 months (range, 15-96). Three patients (3%) have been lost to follow-up after 20-32 months.

RESULTS

No isolated regional nodal failures were identified. Two patients developed recurrence in the breast only (one of whom had a single positive axillary node found pathologically after mastectomy). One patient developed simultaneous local and distant failures, and six patients developed distant failures only. One patient developed a contralateral ductal carcinoma in situ, and two patients developed other cancers.

CONCLUSION

Among a group of 92 patients with early-stage breast cancer (typically T1 and also typically elderly) treated with tangential breast irradiation alone without axillary dissection, with or without systemic therapy, there were no isolated axillary or supraclavicular regional failures. These results suggest that it is feasible to treat selected clinically node-negative patients with tangential fields alone. Prospective studies of this approach are warranted.

The Roles and Controversies of Radiation Therapy in Breast Conserving Therapy for Breast Cancer

Breast conserving therapy (BCT) is defined as a combination of conservative surgery for resection of the primary tumor, followed by radiation therapy (RT) for the eradication of residual microscopic disease in the breast. At NIH Consensus Development Conference in 1990, BCT was recognized as the preferred treatment for the majority of women with Stage I and II breast cancer. RT is a potent locoregional treament and its role in BCT in reducing local recurrence is already established. On the other hand, the influence of RT on survival outcome has not yet been closely demonstrated so far. RT appears to be useful as neoadjuvant therapy, and also as exclusive local treatment for patients achieving complete regression (CR) after neoadjuvant chemotherapy. The other possible role of RT is to use it as an alternative to axillary dissection in patients with clinically uninvolved nodes. The question of the appropriateness of using RT in all BCT cases is raised. Since the subgroup of patients who would not deserve any benefit by RT has not yet identified, RT should be delivered as standard treatment following breast conserving surgery for early stage breast cancer.

Long-term outcome in patients with four or more positive lymph nodes treated with conservative surgery and radiation therapy

PURPOSE

The purpose of this study was to review management strategies with respect to systemic therapy, radiation therapy treatment techniques, and patient outcome (local regional control, distant metastases, and overall survival) in patients undergoing conservative surgery and radiation therapy (CS + RT) who had four or more lymph nodes involved at the time of original diagnosis.

METHODS AND MATERIALS

Of 1040 patients undergoing CS + RT at our institution prior to December 1989, 579 patients underwent axillary lymph node dissection. Of those patients undergoing axillary lymph node dissection, 167 had positive nodes and 51 of these patients had four or more positive lymph nodes involved and serve as the patient population base for this study. All patients received radiation therapy to the intact breast using tangential fields with subsequent electron beam boost to the tumor bed to a total median dose of 64 Gy. The majority of patients received regional nodal irradiation as follows: 40 patients received RT to the supraclavicular region without axilla to a median dose of 46 Gy, 10 patients received radiation to the supraclavicular region and axilla to a median dose of 46 Gy. Thirty of the 51 patients received a separate internal mammary port with a mixed beam of photons and electrons. One patient received radiation to the tangents alone without regional nodal irradiation. Adjuvant systemic therapy was used in 49 of the 51 patients (96%) with 27 patients receiving chemotherapy alone, 14 patients receiving cytotoxic chemotherapy and tamoxifen, and 8 patients receiving tamoxifen alone.

RESULTS

As of December 1994, with a minimum evaluable follow-up of 5 years and a median follow-up of 9.29 years, there have been 18 distant relapses, 2 nodal relapses, and 5 breast relapses. Actuarial statistics reveal a 10-year distant metastases-free rate of 65%, 10-year nodal recurrence-free rate of 96%, and a 10-year breast recurrence-free rate of 82%. All five patients who sustained a breast relapse were successfully salvaged with mastectomy. Both patients with nodal relapses (one supraclavicular and one axillary/supraclavicular) failed within the irradiated volume. Of the 40 patients treated to the supraclavicular fossa (omitting complete axillary radiation), none failed in the dissected axilla. With a median follow-up of nearly 10 years, 29 of the 51 patients (57%) remain alive without evidence of disease, 15 (29%) have died with disease, 2 (4%) remain alive with disease, and 5 (10%) have died without evidence of disease. Overall actuarial 10-year survival for these 51 patients is 58%.

CONCLUSIONS

We conclude that in patients found to have four or more positive lymph nodes at the time of axillary lymph node dissection, conservative surgery followed by radiation therapy to the intact breast with appropriate adjuvant systemic therapy results in a reasonable long-term survival with a high rate of local regional control. Omission of axillary radiation in this subset of patients appears appropriate because there were no axillary failures among the 41 dissected but unirradiated axillae.

Isolated axillary recurrences after conservative treatment of breast cancer

This retrospective study presents the diagnostic, prognostic and therapeutic problems raised by axillary recurrences (AR). 1589 cases of breast cancer measuring less than 3 cm, treated at the Institut Curie between 1981 and 1987, were studied by a combination of surgery and radiotherapy. Treatment of the breast always included wide local excision associated with irradiation. The axilla was treated either by dissection (865 cases) or by irradiation (724 cases) and 159 patients received chemotherapy. 26 patients (2%) developed AR, confirmed by fine needle aspiration cytology in 92% of cases. None of these 26 patients had initially received chemotherapy. The treatment of the AR was variable, adapted to the initial treatment. 22 patients retained their breast during treatment of the AR and none subsequently developed a local recurrence. 4 mastectomies were performed and histological examination revealed a subclinical local recurrence in 2 cases. The TNM classification, menopausal status, size of the tumour and hormonal receptor status were not risk factors for AR. Young age (P = 0.01) and high histological grade (P = 0.03) were significant risk factors for AR. The AR rate was similar whether axillary dissection or axillary irradiation had been performed. The overall 5-year survival after initial treatment was 85% for AR and 95% for the reference population. The overall 4-year survival after recurrence was 69% and the incidence of metastasis was markedly increased (P = 0.002). 2 of the 26 patients developed lymphoedema of the arm after treatment of AR. We confirm that AR worsens the prognosis, but not significantly more than local recurrence. Young age and the modified histological grading of Scarff Bloom and Richardson were risk factors for AR. Although excision of the AR is necessary to ensure local control, mastectomy is unnecessary when clinical examination and mammography are normal.

Factors affecting acute skin toxicity in patients having breast irradiation after conservative surgery: a prospective study of treatment practice at the Royal Marsden Hospital

The results are presented of a prospective study of acute skin toxicity in 197 patients with early stage breast cancer, who were treated by conservative surgery and postoperative radiotherapy. We have examined the factors determining the severity of the acute skin reaction with particular reference to the degree of dry or moist desquamation at the completion of treatment. One hundred and ten patients had treatment with radiotherapy alone. The remaining 87 received synchronous chemotherapy with breast irradiation, using either the 3M or the 2M regimen, consisting of mitoxantrone and methotrexate, with (3M) or without Mitomycin-C (2M). Patients were analysed according to both the severity and the site of the skin reaction, age, dose, dose variation across the central outline, treatment technique, beam energy, field separation and breast size. A univariate analysis of these results, which has been presented as an odds ratio of the likelihood of developing a moderate or severe reaction in comparison with those scored as mild, has shown that several factors are associated with an increase in the acute skin reaction. These include the use of the semi-supine technique (odds ratio (OR) = 7.3 (95% CI 3.7-14.6)), beam energy (60Co: 6-10 MV photons OR = 5.9 (95% CI 2.6-13.4)), field separation (> or = 20 cm: < 20 cm OR = 4.1 (95% CI 2.2-7.8)), dose variation across the central outline (> or = 10%: < 10% OR = 9.7 (95% CI 2.6-36.4)), inclusion of the axilla (OR = 4.6 (95% CI 2.4-8.9)), and bust size (bra cup size C and D: A and B OR = 4.6 (95% CI 2.7-11.9)). Using multivariate logistic regression, the technique of radiation delivery and bust size were shown to be independently significant variables affecting acute skin reaction. In view of the high correlation between variables (e.g. radiotherapy technique and beam energy) it is still not possible to specify with definite certainty which is the primary variable causing the skin reaction. However 20/57 (35%) of patients treated by the semisupine technique sustained a severe skin reaction, with > 10% dry or moist desquamation in the treatment field. This compares with only 6/140 (4%) patients treated by the supine method. A possible mechanism by which treatment using the semisupine technique may enhance acute toxicity is discussed. We conclude that there are both treatment and patient related factors that will increase the acute skin reaction after breast irradiation.

Axillary lymph nodes and breast cancer: a review

BACKGROUND

The value of surgical staging and treatment of the axillary lymph nodes with either surgery or radiotherapy in the initial management of patients with Stage I or II invasive breast cancer is controversial.

METHODS

A review of retrospective and prospective clinical studies was performed to assess the risks of axillary lymph node involvement and the effectiveness and morbidity of various treatment options.

RESULTS

The risk of axillary lymph node involvement is substantial for most patients, even those with small tumors. The morbidity resulting from a careful Level I/II axillary dissection or moderate-dose axillary radiotherapy is limited. Such treatment is highly effective in preventing axillary recurrence. The symptoms resulting from axillary failure can be controlled in many, but not all, patients. The available data suggest, but do not prove, that the initial use of effective axillary treatment may result in a small improvement in long term outcome in some patient subgroups.

CONCLUSIONS

Most patients should be treated with either axillary surgery or irradiation. Highly selected subgroups of patients may have such low risks of involvement that specific axillary treatment is of little value. However, such subgroups have not yet been well defined. Treatment approaches that do not involve specific axillary treatment should be considered investigational at present, and the patients should be informed as to their potential risks. Prospective clinical studies of these issues should be pursued.

Radiotherapy and the management of the axilla in early breast cancer

The role of radiotherapy in the management of the axilla in early breast cancer is examined. A few, carefully selected, clinically node-negative postmenopausal women may require no intervention to the axilla. Otherwise, surgical clearance is the preferred sole management of the axilla, resulting in an excellent level of local control and providing optimal information for the use of systemic adjuvant therapy. Axillary radiotherapy can also provide equivalent levels of long-term control in the clinically node-negative axilla, but the chronic disabling syndrome of brachial plexopathy is documented at all radiation doses that can sterilize microscopic disease, irrespective of the radiotherapy technique. A combination of radiotherapy and axillary surgery results in an increased morbidity rate compared with either alone. Women who receive radiotherapy to the breast alone are not at risk of brachial plexopathy.

Prediction of axillary lymph node metastases in a screened breast cancer population. South-East Sweden Breast Cancer Group

To define a subgroup of patients, in whom axillary dissection could be omitted, we analysed the frequency of pathologically confirmed lymph node metastases depending on tumour size, hormonal receptors, DNA ploidy, S-phase fraction (SPF), and clinical nodal status among 1,145 patients with stage I-II breast cancer from an area with ongoing screening. Clinical nodal status and tumour size were strongly correlated to pathological nodal status. Also SPF > 10% was strongly correlated to node positivity in univariate analysis. In multivariate analysis there was still a significant correlation among cases with tumour size < or = 20 mm. In conclusion, patients with clinically negative nodal status, and tumour size < or = 20 mm and < or = 10 mm had pathologically positive nodes in 25% and 15% of cases respectively. The addition of SPF did not lower these figures significantly since small tumours with high SPF are few.

Prophylactic supraclavicular fossa radiotherapy in early breast cancer: is it worthwhile?

A total of 291 consecutive patients with early breast cancer who did not receive any supraclavicular prophylactic irradiation of the ipsilateral fossa have been followed for a minimum of 5 years. Isolated relapse in that site occurred in 4.5% of patients and was controlled by radical radiotherapy with a post-relapse 5-year survival of 33%. Relapse with co-existing distant metastases occurred in a further 7% and no patient survived to 3 years. Supraclavicular fossa irradiation contributes to morbidity, does not improve survival and should be abandoned in favour of delayed treatment for proven recurrence.