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Borm KJ, Oechsner M, Combs SE, Duma MN. Deep-Inspiration Breath-Hold Radiation Therapy in Breast Cancer: A Word of Caution on the Dose to the Axillary Lymph Node Levels. Int J Radiat Oncol Biol Phys 2017; 100:263-269. [PMID: 29066123 DOI: 10.1016/j.ijrobp.2017.09.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/26/2017] [Accepted: 09/14/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE To assess the differences in unintended regional nodal irradiation between free breathing (FB) and deep-inspiration breath-hold (DIBH) during tangential field irradiation. METHODS AND MATERIALS We randomly chose 32 patients from our database who underwent both DIBH and FB treatment planning. Contouring of the axillary lymph node levels (LI, LII, and LIII) was performed retrospectively according to the Radiation Therapy Oncology Group contouring atlas. We assessed the center of mass of each level and the planning target volume, as well as the dose distribution (Dmean, Dmedian, Dmax, Dmin, V30, and V40) in the lymph node levels I-III. Subsequently center of mass movement and dose changes due to deep inspiration treatment planning were calculated. RESULTS All lymph node levels showed significant (P<.001) movement in anterior and cranial directions due to DIBH. The overall median movement (range) in the x (lateral), y (anterior-posterior), and z (cranio-caudal) directions was 0.1 cm (0.0-1.1 cm), 0.9 cm (0.1-2.0 cm), and 1.2 cm (0.0-2.6 cm), respectively. Movement of the planning target volume showed significant correlation (r=0.72, r=0.63, r=0.63; P<.05) with levels I-III. The average Dmean during FB/DIBH was as follows: LI 33.9 Gy/30.8 Gy (P<.001), LII 23.7 Gy/24.1 Gy (P=.74), and LIII 14.0 Gy/15.6 Gy (P=.14). V30 was as follows: LI 63.8%/56.5% (P<.001), LII 44.6%/45.5% (P=.76), and LIII 24.2%/27.8% (P<.05). V40 was as follows: LI 58.9%/51.0% (P<.001), LII 39.3%/40.1% (P=.79), and LIII 20.4%/23.9% (P<.05). CONCLUSIONS Deep-inspiration breath-hold results in a significant dose reduction in level I. Only minor changes in dose distribution were recorded for levels II and III. Thus, DIBH seems to have an impact on unintended regional nodal irradiation as compared with FB.
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Affiliation(s)
- Kai Joachim Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany; Institute of Innovative Radiotherapy, Helmholtz Zentrum München, Oberschleißheim, Germany
| | - Marciana-Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany; Institute of Innovative Radiotherapy, Helmholtz Zentrum München, Oberschleißheim, Germany.
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Halpern MT, Chen AY, Marlow NS, Ward E. Disparities in Receipt of Lymph Node Biopsy Among Early-Stage Female Breast Cancer Patients. Ann Surg Oncol 2008; 16:562-70. [DOI: 10.1245/s10434-008-0205-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 09/25/2008] [Accepted: 09/26/2008] [Indexed: 11/18/2022]
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Abstract
BACKGROUND Breast cancer is a major source of morbidity and mortality in elderly women. Despite this, many trials on which clinical practice is based have under-represented the elderly. Consequently there is little evidence to guide best practice in this age group. METHODS A search of the major literature databases was performed using the search terms 'breast cancer' and 'elderly'. Articles relevant to the treatment of breast cancer in the elderly were selected. RESULTS The elderly receive less aggressive treatment for breast cancer compared with younger patients. Primary endocrine therapy is sometimes substituted for operation, and axillary surgery, adjuvant chemotherapy and adjuvant radiotherapy are commonly omitted. Evidence for and against such treatment strategies is inadequate, making it difficult to determine what constitutes best practice. CONCLUSION There is a need for research to be targeted at the older age group of patients with breast cancer to enable the development of specific treatment guidelines.
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Affiliation(s)
- L Wyld
- Academic Surgical Oncology Unit, University of Sheffield, K Floor, Royal Hallamshire Hospital, Glossop Road, UK
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Bourez RLJH, Rutgers EJT, Van De Velde CJH. Will we need lymph node dissection at all in the future? Clin Breast Cancer 2002; 3:315-22; discussion 323-5. [PMID: 12533260 DOI: 10.3816/cbc.2002.n.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Traditionally in the treatment of primary breast cancer, axillary lymph node dissection (ALND) plays an important role. However, a substantial and increasing percentage of patients appear to have no nodal involvement and have been subjected to ALND unnecessarily. The first reason to perform an ALND is axillary nodal staging. After reviewing the literature, it can be concluded that in clinically node-negative patients an adequately conducted lymphatic mapping by sentinel node procedure is equal to ALND for this purpose. The second reason to perform an ALND is to establish the extent of nodal involvement, which might have an impact on adjuvant treatment recommendations. However, there is no evidence available that patients with extensive nodal involvement (= 4 positive nodes) benefit more from adjuvant systemic treatment (either standard or high dose) in terms of reduction of odds of recurrence and mortality compared to patients with limited nodal involvement and optimally administered so-called standard adjuvant treatment. The third reason to perform an ALND is to ensure axillary tumor control. Reviewing the different treatment options, it can be concluded that in clinically node-negative patients axillary control after axillary radiotherapy appears to be similar to axillary control after ALND. In clinically overt axillary involvement, ALND (with or without adjuvant radiotherapy) may result in an improved regional control. In the near future, ALND will not be the standard of care but will be reserved for those patients with proven axillary lymph node involvement. In microscopic disease, radiotherapy may be an alternative with equal control and less morbidity.
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Affiliation(s)
- Robert L J H Bourez
- Department of Radiology, Medical Center Haaglanden, The Hague, The Netherlands
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McCormick B, Botnick M, Hunt M, Petrek J. Are the axillary lymph nodes treated by standard tangent breast fields? J Surg Oncol 2002; 81:12-6; discussion 17-8. [PMID: 12210020 DOI: 10.1002/jso.10148] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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Edge SB, Gold K, Berg CD, Meropol NJ, Tsangaris TN, Gray L, Petersen BM, Hwang YT, Mandelblatt JS. Patient and provider characteristics that affect the use of axillary dissection in older women with stage I-II breast carcinoma. Cancer 2002; 94:2534-41. [PMID: 12173318 DOI: 10.1002/cncr.10540] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Axillary dissection for the evaluation and treatment of patients with breast carcinoma often is not performed in older women. The objective of this study was to examine patient, clinical, and surgeon characteristics associated with the use of axillary dissection after breast-conserving surgery (BCS). METHODS A cohort of 464 women age > or = 67 years who were newly diagnosed with Stage I-II breast carcinoma and who underwent BCS were surveyed along with their 158 surgeons, and their medical records were reviewed. Patient, tumor, and provider characteristics were examined for association with the omission of axillary dissection. RESULTS The majority of women (63.4%) underwent axillary lymph node dissection after BCS. Increasing age was associated strongly with decreasing odds of undergoing axillary lymph node dissection, even after considering patient health and preferences, clinical factors, and provider factors (odds ratio [OR], 0.11; 95% confidence interval [95%CI], 0.05-0.27). Independent of age and other factors, women in the lowest quartile of physical functioning were 37% less likely to undergo axillary lymph node dissection compared with women in the highest quartile (OR, 0.63; 95%CI, 0.62-0.64). Patients who were cared for by surgeons with subspecialty training in oncology were 60% less likely to undergo axillary lymph node dissection compared with patients who were cared for by other surgeons, even after considering other factors (OR, 0.41; 95%CI, 0.25-0.68). CONCLUSIONS The results of this study demonstrated a correlation between lower use of axillary dissection and advancing age, lower functional status, and greater surgeon training. These findings suggest that simple, age-based considerations are important but are not the sole determinants of variations in treatment.
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Affiliation(s)
- Stephen B Edge
- Department of Surgery, Roswell Park Cancer Institute, Buffalo, New York, USA
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Ernst MF, Voogd AC, Balder W, Klinkenbijl JHG, Roukema JA. Early and late morbidity associated with axillary levels I-III dissection in breast cancer. J Surg Oncol 2002; 79:151-5; discussion 156. [PMID: 11870664 DOI: 10.1002/jso.10061] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Axillary dissection may cause substantial morbidity in breast cancer patients. The purpose of this study was to investigate the value of a registration method of morbidity of the arm and shoulder, which is frequently used by surgeons and which includes the measurement of range of movement, strength, and pain. METHODS We surveyed 148 patients who had received an axillary dissection as part of breast cancer surgery. Of these patients, 77 had undergone axillary dissection 6-12 months ago and 71 patients more than 5 years ago. In all patients, an objective measurement of shoulder movement and a subjective measurement of pain and arm strength was performed. RESULTS A difference of more than 20 degrees in abduction, ventral elevation, or dorsal elevation occurred in 12% of the patients. Pain or loss of strength were measured in half of the patients. Shoulder movement, pain, and arm strength were not significantly different between the patients who underwent mastectomy or breast conserving surgery. Also, no significant difference could be found in shoulder movement, pain, and arm strength between the patients who underwent axillary dissection 6-12 months ago and those who underwent it more than 5 years ago. CONCLUSIONS Pain, loss of arm strength, and limitation of shoulder movement are frequent complaints after axillary dissection for breast cancer and appear to be independent of the length of follow-up and the type of surgery (i.e., breast-conservation or mastectomy).
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Affiliation(s)
- Miranda F Ernst
- Department of Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands
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Sakorafas GH, Tsiotou AG, Balsiger BM. Axillary lymph node dissection in breast cancer--current status and controversies, alternative strategies and future perspectives. Acta Oncol 2001; 39:455-66. [PMID: 11041107 DOI: 10.1080/028418600750013366] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Axillary lymph node dissection (ALND) has traditionally been considered as a standard procedure in the surgical management of patients with breast cancer. The goals of ALND in breast cancer surgery are: (a) to provide accurate prognostic information, (b) to maintain local control of the disease in the axilla and (c) to provide a rational basis for decisions about adjuvant therapy. Although controversial, ALND may also be associated with a small therapeutic benefit. Recently, the question of whether ALND is needed for every patient with invasive breast cancer has been the subject of ongoing debate in the literature. This is mainly due to the widespread use of adjuvant systemic therapy for patients with node-negative breast cancer and to the increasingly frequent detection of small invasive cancers by mammographic screening; the majority of these patients have negative axillae. Sentinel lymph node (SLN) biopsy is a new, promising, minimally invasive procedure, which accurately predicts nodal status with minimal morbidity, and reserves ALND for patients with positive SLN biopsies. However, this method is still investigational. Partial (levels I and II) ALND remains the gold standard in the surgical management of patients with breast cancer.
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Affiliation(s)
- G H Sakorafas
- Department of Surgery, Hellenic Air Forces, General Hospital, Athens, Greece.
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Voogd AC, Coebergh JW, Repelaer van Driel OJ, Roumen RM, van Beek MW, Vreugdenhil A, Crommelin MA. The risk of nodal metastases in breast cancer patients with clinically negative lymph nodes: a population-based analysis. Breast Cancer Res Treat 2000; 62:63-9. [PMID: 10989986 DOI: 10.1023/a:1006447825160] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A population-based study was performed to assess the likelihood of axillary lymph node metastases in patients with clinically negative lymph nodes, according to patient age, tumor size and site, estrogen receptor status, histologic type and mode of detection. Data were obtained from the population-based Eindhoven Cancer Registry. During the period 1984-1997, 7680 patients with invasive breast cancer were documented, 6663 of whom underwent axillary dissection. Of the 5125 patients who were known to have clinically negative lymph nodes and underwent axillary dissection, 1748 (34%) had positive lymph nodes at pathological examination. After multivariate analysis, histologic type, tumor size, tumor site and the number of lymph nodes in the axillary specimen remained as independent predictors of the risk of nodal involvement (P < 0.001). Lower risks were found for patients with medullary or tubular carcinoma, smaller tumors, a tumor in the medial part of the breast and patients with less than 16 nodes examined. This study gives reliable estimates of the risk of finding positive lymph nodes in patients with a clinically negative axilla. Such information is useful when considering the need for axillary dissection and to predict the risk of a false-negative result when performing sentinel lymph node biopsy.
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Affiliation(s)
- A C Voogd
- Comprehensive Cancer Center South, Eindhoven, The Netherlands.
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Vlastos G, Fornage BD, Mirza NQ, Bedi D, Lenert JT, Winchester DJ, Tolley SM, Ames FC, Ross MI, Feig BW, Hunt KK, Buzdar AU, Singletary SE. The correlation of axillary ultrasonography with histologic breast cancer downstaging after induction chemotherapy. Am J Surg 2000; 179:446-52. [PMID: 11004328 DOI: 10.1016/s0002-9610(00)00382-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The goal of this study was to examine the role of ultrasonography in detecting axillary lymph node metastases in stage II breast cancer patients after induction chemotherapy (IC). METHODS Of 172 consecutive patients with T1-3, N0-1, M0 breast cancer registered in a prospective IC trial, a subset of 130 evaluable patients were chosen, with (1) both physical and ultrasonographic examinations of the axilla before and after IC; (2) exactly four cycles of IC; (3) no presurgical radiation therapy; and (4) an axillary lymph node dissection. RESULTS Before IC, 32 patients (25%) were negative for axillary involvement by both physical and ultrasonographic examinations. After IC, this number increased to 64 (49%). Of these, 31 (48%) were positive by pathology examination. In most cases, however, the residual tumor was minimal. CONCLUSIONS Stage II breast cancer patients who were or became node negative by both ultrasonographic and physical examinations after IC had a 48% incidence of nodal metastases. Because the residual tumor was minimal, irradiation may be sufficient for adequate local control of the axilla.
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Affiliation(s)
- G Vlastos
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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Crowe P, Temple W. Management of the axilla in early breast cancer: is it time to change tack? THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 2000; 70:288-96. [PMID: 10779062 DOI: 10.1046/j.1440-1622.2000.01801.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The standard surgical treatment of the axilla in patients with early breast cancer is about to undergo a radical change. Although axillary dissection is an excellent procedure for both staging and local control, particularly in the clinically positive axilla, it has considerable morbidity and may understage a significant proportion of patients, because it will usually miss micrometastases that can occur in approximately 10% of 'node negative' patients. An increasing number of patients whose tumours are either non-invasive (ductal carcinoma in situ; DCIS), micro-invasive, tubular cancers or low-grade T1a tumours without lymphovascular invasion may be spared axillary surgery because the risk of axillary disease is 0-3%. Many studies, both prospective trials and large retrospective series, show that axillary radiotherapy alone provides similar local control rates to axillary dissection in patients with clinically negative axillas. Primary treatment of the axilla with radiotherapy alone, however, does not allow appropriate staging. Sentinel lymph node biopsy is being increasingly used in patients with breast cancer to provide this information. When a sentinel node is identified it is equal to or better than axillary dissection for staging the axilla and, if the node is positive, it will help select patients who should then proceed to further axillary surgery or axillary radiotherapy. Although sentinel lymph node biopsy is being rapidly adopted in many centres worldwide, the results of randomized controlled trials are needed before it can be recommended as the standard of care.
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Affiliation(s)
- P Crowe
- Tom Baker Cancer Centre, Calgary, Alberta, Canada.
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