Radiation therapy and survival in breast cancer patients with 10 or more positive axillary lymph nodes treated with mastectomy

Nomogram for Predicting the Overall Survival of Patients With Breast Cancer With Pathologic Nodal Status N3

BACKGROUND

Patients with breast cancer with pathologic N3 (pN3) lymph node status have been proven to have a poor prognosis. This study aimed to establish a nomogram to predict overall survival (OS) in patients with pN3 breast cancer.

MATERIALS AND METHODS

The eligible patients from the Surveillance, Epidemiology, and End Results (SEER) database were randomly divided into training and validation cohorts. χ² tests and survival curves were performed to define the consistency between these 2 cohorts. Univariate and multivariate logistic regressions were carried out to identify the independent clinicopathologic factors of patients with pN3 breast cancer. A nomogram was developed and validated internally and externally by a calibration curve and compared with the seventh edition American Joint Committee on Cancer TNM staging classification in discrimination ability.

RESULTS

Race, age at diagnosis, marital status, grade, T stage, N stage, breast cancer subtype, surgery, radiotherapy, and chemotherapy were independent predictive factors of OS in pN3 breast cancer. We developed a nomogram to predict 1-, 3-, and 5-year OS and further validated it in both cohorts, demonstrating better prediction capacity in OS than that of the seventh edition American Joint Committee on Cancer TNM staging classification (area under the curve in the receiver operating characteristic curve, 0.745 and 0.611 in the training cohort and 0.768 and 0.624 in the validation cohort, respectively).

CONCLUSION

We have developed and validated the first nomogram for predicting the survival of pN3 breast cancer. This nomogram accurately and reliably predicted the OS of patients with pN3 breast cancer. However, more prognostic factors need to be further explored to improve the nomogram.

A retrospective prognostic evaluation analysis using the 8th edition of the American Joint Committee on Cancer staging system for breast cancer

Purpose

Breast cancer is a group of diseases with different intrinsic molecular subtypes. However, anatomic staging alone is insufficient to determine prognosis. The present study analyzed the prognostic value of the American Joint Committee for Cancer (AJCC) 8th edition cancer staging system.

Methods

This retrospective, single-center study included breast cancer cases diagnosed from January 1999 to December 2008. We restaged patients based on the 8th edition AJCC cancer staging system and analyzed the prognostic value of the anatomic and prognostic staged groups. Follow-up data including disease-free survival (DFS), overall survival (OS), and clinic-pathological data were collected to analyze the differences between the two staging subgroups.

Results

The study enrolled 7458 breast cancer patients with a 98.7-month median follow-up. Both the 5-year DFS and OS were significantly different between the anatomic and prognostic staged groups. The 5-year OS according to disease subtype was as follows: hormone receptor-positive/human epidermal growth factor receptor 2-negative [HR(+)/HER2(−)], 90.9%; HR(+)/HER2(+), 84.7%; HR(−)/HER2(+), 81.1%; and HR(−)/HER2(−), 80.9%. According to the anatomic stage, the 5-year OS of patients with stage III HR(+)/HER2(−) disease was superior to that of patients with stage II HR(−)/HER2(−) disease (88.3 vs. 86.5%). Per the prognostic stage, both the 5-year DFS and OS rates of patients with stage II HR(−)/HER2(−) disease were higher than those of patients with stage III HR(+)/HER2(−) disease (90.1 and 94.3% vs. 79.1 and 88.9%).

Conclusions

The prognostic staging system is a refined version of the anatomic staging system and encourages a more personalized approach to breast cancer treatment.

Metastatic axillary node ratio predicts recurrence and poor long-term prognosis in patients with advanced stage IIIC (pN3) breast cancer

Purpose

Patients with stage IIIC breast cancer are classified as having pathologic nodal stage 3 (pN3) according to the 7th American Joint Committee on Cancer Tumor Node Metastasis (AJCC TNM) staging system. However, the prognosis of patients with this stage is still highly variable. This study was carried out to investigate the validity of metastatic axillary lymph node ratio (mALNR) as a predictor of long-term prognosis in stage IIIC breast cancer.

Methods

Medical records of 297 patients who underwent surgery with more than level II axillary dissection for breast cancer and who were diagnosed with pN3 by pathology between 1990 and 2010, were reviewed. Clinicopathologic variables were evaluated as prognostic factors of disease-free and overall survival by univariate and multivariate analyses.

Results

A preliminary analysis revealed the cutoff value of mALNR to be 0.65 (Low65 group vs. High65 group). The mean mALNR was 0.62 (0.16–1.0) and was the most significant independent predictor of disease-free and overall survival on multivariate analysis. The rates of recurrence were significantly different according to mALNR (Low65, 40.3%; High65, 63.0%; P < 0.001). The 10-year disease-free (Low65, 57.0%; High65, 35.0%) and overall (Low65, 64.2%; High65, 38.3%) survival rates decreased significantly with increased mALNR (P < 0.001).

Conclusion

Patients with stage IIIC breast cancer can be subdivided into subgroups with significantly different long-term prognoses. Our data suggest that the mALNR is an independent risk factor of recurrence and mortality. The mALNR is a valuable prognostic factor to predict the long-term prognosis of stage IIIC breast cancer patients.

Lymph Node Ratio as a Risk Factor for Locoregional Recurrence in Breast Cancer Patients with 10 or More Axillary Nodes

PURPOSE

We analyzed the association of lymph node ratio (LNR) wth locoregional control (LRC) in breast cancer patients with ≥10 involved axillary lymph nodes who underwent multimodality treatment.

METHODS

We retrospectively analyzed 234 breast cancer patients with ≥10 involved axillary lymph nodes between 2000 and 2011. All patients received adjuvant chemotherapy and radiotherapy (RT) after radical surgery. The cutoff value of LNR was obtained using receiver operating characteristic curve analysis. The majority of patients (87.2%) received chemotherapeutic regimen including taxane. RT consisted of tangential fields to the chest wall or intact breast, delivered at a median dose of 50 Gy, and a single anterior port to the supraclavicular lymph node area, delivered at a median dose of 50 Gy. For patients who underwent breast-conserving surgery, an electron boost with a total dose of 9 to 15 Gy was delivered to the tumor bed.

RESULTS

Within a median follow-up period of 73.5 months (range, 11-183 months), locoregional recurrence (LRR) occurred in 30 patients (12.8%) and the 5-year LRC rate was 88.8%. After multivariate analysis, LNR ≥0.7 was the only independent factor significantly associated with LRC (hazard ratio, 2.06; 95% confidence interval, 0.99-4.29; p=0.05).

CONCLUSION

An aggressive multimodal treatment approach showed favorable locoregional outcome in patients with ≥10 involved axillary lymph nodes. However, patients with a high LNR ≥0.7 still had an increased risk for LRR, even in the setting of current local treatments.

Prognostically Distinctive Subgroup in Pathologic N3 Breast Cancer

Purpose

The aim of this retrospective study was to investigate whether there are prognostically different subgroups among patients with pathologic N3 (pN3) breast cancer.

Methods

The records of 220 patients who underwent surgery for pN3 breast cancer from January 2006 to September 2012 were reviewed. All patients received adjuvant therapy according to standard protocols. The primary outcome was disease-free survival (DFS).

Results

Patients were followed for a median time of 68.3 months after their primary surgery (range, 10–122 months), during which time 75 patients (34.1%) had developed disease recurrence and 48 patients (21.8%) had died. The DFS and overall survival were 67.8% and 86.1%, respectively, at 5 years. Multiple logistic regression analysis showed that young age (<35 years, p=0.009), high serum neutrophil/lymphocyte ratio (>3.0) (p=0.020), high nodal ratio (number of metastatic lymph nodes divided by number of removed nodes) (>0.65) (p=0.062), and molecular phenotype (p=0.012) were significantly associated with tumor recurrence. Tumor biological subtype was the most significant predictor of recurrence. The 5-year DFS rates in patients with hormone receptor (HR) positive and human epidermal growth factor receptor 2 (HER2) negative, HR+HER2+, HR–HER2+, and triple negative subtypes were 82%, 63%, 58%, and 37%, respectively.

Conclusion

Clinical outcomes of patients with extensive nodal metastasis were heterogeneous in terms of prognosis. Tumor biological subtype was the most important prognostic factor for pN3 disease. The prognosis of patients with HR+HER2– subtype in pN3 breast cancer was similar to that of patients with stage II breast cancer.

A proposal for a new classification of T4 breast cancer as stage IIIC: a report from the Korean Breast Cancer Society

The objective of this study is to investigate staging system of the stage IIIB and stage IIIC Breast cancer and determine the criteria for an update of the classification system. Since AJCC 6th edition, it is pointed out that stage IIIB showed a worse outcome compared with stage IIIC. Using information from two databases, including the nationwide Korean Breast Cancer Registry (KBCR), three cohorts composed of patients from the Asan Medical Center from 1989 to 2002 (cohort I), from 2003 to 2008 (cohort II), and KBCR from 2003 to 2005 (cohort III) were assembled. New classifications were suggested that rearranged stage IIIB as T1-3N3 disease and stage IIIC as T4 any N disease. From the joint analysis of 9640, invasive breast cancer patients from cohorts I and II showed the stage IIIB group showed a significantly worse DFS (HR 10.4, 95% CI 6.9-15.7) compared with the stage IIIC group (HR 7.2, 95% CI 5.9-8.7). T4d breast cancer showed worse DFS than T4 abc breast cancer but not significant (p = 0.505). The survival of patients with T1N3 and T2N3 tumors was higher than the other groups, and patients with T4N3 tumors showed the worst survival outcomes in terms of DFS, CSS. Using new suggested classification, in cohort III, the stage IIIB HR for CSS was changed from 15.4 (95% CI 10.6-22.1) in the AJCC 6th edition to 12.6 (95% CI 10.1-15.6) in the proposed new staging system. The stage IIIC HR for CSS was changed from 13.3 (95% CI 10.7-16.4) in the AJCC 6th edition to 18.9 (95% CI 14.0-25.6) in the proposed new staging using stage I as a reference. Reclassification of T4 any N disease as stage IIIC and T1-3N3 disease as stage IIIB is appropriate.

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.

The prognostic significance of early stage lymph node positivity in operable invasive breast carcinoma: number or stage

AIM

The earlier detection of breast cancer through mammographic screening has resulted in a shift in stage distribution with patients who are node-positive tending to present with a lower number of positive lymph nodes (LN). This study aims to assess the prognostic value of absolute number of positive nodes in the pN1 TNM stage (1-3 positive LN) and whether the prognostic value of the number of nodes in this clinically important stage justifies its consideration in management decisions.

METHODS

This study is based on a large and well-characterised consecutive series of operable breast cancer (3491 cases), treated according to standard protocols in a single institution, with a long-term follow-up.

RESULTS

LN stages and the absolute number of LN are associated with both breast cancer specific survival (BCSS) and distant metastasis free survival (DMFS). In the pN1 stage, patients with three positive LN (14% of pN1) show shorter BCSS (HR=1.9, (95% CI 1.3 to 2.6)) and shorter DMFS (HR=2.2, (95% CI 1.6 to 2.9)) when compared with one and/or two positive nodes. This effect is noted in the whole series as well as in different subgroups based on tumour size (pT1c and pT2), histological grade (grade 2 and 3), vascular invasion and oestrogen receptor status (both positive and negative). Multivariable analyses showed that three positive LN, compared with one and two positive LN, are an independent predictor of shorter BCSS and DMFS.

CONCLUSION

The number of LN in the pN1 stage yielded potentially informative risk assignments with three positive LN providing an independent predictor of poorer outcome.

Factors influencing the outcome of breast cancer patients with 10 or more metastasized axillary lymph nodes

BACKGROUND

The purpose of this study was to investigate prognostic factors in breast cancer patients with metastasis of ten or more lymph nodes (pathologic N3a).

METHODS

We conducted a retrospective analysis of the cases of 304 breast cancer patients with pathologic N3a disease who had undergone definitive surgery between 1986 and 2006, and investigated the correlation between clinicopathologic characteristics and treatment outcomes.

RESULTS

With a median follow-up period of 55 months, the 5-year disease-free survival rate was 42.9% and the overall survival rate was 57.8%. Univariate analysis showed that the factors associated with poor disease-free survival were: age < 35 years (P = 0.001), history of neoadjuvant chemotherapy (P < 0.001), T4 stage (P < 0.001), 20 or more positive lymph nodes (P < 0.001), presence of lymphovascular invasion (P = 0.003), and negative progesterone receptor expression (P = 0.003). Multivariate analysis showed the factors with independent prognostic significance to be: history of neoadjuvant chemotherapy (hazard ratio [HR] 3.163; 95% confidence interval [CI], 2.025-4.941; P < 0.001), 20 or more positive nodes (HR 1.598; 95% CI, 1.063-2.402; P = 0.024), and presence of lymphovascular invasion (HR 1.636; 95% CI, 1.009-2.654; P = 0.046). Factors associated with poor overall survival in univariate analysis were: age < 35 years (P = 0.033), history of neoadjuvant chemotherapy (P < 0.001), T4 stage (P = 0.001), 20 or more positive lymph nodes (P < 0.001), and negative progesterone receptor expression (P = 0.013). Multivariate analysis showed these factors to be: history of neoadjuvant chemotherapy (HR 2.900; 95% CI, 2.011-4.182; P < 0.001), and 20 or more positive nodes (HR 1.956; 95% CI, 1.419-2.696; P < 0.001).

CONCLUSION

Cases of breast tumors with extensive nodal metastasis were found to be heterogeneous in terms of prognosis. History of previous neoadjuvant chemotherapy and higher numbers of metastatic lymph nodes were found to be the two most important prognostic markers for pathologic N3a disease. New strategies such as biologic therapy and novel combinations should be considered for application in patients with poor prognosis, rather than conventional treatment.

Implications of applied research for prognosis and therapy of breast cancer

Breast cancer is the one of leading causes of cancer-related deaths in women within economically developed regions of the world. The heterogeneity of the natural history of breast cancer complicates patient management in that there is tremendous variability in response to treatment and for survival. More recently, several biomarkers (hormone receptor status and HER2 expression) have been added to the risk evaluation and therapeutic assessments. Evolving knowledge of molecular biology and newer techniques, such as genomics and proteomics, offer the potential to better define the biologic nature of the disease process, both for risk and therapy. This review discusses classical as well as new prognostic and predictive techniques. These are leading to a paradigm shift from empirical treatment to an individually tailored approach, which may soon become a realistic option for patients, based on specific molecular profiles.

Axillary surgery in breast cancer patients

Surgeons have routinely removed ipsilateral axillary lymph nodes from women with breast cancer for over 100 years. The procedure provides important staging information, enhances regional control of the malignancy and may improve survival. As screening of breast cancer has increased, the mean size of newly diagnosed primary invasive breast cancers has steadily decreased and so has the number of women with lymph node metastases. Recognising that the therapeutic benefit of removing normal nodes may be low, alternatives to the routine level I/II axillary lymph node dissection have been sought. A decade ago sentinel lymph node biopsy (SLNB) was introduced. Because of its high accuracy and relatively low morbidity, this technique is now widely used to identify women with histologically involved nodes prior to the formal axillary node dissection. Specifically, SLNB has allowed surgeons to avoid a formal axillary lymph node biopsy in women with histologically uninvolved sentinel nodes, while identifying women with involved sentinel nodes who derive the most benefit from a completion axillary node dissection. Despite the increasing use of SLNB for initial management of the axilla in women with breast cancer, important questions remain regarding patient selection criteria and optimal surgical methods for performing the biopsy. This article discusses the evolution of axillary node surgery for women with breast cancer.

Breast cancer patients with 10 or more involved axillary lymph nodes treated by multimodality therapy: influence of clinical presentation on outcome

PURPOSE

To analyze tumor control and survival for breast cancer patients with 10 or more positive lymph nodes without systemic disease, treated by adjuvant radiation alone or combined-modality therapy.

METHODS AND MATERIALS

We reviewed the records of 309 consecutive patients with these characteristics who received locoregional radiotherapy (RT) at our institution. The majority of patients had clinical Stage II or IIIA-B disease (43% and 48%, respectively). The median number of positive axillary lymph nodes was 15 (range, 10-78). Adjuvant therapy consisted of RT alone, with or without chemotherapy, tamoxifen, and/or ovarian castration.

RESULTS

The overall 5-year and 10-year disease-free survival (DFS) rates were 20% and 7%, respectively. Median DFS was higher for patients with Stage I-II compared with those with Stage IIIABC (28 vs. 19 months; p = 0.006). Median DFS for patients aged <or=35 years was lower than that of older patients (12 vs. 24 months; p < 0.0001). Patients treated with a combination therapy had a higher 5-year DFS rate compared with those treated by RT alone (26% vs. 11%; p = 0.03). In multivariate analysis, clinical stage (III vs. I, II; relative risk = 1.8, p = 0.002) and age (<or=35 vs. others; relative risk = 2.6, p <0.001) were found to be independent variables for DFS.

CONCLUSION

This retrospective data analysis identified young age and advanced clinical stage as pertinent and independent clinical prognostic factors for breast cancer patients with advanced axillary disease (10 or more involved nodes). These factors can be used for further prognostic classification.

Comparison of Local Recurrence and Distant Metastases between Breast Cancer Patients after Postmastectomy Radiotherapy with and without Immediate TRAM Flap Reconstruction

BACKGROUND

The purpose of this study was to compare the local recurrence and distant metastasis of postmastectomy radiotherapy for breast cancer patients with and without immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction.

METHODS

Between March of 1997 and October of 2001, 191 breast cancer patients received postmastectomy radiotherapy: 82 patients had TRAM flap reconstruction (TRAM flap group) and 109 patients did not (non-TRAM flap group). The mean radiation dose to the chest wall or entire TRAM flap, axillary area, and lower neck was 50 Gy (range, 48 to 54 Gy). The median follow-up period was 40 months.

RESULTS

The percentages of chest wall recurrence were 3.7 percent (three of 82) in the TRAM flap group and 1.8 percent (two of 109) in the non-TRAM flap group (p = 0.653). The percentages of distant metastases were 12.2 percent (10 of 82) in the TRAM group and 15.6 percent (17 of 109) for the non-TRAM group (p = 0.67). The percentages of acute radiation dermatitis according to Radiation Therapy Oncology Group scoring criteria (TRAM flap group versus non-TRAM flap group) were as follows: grade I, 74 of 82 (90 percent) versus 93 of 109 (85 percent); grade II, seven of 82 (9 percent) versus 13 of 109 (12 percent); grade III, one of 82 (1 percent) versus three of 109 (3 percent) (p = 0.558). In the TRAM flap group, the increased percentage of fat necrosis was 8 percent. No flap loss was detected.

CONCLUSIONS

There were no significant differences in the incidences of complication, locoregional recurrence, and distant metastasis between the TRAM flap and non-TRAM flap patients. The authors' results suggest that immediate TRAM flap reconstruction can be considered a feasible treatment for breast cancer patients requiring postmastectomy radiotherapy.

Multivariate analyses of locoregional recurrences and skin complications after postmastectomy radiotherapy using electrons or photons

PURPOSE

We retrospectively analyzed factors of locoregional (LR) recurrence and skin complications in patients after postmastectomy radiotherapy (PMRT).

METHODS AND MATERIALS

From January 1988 to December 1999, a total of 246 women with Stage II and III breast cancer received PMRT. Doses of 46 to 52.2 Gy/23 to 29 fractions were delivered to the chest wall (CW) and peripheral lymphatic drainage with 12 to 15 MeV single-portal electrons or 6MV photons. Of the patients, 84 patients received an additional 6 to 20 Gy boost to the surgical scar using 9 MeV electrons. We used the Cox regression model for multivariate analyses of CW, supraclavicular nodes (SCN), and LR recurrence.

RESULTS

N3 stage (positive nodes >9) (p = 0.003) and diabetes (p = 0.004) were independent factors of CW recurrence. Analysis of ipsilateral SCN recurrence showed that N3 stage (p < 0.001) and electrons (p = 0.006) were independent factors. For LR recurrence, N3 (p < 0.001), T3 to T4 (p = 0.033) and electrons (p = 0.003) were significant factors. Analysis of skin telangiectasia revealed that electrons (p < 0.001) and surgical scar boost (p = 0.003) were independent factors.

CONCLUSIONS

Photons are superior to single-portal electrons in patients receiving postmastectomy radiotherapy because of better locoregional control and less skin telangiectasia. In patients in whom the number of positive axillary nodes is >9, more aggressive treatment may be considered for better locoregional control.

Development of axillary surgery in breast cancer

Axillary surgery is a critical part of the treatment of breast carcinoma: its importance is related to the staging of disease, prescription of adjuvant therapy and prognosis. For years, complete axillary dissection has remained the standard approach to breast cancer lymphatic staging; its value is still high, but the development of sentinel-node biopsy has significantly changed the indication of the procedure. We discuss the evolution of axillary surgery in breast cancer.

The natural history of breast carcinoma in patients with ≥ 10 metastatic axillary lymph nodes before and after the advent of adjuvant therapy

BACKGROUND

The majority of patients with breast carcinoma with > or = 10 metastatic axillary lymph nodes (ALNs) develop recurrent disease within 5 years from diagnosis. The purpose of the current study, performed retrospectively, was to characterize the natural history of this subset of patients, both before and after the advent of adjuvant anthracycline-based chemotherapy and tamoxifen.

METHODS

Retrospectively, patients with primary breast carcinoma (N = 882) with > or = 10 metastatic ALNs, treated between 1954 and 1998, were selected from 3 institutions: The University of Texas M. D. Anderson Cancer Center (Houston, TX); the Institut Gustave Roussy (Villejuif, France); and Hospital Clinico Universitario (Valencia, Spain). All patient data had been registered prospectively in clinical databases. One group consisted of 314 patients treated with locoregional therapy alone (no adjuvant therapy) from 1954 to 1983. The second group included 568 patients who received adjuvant anthracycline-based chemotherapy between 1974 and 1998 with or without adjuvant tamoxifen.

RESULTS

The median follow-up time was 140 months. Disease-free survival rates at 15 and 20 years for the no adjuvant therapy and adjuvant therapy groups were 17% and 16% versus 26% and 24%, respectively. The overall survival rates at 20 years for the no adjuvant therapy and the adjuvant therapy groups were 9% and 21%, respectively. By multivariate analysis, the independent factors associated with survival in the adjuvant therapy group were tumor size and the number of metastatic lymph nodes.

CONCLUSIONS

The retrospective analysis suggested that adjuvant anthracycline-based chemotherapy and hormonal therapy have altered the natural history in this high-risk group of patients. However, despite such improvements, survival rates remained low, and innovative therapeutic approaches are, therefore, needed to improve clinical outcomes.

Sensitive, noninvasive detection of lymph node metastases

BACKGROUND

Many primary malignancies spread via lymphatic dissemination, and accurate staging therefore still relies on surgical exploration. The purpose of this study was to explore the possibility of semiautomated noninvasive nodal cancer staging using a nanoparticle-enhanced lymphotropic magnetic resonance imaging (LMRI) technique.

METHODS AND FINDINGS

We measured magnetic tissue parameters of cancer metastases and normal unmatched lymph nodes by noninvasive LMRI using a learning dataset consisting of 97 histologically proven nodes. We then prospectively tested the accuracy of these parameters against 216 histologically validated lymph nodes from 34 patients with primary cancers, in semiautomated fashion. We found unique magnetic tissue parameters that accurately distinguished metastatic from normal nodes with an overall sensitivity of 98% and specificity of 92%. The parameters could be applied to datasets in a semiautomated fashion and be used for three-dimensional reconstruction of complete nodal anatomy for different primary cancers.

CONCLUSION

These results suggest for the first time the feasibility of semiautomated nodal cancer staging by noninvasive imaging.

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.

Revision of breast cancer staging: the 6th edition of the TNM Classification

A Breast Task Force comprised of nationally known experts in the field of breast cancer treatment was charged with recommending additions and changes for the 6th edition of the TNM Classification that were based on published evidence and/or were consistent with widespread clinical consensus. Additions made to the staging system were designed to facilitate the uniform collection of clinically relevant information about new techniques for the detection of metastatic cells. These additions include quantitative criteria to distinguish micrometastases from isolated tumor cells, and specific identifiers to record the use of sentinel lymph node biopsy, immunohistochemical (IHC) staining, and molecular biology techniques. Revisions of the previous staging system are related to the number of affected axillary lymph nodes and to the classification of level III axillary lymph nodes and lymph nodes outside of the axilla.

Management of high-risk node-positive breast cancer by standard-dose chemotherapy and loco-regional radiotherapy

One-hundred, thirty-six women, aged up to 76 years, with high-risk breast cancer were treated with postoperative radiotherapy and 9 cycles of adjuvant chemotherapy in standard doses. Treatment-related toxicity was mild. At a median follow-up of 7.3 years, 39.6% are disease-free. At 5 and 10 years overall survival was 55% and 34% respectively; disease-free survival was 39% and 33% respectively. Eighteen patients (13.2%) developed loco-regional recurrence, which was uncontrolled in four. When compared to series treated with adjuvant chemotherapy, but without radiotherapy, there are apparent survival gains of 10-15% at 5 and 10 years. These results in both pre- and post-menopausal patients compare favourably with results of high-dose chemotherapy and stem-cell rescue in much more highly selected patients.

Tumor acidity, ion trapping and chemotherapeutics. I. Acid pH affects the distribution of chemotherapeutic agents in vitro

Resistance to anti-cancer chemotherapies often leads to regional failure, and can be caused by biochemical and/or physiological mechanisms. Biochemical mechanisms include the overexpression of resistance-conferring proteins. In contrast, physiological resistance involves the tumor microenvironment, and can be caused by poor perfusion, hypoxia and/or acidity. This communication investigates the role of tumor acidity in resistance to a panel of chemotherapeutic agents commonly used against breast cancer, such as anthracyclines, taxanes, anti-metabolites and alkylating agents. The effects of pH on the cytotoxicity of these agents were determined, and ion trapping was confirmed by monitoring the effect of pH on the cellular uptake of radiolabeled anthracyclines. Furthermore, pH-dependent cytotoxicity and uptake were compared between parental drug sensitive MCF-7 cells and variants overexpressing p-glycoprotein (MDR-1) and Breast Cancer Resistance Protein. These data indicate that the magnitude of physiological resistance from pH-dependent ion trapping is comparable to biochemical resistance caused by overexpression of drug efflux pumps. Hence, microenvironment-based ion trapping is a significant barrier to anthracycline-based chemotherapy and can itself be a therapeutic target to enhance the efficacy of existing chemotherapies.

Staging system for breast cancer: revisions for the 6th edition of the AJCC Cancer Staging Manual

Since its inception, the AJCC staging system for breast cancer has been in an almost constant state of evolution, striving with each revision to reflect the most up-to-date clinical research as well as the widespread consensus among physicians about appropriate diagnostic and treatment standards. To date, these revisions have essentially represented a "fine-tuning" of the initial judgment that tumor size, lymph node status, and presence of distant metastases are the most significant prognostic factors for breast cancer. With the problems of standardization and reproducibility being resolved, it is likely that histologic grade will join this group of independent markers and be incorporated into the AJCC staging system in the near future. Over the last 15 years. considerable attention has been focused on the discovery of new markers visualized with immunohistochemistry and RT-PCR that may be validated as independent prognostic indicators (reviewed by Mirza et al). To date, the usefulness of many of these markers has been limited by lack of standardization in measurement techniques, but several show great promise for the future. By increasing the number of prognostic markers that can give independent information about patient outcome, physicians will be better able to determine optimal treatment approaches for individual patients.

Sentinel node biopsy: an in depth appraisal

Sentinel node biopsy (SNB) in primary breast cancer has been taken-up widely to avoid the morbidity attributable to axillary node clearance (ANC). Currently many issues surrounding SNB are undecided. This review summarises why some form of axillary surgery is required and presents data on all aspects of SNB including methodology, clinical results and problems that may delay the introduction of SNB as best practice for all patients with primary breast cancer. There is no long or medium term data relating to the consequences of replacing ANC with SNB, but the mechanisms and probable magnitude of both beneficial and detrimental effects are estimated. A low level of false negative results are inherent to the technique but it is demonstrated that SNB is likely to have an only marginal (0.6%) effect on survival that would be undetectable by clinical trials. Patient sub-groups particularly likely to benefit from SNB are identified.

Revision of the American Joint Committee on Cancer staging system for breast cancer

PURPOSE

To revise the American Joint Committee on Cancer staging system for breast carcinoma.

MATERIALS AND METHODS

A Breast Task Force submitted recommended changes and additions to the existing staging system that were (1) evidence-based and/or consistent with widespread clinical consensus about appropriate diagnostic and treatment standards and (2) useful for the uniform accrual of outcome information in national databases.

RESULTS

Major changes included the following: size-based discrimination between micrometastases and isolated tumor cells; identifiers to indicate usage of innovative technical approaches; classification of lymph node status by number of involved axillary lymph nodes; and new classifications for metastasis to the infraclavicular, internal mammary, and supraclavicular lymph nodes.

CONCLUSION

This revised staging system will be officially adopted for use in tumor registries in January 2003.

Predictors for pneumonitis during locoregional radiotherapy in high-risk patients with breast carcinoma treated with high-dose chemotherapy and stem-cell rescue

BACKGROUND

To study the predictive value of serial pulmonary function testing (PFT) for toxicity in patients who have received high-dose chemotherapy (HDCT) and stem-cell rescue for breast carcinoma. These patients are at risk of developing therapy-related pneumonitis (TRP) during or after radiotherapy (RT).

METHODS

Sixty-eight patients who received induction chemotherapy (CT) and consolidation HDCT (cyclophosphamide, cisplatin, carmustine) underwent serial PFTs before induction CT, after HDCT, and before locoregional RT. The rate of TRP, i.e., pulmonary complications of Grade 2 or higher (World Health Organization classification), was studied during and 2 months after RT. We analyzed the time-course of changes in the diffusing capacity of carbon monoxide (DLCO) and forced expiratory volume at one second (FEV(1)) and studied the differences between patients who developed TRP and those who did not.

RESULTS

The incidence of TRP was 46%. There were marked reductions in DLCO and FEV(1) at the time of RT compared with baseline (Wilcoxon signed rank test: P < 0.001). However, pre-RT PFT values did not predict subsequent development of TRP. Instead, the ratio of pre-RT DLCO to the minimum post- HDCT DLCO, i.e., trend of improvement, predicted the development of TRP in patients (logistic regression analysis: P = 0.048). At a cutoff level of 1, the positive and negative predictive values for this ratio were 61% and 87%, respectively. There was an association between this ratio and a longer interval between HDCT and RT (Spearman rank correlation: P = 0.002).

CONCLUSIONS

The results suggest that the directional trend of DLCO after HDCT, i.e., no recovery from nadir values, is a predictor for TRP. TRP patients have a shorter median interval between HDCT and RT than asymptomatic patients. To minimize the occurrence of TRP, one should consider either delaying RT beyond 2 months following carmustine-based HDCT to allow the PFTs to partly recover, or confirm apositive directional trend for improvement of DLCO at the start of RT compared to the post-HDCT nadir value.

Prediction of supraclavicular lymph node metastasis in breast carcinoma

PURPOSE

Supraclavicular lymph node metastasis in breast cancer patients has a poor prognosis, and aggressive local treatment has usually resulted in severe morbidity. The purpose of this study was to select high-risk neck metastasis patients for prophylactic radiotherapy.

METHODS

Between 1990 and 1998, 2658 consecutive invasive breast cancer patients underwent surgery and adjuvant therapy in the hospital. The median age was 47 years (range 22-92). The median follow-up period was 39 months. The following factors were analyzed: age, tumor size, tumor location, histologic type, histologic grade, estrogen and progesterone receptor status, DNA flow cytometry study results, number of positive axillary lymph nodes, use of chemotherapy, radiotherapy, and/or hormonal therapy, and level of involved axillary nodes.

RESULTS

Of the 2658 patients, 113 (4.3%) developed supraclavicular lymph node metastasis during this period. Young age (< or =40 years), tumor size >3 cm, high histologic grade, angiolymphatic invasion, negative estrogen receptor status, synthetic phase fraction >4%, >4 positive nodes, and level II or III involved nodes were all significant for predicting neck metastasis in the univariate analysis. Three predictive factors were significant after multivariate analysis: high histologic grade, >4 positive nodes, and axillary level II or III involved nodes. In patients with axillary level I involved nodes and < or =4 positive nodes, the incidence was 4.4%. If axillary level III was involved, the rate of supraclavicular lymph node metastasis was 15.1%.

CONCLUSION

The incidence of supraclavicular lymph node metastasis was higher in the groups with >4 positive nodes and in those with axillary level II or III involved nodes. Selective use of comprehensive radiotherapy for these high-risk patients will achieve good locoregional control.

Pulmonary complications following different radiotherapy techniques for breast cancer, and the association to irradiated lung volume and dose

PURPOSE

This study investigates the incidence of short-term pulmonary complications following radiotherapy (RT) for breast cancer (BC) with different treatment techniques/incidentally irradiated lung volumes and the importance of confounding factors on RT-induced pulmonary complications.

PATIENTS AND METHODS

Prospectively, 475 patients with BC were followed for pulmonary complications 1, 4 and 7 months post-RT. Mean lung dose volume histograms (MDVH) were constructed and compared for the different RT-techniques. Among a subset of the mastectomized patients treated with loco-regional (LR-) RT, who had undergone complete three-dimensional (3-D) dose planning (n = 43), MDVH for asymptomatic patients was compared with MDVH for patients experiencing both radiological and clinical pulmonary side-effects.

RESULTS

Moderate pulmonary complications, that is requiring treatment with corticosteroids, were rare following local RT (< 1%), but were diagnosed among 11% of the patients treated with LR-RT. A correlation between increasing irradiated lung volumes at the >20 Gy-level (V20), based on MDVH for the RT-techniques, and pulmonary complications was found (P < 0.001). Furthermore, increasing age and reduced pre-RT functional level were independently associated with a higher rate of pulmonary complications (P = 0.005 and P = 0.018). Among the subgroup of mastectomized patients treated with LR-RT, who had undergone complete 3-D dose planning, a difference in mean V20 was found between patients experiencing both clinical and radiological pulmonary side-effects compared to patients experiencing neither of the two side-effects (P = 0.007).

CONCLUSION

Moderate pulmonary complications following local RT for BC are rare. The incidence of short-term moderate pulmonary complications in LR-RT is, however, clinically significant and to define quality assurance guidelines for these RT-techniques, 3-D RT planning can be used.

Determinants of axillary recurrence after axillary lymph node dissection for invasive breast cancer

AIM

This study was undertaken to gain insight into the risk factors for axillary recurrence among patients with invasive breast cancer who underwent breast-conserving treatment or mastectomy and axillary lymph node dissection.

METHODS

In a matched case-control design, 59 patients with axillary recurrence and 295 randomly selected control patients without axillary recurrence were compared. Matching factors included age, year of incidence of the primary tumour and postsurgical axillary nodal status.

RESULTS

For patients with negative axillary lymph nodes, those with a tumour in the medial part of the breast had a 73% (95% CI: 4-92%) lower risk of axillary recurrence compared to those with a tumour in the lateral part of the breast. For the patients with positive axillary lymph nodes the risk of axillary recurrence was 65% (95% CI: 16-86%) lower for those who had received axillary irradiation compared to those without axillary irradiation. Within the age group <50 years, the risk or axillary recurrence was 82% lower (95% CI: 45-94%) for patients with more than six lymph nodes found in the axillary specimen compared to those with six or less than six lymph nodes.

CONCLUSIONS

Although based on a small number of patients, this study indicates that axillary irradiation is effective in reducing the risk of axillary recurrence for patients with positive lymph nodes. This favourable effect only applies to the subgroup with extranodal extension or nodal involvement in the apex of the axilla, as these were the only patients receiving axillary radiation during the study period.

Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology

OBJECTIVE

To determine indications for the use of postmastectomy radiotherapy (PMRT) for patients with invasive breast cancer with involved axillary lymph nodes or locally advanced disease who receive systemic therapy. These guidelines are intended for use in the care of patients outside of clinical trials.

POTENTIAL INTERVENTION

The benefits and risks of PMRT in such patients, as well as subgroups of these patients, were considered. The details of the PMRT technique were also evaluated.

OUTCOMES

The outcomes considered included freedom from local-regional recurrence, survival (disease-free and overall), and long-term toxicity.

EVIDENCE

An expert multidisciplinary panel reviewed pertinent information from the published literature through July 2000; certain investigators were contacted for more recent and, in some cases, unpublished information. A computerized search was performed of MEDLINE data; directed searches based on the bibliographies of primary articles were also performed.

VALUES

Levels of evidence and guideline grades were assigned by the Panel using standard criteria. A "recommendation" was made when level I or II evidence was available and there was consensus as to its meaning. A "suggestion" was made based on level III, IV, or V evidence and there was consensus as to its meaning. Areas of clinical importance were pointed out where guidelines could not be formulated due to insufficient evidence or lack of consensus.

RECOMMENDATIONS

The recommendations, suggestions, and expert opinions of the Panel are described in this article.

VALIDATION

Seven outside reviewers, the American Society of Clinical Oncology (ASCO) Health Services Research Committee members, and the ASCO Board of Directors reviewed this document.

Does sentinel lymphadenectomy improve staging and alter therapy in elderly women with breast cancer?

BACKGROUND

Routine axillary lymph node dissection (ALND) for elderly women with invasive breast cancer has been questioned because it rarely alters therapy yet carries a significant morbidity rate. Sentinel lymphadenectomy (SLND) improves axillary staging and alters therapy in women with T1 breast cancer, but it is not clear whether SLND alters therapy in elderly women with breast cancer.

METHODS

A prospective breast cancer data base was used to identify women 70 years old and older who underwent SLND for axillary staging of invasive breast cancer between 1991 and 1998.

RESULTS

There were 75 invasive breast cancers in 73 women. The mean patient age was 74.5 years (range, 70-90 years). Median tumor size was 1.4 cm (range, 0.1-6.2 cm). Of the 75 tumors, 42 (56%) had favorable primary characteristics; the remaining tumors had unfavorable characteristics. SLND was performed alone in 17 cases (23%) and was followed by completion ALND in 58 cases (77%). Positive lymph nodes were identified in 32 cases (43%); 26 (81.3%) were detected by hematoxylin and eosin stains, and 6 (18.7%) were detected by immunohistochemistry alone. Five patients (6.9%) received adjuvant chemotherapy. Seven patients (9.6%) received axillary/supraclavicular radiation for positive nodes. Ten (13.7%) of 73 patients had obvious alterations in therapy because of axillary nodal status. As a result of SLND, 3 (13.6%) of 22 patients with tumors 1.0 cm or smaller received tamoxifen, and 7 (15%) of 46 patients with tumors between 1.0 and 3.0 cm in size had changes in therapy. When patient and tumor characteristics were analyzed to determine relationships to therapeutic decision-making, nodal status was the variable most significantly associated with changes in therapy (P = .0001).

CONCLUSIONS

SLND improves axillary staging in elderly women with invasive breast cancer. Results of immunohistochemistry do not alter therapy in this group of individuals (P = .6367). In patients with small primary tumors, SLND alters therapy by increasing the number of patients receiving tamoxifen. In addition, SLND affects adjuvant systemic chemotherapy and regional radiotherapy in a significant number of patients with larger tumors, particularly tumors between 1.0 and 3.0 cm.

Role of axillary surgery in early breast cancer: review of the current evidence

BACKGROUND

Controversy continues to surround the best practice for management of the axilla in patients with early breast cancer (EBC), particularly the clinically negative axilla. The balance between therapeutic and staging roles of axillary surgery (with the consequent morbidity of the procedures utilized) has altered. This is due to the increasing frequency of women presenting with early stage disease, the more widespread utilization of adjuvant chemoendocrine therapy and, more recently, the advent of alternative staging procedures, principally sentinel node biopsy (SNB). The aim of the present review is to critically analyse the current literature concerning the preferred management of the axilla in early breast cancer and make evidence-based recommendations on current management.

METHODS

A review was undertaken of the English language medical literature, using MEDLINE database software and cross-referencing major articles on the subject, focusing on the last 10 years. The following combinations of key words have been searched: breast neoplasms, axilla, axillary dissection, survival, prognosis, and sentinel node biopsy.

RESULTS

Despite the trend to more frequent earlier stage diagnosis, levels I and II axillary dissection remain the treatment of choice in the majority of women with EBC and a clinically negative axilla.

CONCLUSIONS

Sentinel node biopsy has no proven superiority over axillary dissection because no randomized controlled trials have been completed to date. Despite this, SNB will become increasingly utilized due to encouraging results from major centres responsible for its development, and patient demand. Therefore if patients are not being enrolled in clinical trials strict quality controls need to be established at a local level before SNB is allowed to replace standard treatment of the axilla. Unless this is strictly adhered to there is a significant risk of an increase in the frequency of axillary relapse and possible increased understaging and resultant inadequate treatment of patients.

Sentinel lymph node biopsy for breast cancer: a suitable alternative to routine axillary dissection in multi-institutional practice when optimal technique is used

PURPOSE

Previous studies have demonstrated the feasibility of sentinel lymph node (SLN) biopsy for nodal staging of patients with breast cancer. However, unacceptably high false-negative rates have been reported in several studies, raising doubt about the applicability of this technique in widespread surgical practice. Controversy persists regarding the optimal technique for correctly identifying the SLN. Some investigators advocate SLN biopsy using injection of a vital blue dye, others recommend radioactive colloid, and still others recommend the use of both agents together.

PATIENTS AND METHODS

A total of 806 patients were enrolled by 99 surgeons. SLN biopsy was performed by single-agent (blue dye alone or radioactive colloid alone) or dual-agent injection at the discretion of the operating surgeon. All patients underwent attempted SLN biopsy followed by completion level I/II axillary lymph node dissection to determine the false-negative rate.

RESULTS

There was no significant difference (86% v 90%) in the SLN identification rate among patients who underwent single- versus dual-agent injection. The false-negative rates were 11.8% and 5.8% for single- versus dual-agent injection, respectively (P <.05). Dual-agent injection resulted in a greater mean number of SLNs identified per patient (2. 1 v 1.5; P <.0001). The SLN identification rate was significantly less for patients older than 50 years as compared with that of younger patients (87.6% v 92.6%; P =.03). Upper-outer quadrant tumor location was associated with an increased likelihood of a false-negative result compared with all other locations (11.2% v 3. 9%; P <.05).

CONCLUSION

In multi-institutional practice, SLN biopsy using dual-agent injection provides optimal sensitivity for detection of nodal metastases. The acceptable SLN identification and false-negative rates associated with the dual-agent injection technique indicate that this procedure is a suitable alternative to routine axillary dissection across a wide spectrum of surgical practice and hospital environments.

Management of the axilla in early breast cancer: is it time to change tack?

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.

Importance of radiation therapy for breast cancer patients treated with high-dose chemotherapy and stem cell transplant

PURPOSE

To determine local-regional failure rates in breast cancer patients treated with surgery and high-dose chemotherapy with stem cell transplant and to relate local-regional failure to the use and timing of radiation treatment.

METHODS AND MATERIALS

We retrospectively reviewed the records of 165 breast cancer patients treated on institutional protocols with surgery and high-dose chemotherapy with stem cell transplant. All patients had either Stage III disease, 10 or more positive axillary lymph nodes, or 4 or more positive axillary lymph nodes following neoadjuvant chemotherapy. Twelve patients had inflammatory breast cancer. Thirteen patients treated with breast preservation and 5 patients who died from toxicity within 30 days of transplant were excluded from the analyses of local-regional recurrences. In the remaining 147 patients, 108 were treated with adjuvant radiation and 39 were not. The disease stage distribution for these two groups was comparable. The median follow-up for surviving patients was 35 months.

RESULTS

The 3- and 5-year actuarial disease-free survival (DFS) for the entire group was 60% and 51%, respectively. The 5-year rates of freedom from isolated local-regional recurrence were 95% in the patients treated with adjuvant radiation and 86% in the patients who did not receive radiation (p = 0.014, log rank comparison). The 5-year rates of any local-regional recurrence as a first event (isolated recurrences plus those with simultaneous local-regional and distant recurrences) were 92% versus 82%, respectively for patients whose treatment did and did not include radiation (p = 0.038). We could not demonstrate a correlation of the timing of radiation with the risk of local-regional recurrence.

CONCLUSIONS

These data indicate that high-dose chemotherapy does not negate the importance of radiation in optimizing local-regional control in patients with high-risk breast cancer. Given the results of recent randomized trials studying postmastectomy radiation, which show that improving local-regional control improves overall survival (OS), we believe that all breast cancer patients with high-risk primary breast cancer who are treated with high-dose chemotherapy with stem cell transplant should receive radiation as a component of their treatment.

[Postmastectomy locoregional radiotherapy for breast cancer: literature review]

Postoperative radiotherapy is controversial after radical mastectomy. Recent clinical trials have shown an increase in survival with this irradiation and conclusions of previous meta-analyses should be reconsidered. The results of a large number of randomized clinical trials in which women received post-mastectomy radiotherapy or not have been reviewed. These trials showed a decrease in locoregional failure with the use of postoperative radiotherapy but survival advantages have not been clearly identified. A larger number of randomized clinical trials compared postoperative radiotherapy alone, chemotherapy alone and the association of the two treatments. They showed that chemotherapy was less active locally than radiotherapy and that radiotherapy and chemotherapy significantly increased both disease-free and overall survival rates in the groups which received postoperative radiotherapy. These favourable results were, however, obtained with optimal radiotherapy techniques and a relative sparing of lung tissue and cardiac muscle. Many retrospective clinical analyses concluded that results obtained in locoregional failure rate were poor and that these failures led to an increase in future risks. Both radiotherapy and systemic treatment should be delivered after mastectomy, reserved for patients with a high risk of locoregional relapses, particularly of nodes and/or tumors with a diameter > or = 5 cm. However, radiotherapy could produce secondary effects, and techniques of radiotherapy should be optimal.

Radiation therapy in management of breast cancer

Randomized trials have demonstrated the efficacy of radiation therapy in the treatment of breast cancer. A reduction in the risk of recurrence has been shown in breast conservation for ductal carcinoma in situ and in invasive cancers after breast conservation and mastectomy. The importance of local control in breast cancer is becoming more apparent. Defining the groups of patients who most benefit from the therapy and improving treatment delivery systems to enhance the therapeutic index are ongoing challenges.

Management of axillary lymph nodes in breast cancer: a national patterns of care study of 17,151 patients

OBJECTIVE

To determine the rates of axillary lymph node dissection (ALND) and axillary irradiation (AI) in patients with breast cancer and to identify the factors influencing them.

SUMMARY BACKGROUND DATA

Routine performance of ALND in the treatment of breast cancer has become controversial. AI has been proposed as an alternative to ALND, and it has been suggested that AI in addition to ALND may decrease local failure in high-risk patients.

METHODS

A joint study was conducted by the Commission on Cancer of the American College of Surgeons and the American College of Radiology. A total of 17,151 patients with stage I and II breast cancer treated at 819 institutions in 1994 were studied.

RESULTS

A total of 15,992 patients underwent ALND (93%). The mean ages of patients who did and did not undergo ALND were 60.4 and 73.0 years. Univariate analysis demonstrated significantly decreased rates of ALND for women age 70 or older (86% vs. 97%), patients with clinical T1 a tumors (81% vs. 93%), grade I histology (90% vs. 95%), and patients with favorable tumor types (88% vs. 94%). The ALND rate did not vary between palpable and nonpalpable tumors. Multivariate analysis of variables affecting the rate of ALND identified type of surgery, age, tumor size, histology, and payer status as significant. A total of 889 patients received AI. Patients not undergoing ALND were more likely to receive AI (10% vs. 5%). A total of 1.6% of patients with no lymph node metastasis underwent AI, 8.9% of those with one to three positive nodes underwent AI, 24.0% of those with four to nine positive lymph nodes underwent AI, and 29.9% of those with > or = 10 positive lymph nodes underwent AI. Multivariate analysis of variables affecting the proportion of patients who received AI and had undergone ALND identified nodal status and type of surgery as significant.

CONCLUSIONS

Axillary lymph node dissection continues to be routinely applied in the treatment of breast cancer, and AI remains underused in patients at high risk for local regional relapse.

Survival and pattern of failure following locoregional recurrence of breast cancer

This study analyzed prognostic factors at primary diagnosis and at first recurrence for impact on survival after isolated locoregional failure. The aims were: (1) assessment of prognostic factors for time to second locoregional failure, distant failure, and survival in isolated locoregional recurrence of breast cancer after mastectomy; and (2) investigation of the impact of a second locoregional failure on dissemination and survival. Between 1983 and 1985, 99 patients who had undergone mastectomy and then developed isolated local and/or regional recurrences, were treated with radical excision and radiotherapy; none of these patients had distant metastases. Survival and the times to second local failure and distant metastasis were analyzed according to potential prognostic factors. The median follow-up was 123 months; 38 patients were still alive. Median survival was 89 months and the 10-year survival rate was 38%, with no difference between local and regional recurrences. A total of 43 patients developed a second locoregional recurrence after a median of 73 months; primary tumour size and initial node status were significant independent prognostic factors. The annual hazard rates for recurrence were similar for patients developing local failure or systemic recurrence. The 10-year rate of dissemination was 49% for patients with locoregional control, compared with 51% for patients who had a second locoregional recurrence. The prognostic factors for survival were node status at mastectomy and haemoglobin level at first recurrence. The development of a second locoregional recurrence was not associated with an increased risk of dissemination or reduced survival. Differences in prognostic factors for locoregional control and distant metastases suggest that these recurrences represent different biological entities that require different treatment strategies. However, as the achievement of locoregional control had no influence on prognosis, the use of systemic adjuvant therapy may be warranted in a subset of these patients.

Long-term Results of Postoperative Prophylactic Nodal Irradiation for Node-Positive, High-Risk Breast Cancer Patients

OBJECTIVE: To retrospectively evaluate the long-term results of postoperativenodal irradiation. Patients: A total of 271 patients with breast cancer treated between 1976 and1993 were analyzed retrospectively. All patients underwent modified radical mastectomy and exhibited extensive axillary lymph node involvement. METHODS: Of 271 patients, 116 were non-randomly selected for postoperative irradiation (RT)of the internal mammary and supraclavicular nodes. Intensive chemotherapy (CT) such as cyclophosphamide, methotrexate, and 5-FU (CMF) was not used for adjuvant systemic therapy. Eight clinical and laboratory parameters were evaluated for their significance with regard to survival and local control at theirradiated area. Each factor was tested for significance with uni- and multivariate analysis. RESULTS: The minimum and median follow-up periods for survivors were 37 and 104 months, respectively. Ten-year cause-specific overall survival (OS), disease free survival (DFS), and local control within the irradiated field (LC) for the whole cohort were 51.9%, 33.0% and 78.8%, respectively. Multivariate analysis showed that the estrogen receptor status and the number of involved nodes were themost significant prognostic factors for both OS and DFS in this group of patients. Adding RT did not improve either OS or DFS. For local control, radiation therapy as well as estrogen receptor status were significant prognostic factors. CONCLUSION: Although postoperative nodal irradiation clearly reduced the incidence of local recurrence, it did not improve the survival of high risk patients. A clinical trial which combines an intensive CT and postoperative radiotherapyshould be undertaken.

Locoregional failure rates in patients with involved axillary nodes after mastectomy and systemic therapy

Published series vary substantially in describing the incidence of locoregional failure after mastectomy among patients with involved axillary lymph nodes who receive systemic therapy. There are few data on such risks with regards to particular patient subsets (such as those defined by combinations of tumor size and nodal status). This article reviews the available data on these subjects as well as problems in their interpretation and clinical use.

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.

Postmastectomy radiation in patients with one to three positive axillary nodes receiving adjuvant chemotherapy: An unresolved issue

The rationale for postmastectomy radiation is based on the prevention of locoregional recurrence in the chest wall, regional lymphatics, or both. The randomized trials of postmastectomy radiation in patients with one to three positive nodes receiving adjuvant chemotherapy have shown a proportional reduction in locoregional recurrence rates of two thirds. The absolute benefit, however, varies with the magnitude of the risk in patients who do not receive radiation. The survival benefit from radiation is best explained by the prevention of an isolated locoregional recurrence, which could serve as a source of fatal distant metastases and parallels the difference in the total incidence of distant metastases. The current dilemma is to identify patients with one to three positive nodes who have had an adequate axillary dissection and remain at substantial risk for a locoregional recurrence despite adjuvant chemotherapy. The routine use of postmastectomy radiation in all axillary node-positive patients requires further evaluation.

Locoregional failure 10 years after mastectomy and adjuvant chemotherapy with or without tamoxifen without irradiation: experience of the Eastern Cooperative Oncology Group

PURPOSE

To assess patterns of failure and how selected prognostic and treatment factors affect the risks of locoregional failure (LRF) after mastectomy in breast cancer patients with histologically involved axillary nodes treated with chemotherapy with or without tamoxifen without irradiation.

PATIENTS AND METHODS

The study population consisted of 2,016 patients entered onto four randomized trials conducted by the Eastern Cooperative Oncology Group. The median follow-up time for patients without recurrence was 12.1 years (range, 0.07 to 19.1 years).

RESULTS

A total of 1,099 patients (55%) experienced disease recurrence. The first sites of failure were as follows: isolated LRF, 254 (13%); LRF with simultaneous distant failure (DF), 166 (8%); and distant only, 679 (34%). The risk of LRF with or without simultaneous DF at 10 years was 12.9% in patients with one to three positive nodes and 28.7% for patients with four or more positive nodes. Multivariate analysis showed that increasing tumor size, increasing numbers of involved nodes, negative estrogen receptor protein status, and decreasing number of nodes examined were significant for increasing the rate of LRF with or without simultaneous DF.

CONCLUSION

LRF after mastectomy is a substantial clinical problem, despite the use of chemotherapy with or without tamoxifen. Prospective randomized trials will be necessary to estimate accurately the potential disease-free and overall survival benefits of postmastectomy radiotherapy for patients in particular prognostic subgroups treated with presently used and future systemic therapy regimens.