Locoregional recurrence patterns after mastectomy and doxorubicin-based chemotherapy: implications for postoperative irradiation

The impact of bolus on clinical outcomes for post-mastectomy breast cancer patients treated with IMRT: data from China

PURPOSE

This study aims to investigate the effects of chest wall bolus in intensity-modulated radiotherapy (IMRT) technology on clinical outcomes for post-mastectomy breast cancer patients.

MATERIALS AND METHODS

This retrospective study included patients with invasive carcinoma ((y)pT0-4, (y)pN0-3) who received photon IMRT after mastectomy at the Affiliated Hospital of Qingdao University from 2014 to 2019. The patients were divided into two groups based on whether they received daily bolus application or not, and the baseline characteristics were matched using propensity score matching (PSM). Cumulative incidence (CI) of local recurrence (LR), locoregional recurrence (LRR), overall survival (OS) and disease-free survival (DFS) were evaluated with a log-rank test. Acute skin toxicity and late radiation pneumonia was analyzed using chi-square test.

RESULTS

A total of 529 patients were included in this study, among whom 254 (48%) patients received bolus application. The median follow-up time was 60 months. After matching, 175 well-paired patients were selected. The adjusted 5-year outcomes (95% confidence interval) in patients treated with and without bolus were, respectively: CI of LR 2.42% (0.04-4.74) versus 2.38% (0.05-4.65), CI of LRR 2.42% (0.04-4.74) versus 3.59% (0.73-6.37), DFS 88.12% (83.35-93.18) versus 84.69% (79.42-90.30), OS 94.21% (90.79-97.76) versus 95.86% (92.91-98.91). No correlation between bolus application and skin toxicity (P = 0.555) and late pneumonia (P = 0.333) was observed.

CONCLUSIONS

The study revealed a low recurrence rate using IMRT technology. The daily used 5 mm chest wall bolus was not associated with improved clinical outcomes.

Internal mammary node abnormality in imaging studies and treatment outcomes in patients with breast cancer

The clinical significance of mild internal mammary node (IMN) enlargement (Mild-IMN) is uncertain. This study aimed to evaluate the relationship between treatment outcomes and IMN status in patients with breast cancer who underwent postmastectomy radiation therapy between January 2010 and December 2018. Overall, 250 patients were categorized based on IMN status: Clinically normal IMN (Normal-IMN; n=172), Mild-IMN (n=39) and clinically metastatic IMN (cMet-IMN; n=39). None of the patients in the Normal- or Mild-IMN groups received IMN irradiation. In the cMet-IMN group, 25 patients underwent IMN irradiation with an IMN boost (10 Gy in 5 fractions), while 14 patients did not. The median follow-up time was 80.0 months (range, 7.2-147.6 months). The 7-year overall survival (OS), disease-free survival (DFS) and IMN recurrence-free survival (IRF) rates were 80.2, 73.0 and 93.4%, respectively. Multivariate analyses indicated that only cMet-IMN had a significant impact on OS [hazard ratio (HR), 1.66; 95% CI, 1.01-3.68; P=0.05] and DFS (HR, 1.91; 95% CI, 1.08-3.39; P=0.03), while cMet-IMN did not have a significant impact on IRF (HR, 1.66; 95% CI, 0.41-6.78; P=0.48). Additionally, receiving an IMN boost had no influence on OS (HR, 1.11; 95% CI, 0.37-2.34; P=0.84), DFS (HR, 1.28; 95% CI, 0.51-3.22; P=0.60) or IRF (HR, 1.94; 95% CI, 0.22-17.47; P=0.55). In conclusion, the impact of Mild-IMN on clinical outcomes was small. Although irradiation for cMet-IMN is important, the impact of the cMet-IMN boost with 10 Gy in 5 fractions on clinical outcomes may also be limited.

Radiotherapy to regional nodes in early breast cancer: an individual patient data meta-analysis of 14 324 women in 16 trials

BACKGROUND

Radiotherapy has become much better targeted since the 1980s, improving both safety and efficacy. In breast cancer, radiotherapy to regional lymph nodes aims to reduce risks of recurrence and death. Its effects have been studied in randomised trials, some before the 1980s and some after. We aimed to assess the effects of regional node radiotherapy in these two eras.

METHODS

In this meta-analysis of individual patient data, we sought data from all randomised trials of regional lymph node radiotherapy versus no regional lymph node radiotherapy in women with early breast cancer (including one study that irradiated lymph nodes only if the cancer was right-sided). Trials were identified through the EBCTCG's regular systematic searches of databases including MEDLINE, Embase, the Cochrane Library, and meeting abstracts. Trials were eligible if they began before Jan 1, 2009. The only systematic difference between treatment groups was in regional node radiotherapy (to the internal mammary chain, supraclavicular fossa, or axilla, or any combinations of these). Primary outcomes were recurrence at any site, breast cancer mortality, non-breast-cancer mortality, and all-cause mortality. Data were supplied by trialists and standardised into a format suitable for analysis. A summary of the formatted data was returned to trialists for verification. Log-rank analyses yielded first-event rate ratios (RRs) and confidence intervals.

FINDINGS

We found 17 eligible trials, 16 of which had available data (for 14 324 participants), and one of which (henceforth excluded), had unavailable data (for 165 participants). In the eight newer trials (12 167 patients), which started during 1989-2008, regional node radiotherapy significantly reduced recurrence (rate ratio 0·88, 95% CI 0·81-0·95; p=0·0008). The main effect was on distant recurrence as few regional node recurrences were reported. Radiotherapy significantly reduced breast cancer mortality (RR 0·87, 95% CI 0·80-0·94; p=0·0010), with no significant effect on non-breast-cancer mortality (0·97, 0·84-1·11; p=0·63), leading to significantly reduced all-cause mortality (0·90, 0·84-0·96; p=0·0022). In an illustrative calculation, estimated absolute reductions in 15-year breast cancer mortality were 1·6% for women with no positive axillary nodes, 2·7% for those with one to three positive axillary nodes, and 4·5% for those with four or more positive axillary nodes. In the eight older trials (2157 patients), which started during 1961-78, regional node radiotherapy had little effect on breast cancer mortality (RR 1·04, 95% CI 0·91-1·20; p=0·55), but significantly increased non-breast-cancer mortality (1·42, 1·18-1·71; p=0·00023), with risk mainly after year 20, and all-cause mortality (1·17, 1·04-1·31; p=0·0067).

INTERPRETATION

Regional node radiotherapy significantly reduced breast cancer mortality and all-cause mortality in trials done after the 1980s, but not in older trials. These contrasting findings could reflect radiotherapy improvements since the 1980s.

FUNDING

Cancer Research UK, Medical Research Council.

Machine learning‑based radiomics models for prediction of locoregional recurrence in patients with breast cancer

Locoregional recurrence (LRR) is the predominant pattern of relapse after definitive breast cancer treatment. The present study aimed to develop machine learning (ML)-based radiomics models to predict LRR in patients with breast cancer by using preoperative magnetic resonance imaging (MRI) data. Data from patients with localized breast cancer that underwent preoperative MRI between January 2013 and December 2017 were collected. Propensity score matching (PSM) was performed to adjust for clinical factors between patients with and without LRR. Radiomics features were obtained from T2-weighted with and without fat-suppressed MRI and contrast-enhanced T1-weighted with fat-suppressed MRI. In the present study five ML models were designed, three base models (support vector machine, random forest, and logistic regression) and two ensemble models (voting model and stacking model) composed of the three base models, and the performance of each base model was compared with the stacking model. After PSM, 28 patients with LRR and 86 patients without LRR were included. Of these 114 patients, 80 patients were randomly selected to train the models, and the remaining 34 patients were used to evaluate the performance of the trained models. In total, 5,064 features were obtained from each patient, and 47-51 features were selected by applying variance threshold and least absolute shrinkage and selection operator. The stacking model demonstrated superior performance in area under the receiver operating characteristic curve (AUC), with an AUC of 0.78 compared to a range of 0.61 to 0.70 for the other models. An external validation study to investigate the efficacy of the stacking model of the present study was initiated and is still ongoing (Korean Radiation Oncology Group 2206).

Post-mastectomy radiotherapy for women with early breast cancer and one to three positive lymph nodes

BACKGROUND

Continual improvement in adjuvant therapies has resulted in a better prognosis for women diagnosed with breast cancer. A surrogate marker used to detect the spread of disease after treatment of breast cancer is local and regional recurrence. The risk of local and regional recurrence after mastectomy increases with the number of axillary lymph nodes affected by cancer. There is a consensus to use radiotherapy as an adjuvant treatment after mastectomy (postmastectomy radiotherapy (PMRT)) in women diagnosed with breast cancer and found to have disease in four or more positive axillary lymph nodes. Despite data showing almost double the risk of local and regional recurrence in women treated with mastectomy and found to have one to three positive lymph nodes, there is a lack of international consensus on the use of PMRT in this group.

OBJECTIVES

To assess the effects of PMRT in women diagnosed with early breast cancer and found to have one to three positive axillary lymph nodes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov up to 24 September 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). The inclusion criteria included women diagnosed with breast cancer treated with simple or modified radical mastectomy and axillary surgery (sentinel lymph node biopsy (SLNB) alone or those undergoing axillary lymph node clearance with or without prior SLNB). We included only women receiving PMRT using X-rays (electron and photon radiation), and we defined the radiotherapy dose to reflect what is currently being recommended (i.e. 40 Gray (Gy) to 50 Gy in 15 to 25/28 fractions in 3 to 5 weeks. The included studies did not administer any boost to the tumour bed. In this review, we excluded studies using neoadjuvant chemotherapy as a supportive treatment before surgery.

DATA COLLECTION AND ANALYSIS

We used Covidence to screen records. We collected data on tumour characteristics, adjuvant treatments and the outcomes of local and regional recurrence, overall survival, disease-free survival, time to progression, short- and long-term adverse events and quality of life. We reported on time-to-event outcome measures using the hazard ratio (HR) and subdistribution HR. We used Cochrane's risk of bias tool (RoB 1), and we presented overall certainty of the evidence using the GRADE approach.

MAIN RESULTS

The RCTs included in this review were subgroup analyses of original RCTs conducted in the 1980s to assess the effectiveness of PMRT. Hence, the type and duration of adjuvant systemic treatments used in the studies included in this review were suboptimal compared to the current standard of care. The review involved three RCTs with a total of 829 women diagnosed with breast cancer and low-volume axillary disease. Amongst the included studies, only a single study pertained to the modern-day radiotherapy practice. The results from this one study showed a reduction of local and regional recurrence (HR 0.20, 95% confidence interval (CI) 0.13 to 0.33, 1 study, 522 women; low-certainty evidence) and improvement in overall survival with PMRT (HR 0.76, 95% CI 0.60 to 0.97, 1 study, 522 women; moderate-certainty evidence). One of the other studies using radiotherapy techniques that do not reflect modern-day practice reported on disease-free survival in women with low-volume axillary disease (subdistribution HR 0.63, 95% CI 0.41 to 0.96, 1 study, 173 women). None of the included studies reported on PMRT side effects or quality-of-life outcome measures.

AUTHORS' CONCLUSIONS

Based on one study, the use of PMRT in women diagnosed with breast cancer and low-volume axillary disease indicated a reduction in locoregional recurrence and an improvement in survival. There is a need for more research to be conducted using modern-day radiotherapy equipment and methods to support and supplement the review findings.

Risk factors to identify the indication for regional nodal irradiation in T1-2N1M0 breast cancer: A joint analysis of 4,243 real-world cases from two institutions

Purpose

The aim of this study is to evaluate the role of regional nodal irradiation (RNI) in patients with T1-2N1M0 breast cancer and to identify the subgroup that could benefit from RNI.

Methods and materials

A total of 4,243 women with pT1-2N1M0 breast cancer treated at two institutions in China were retrospectively reviewed. Survival rates were calculated by the Kaplan-Meier method and compared by the log-rank test. The association of risk factors with survival outcomes was evaluated using multivariable proportional hazards regression.

Results

A total of 932 patients (22.0%) received RNI. At a median follow-up of 5.9 years, the 5-year locoregional recurrence (LRR), distant metastasis (DM), disease-free survival (DFS), and overall survival (OS) rates were 4.0% and 7.2% (P = 0.001), 13.2% and 10.6% (P = 0.465), 85.0% and 84.7% (P = 0.131), and 93.9% and 92.8% (P = 0.004) in the RNI and non-RNI groups, respectively. Multivariate analysis revealed that RNI was an independent prognostic factor for lower LRR (P = 0.001) and longer DFS (P = 0.013). Patients were stratified into low-, intermediate-, and high-risk groups based on the eight non-therapeutic risk factors. RNI significantly decreased the 5-year LRR (2.2% vs. 7.0%, P = 0.001) and improved the 5-year DFS (88.8% vs. 84.9%, P = 0.015) and OS (95.8% vs. 93.9%, P = 0.010) in the intermediate-risk group. However, neither the low-risk group nor the high-risk group had survival benefit from RNI.

Conclusion

T1-2N1M0 breast cancer is a heterogeneous disease. We found that RNI only improved survival in the intermediate-risk group. It might be omitted in low-risk patients, and the role of RNI in high-risk patients needs further study.

Extranodal extension, an international survey on its evaluation and reporting in breast cancer patients

Lymph node metastasis is the most important prognostic factor for breast cancer patients. In addition to the number of nodes involved and the largest metastatic focus, extranodal extension (ENE) is also used to subclassify breast cancer patients into different risk groups. More recently, pathologists are required to report the size/extent of ENE per the new CAP guideline, as it seems to be associated with more axillary nodal burden and/or a worse prognosis. Although the definition of ENE is largely understood and agreed upon among pathologists around the world, evaluation and reporting for the size of ENE are not. To understand current practice, we conducted an international survey among pathologists who are interested in breast pathology. A total of 70 pathologists responded. The results showed that (1) 98% of the participants reported the presence or absence of ENE and 61% also reported the size of ENE in millimeter (mm). (2) There was no uniform method of measuring the size of ENE; 47% measured the largest dimension regardless of orientation, while 30% measured the largest perpendicular distance from the capsule. (3) The most common factors affecting the accuracy in diagnosis of ENE are the presence of lymphovascular invasion (LVI), lack of capsule integrity, and the presence of fatty hilar or fatty replacement of a lymph node. (4) 71% felt that the H&E stain is adequate to evaluate ENE, deeper levels and IHC analysis for vascular and cytokeratin markers can be helpful if needed. (5) 75% agreed that there is an urgent need to standardize the measurement and reporting for ENE. Our survey highlights the variation in ENE evaluation and the need for its standardization in breast cancer patients with axillary node metastasis.

Management of Long-Term Sores and Ulcers of Breast Cancer Survivors With Chinese Herbal Medicines: A Case Report

BACKGROUND

The treatment of long-term sores and ulcers of breast cancer metastatic recurrence is a serious challenge with successful cases rarely being documented. Herein we reported a successful case using the internal vitality supporting method of Chinese herbal medicine (CHM).

CASE SUMMARY

A 59-year-old female Chinese patient, 10 years after breast cancer surgery, developed metastatic lesions in the lung. Thereafter she received radiofrequency ablation and adjuvant treatments for 1 year with severe sequelae, a right unhealed sore and ulcer. She became frustrated and depressive. And subsequently sought exclusive treatment under the guidance of a Traditional Chinese Medicine (TCM) physician. The patient's condition was categorized as a Qi (or vitality) deficiency-related sore and ulcer. In the next six months, the patient still follows a traditional Chinese medicine therapeutic regimen based on the internal vitality supporting method of Chinese herbs.

CONCLUSION

The sore and ulcer from the surgical wound were healed. Up to now, the tumor markers have remained stable. TCM personalized survivorship treatment and psychosocial support can help patients improve their quality of life after acute treatment and in the long-term for cancer survivors.

How to Perform Repeat Sentinel Node Biopsy Safely After a Previous Mastectomy: Technical Features and Oncologic Outcomes

BACKGROUND

The latest National Comprehensive Cancer Network Breast Cancer Guidelines still discourage repeat sentinel node biopsy (SNB) after mastectomy, and the largest multicentric study available reports only 35 cases in the absence of previous axillary dissection (AD).

METHODS

From January 2003 to November 2018, 89 patients of the European Institute of Oncology with local recurrence of breast cancer after mastectomy, free of distant metastases, with a clinically negative axilla and a negative axillary ultrasound, in absence of AD, underwent lymphatic mapping before wide local excision.

RESULTS

During surgery, SNB was successful for 99% of the patients, with 14% being metastatic. Additional metastatic nodes removed by AD after a positive sentinel node occurred in 82% of cases. After a medium follow-up period of 3.7 years, the overall survival rate was 96.7%, and the disease-free survival rate was 84.4%. No axillary relapse after AD was recorded. One patient who refused human epidermal growth factor receptor 2 (HER2)-targeted treatment experienced ipsilateral axillary recurrence after a negative repeat SNB. The first axillary level was never directly irradiated because all the patients with positive repeat SNB underwent AD. For invasive luminal-like HER2-negative recurrences, the metastatic sentinel node was significantly associated with the choice to prescribe adjuvant chemotherapy (p = 0.003).

CONCLUSIONS

In specialized centers, repeat axillary SNB for patients with local recurrence after mastectomy in the absence of previous AD can represent a safe option for detection and removal of occult axillary disease that would otherwise not be excised/irradiated to achieve better local control and could possibly influence the choice of adjuvant treatments.

Locoregional recurrence in skin-sparing and nipple-sparing mastectomies

BACKGROUND

Skin- and nipple-sparing mastectomies (SSMs/NSMs) present as an alternative for patients requiring mastectomy, with better aesthetic results. We aimed to evaluate the locoregional recurrence (LRR) rate and its predictive factors.

METHODS

Retrospective analysis of all consecutive cases of SSM and NSM for a primary diagnosis of in situ or invasive breast cancer, at a national cancer center, from January 1st, 2013 to May 31st, 2019. The primary outcome was LRR. Secondary outcomes included LRR predictive factors, overall survival (OS), and disease-free survival (DFS).

RESULTS

There were included 461 patients; 402 (87%) with invasive carcinoma. The median age was 46 (interquartile range [IQR]: 40-53) years. Ninety (20%) patients had locally advanced disease. LRR rate was 3.0%, with a median follow-up time of 39 (IQR: 21-59) months. The median time to recurrence was 22 (IQR: 10-45) months. Factors independently associated with LRR were high histological grade, negative estrogen receptor status, and high Ki67 (p < 0.05). OS was 94.8% and DFS was 92.8%. LRR was associated with decreased OS.

DISCUSSION

SSM and NSM present as a safe approach to breast cancer requiring mastectomy, including selected patients with a locally advanced tumor. The associated LRR rate is 3.0%, with risk factors being high grade, negative estrogen receptor status, and high Ki67.

Unusual sonographic appearance of breast cancer metastasis to the pectoralis muscle

Breast cancer is one of the most common malignancies in women. It frequently metastasizes to the lungs, liver, and bone. Breast cancer metastasis to skeletal muscles is rare. Chest wall recurrence in patients that have undergone mastectomy is the most frequent form of local recurrence, and it is generally accompanied by nodules or masses on the chest wall. Here, we describe a case of the unusual appearance of invasive lobular cancer metastasis to the pectoral muscles without discrete nodules or masses in a patient who had undergone mastectomy 12 years ago.

Postmastectomy radiation therapy and survival outcome in older patients with T1-2N1 breast cancer

Background

The prognostic impact of postmastectomy radiation therapy (PMRT) on contemporary older patients with T1-2N1 breast cancer is unclear. We aimed to investigate the effect of PMRT in this setting.

Methods

Leveraging the Surveillance, Epidemiology, and End Results (SEER) program data from 2004 to 2015, 7052 patients aged 70 years or older with T1-2N1 breast cancer were identified for this propensity-matched analysis. Fine and Gray competing risks regression was conducted to explore the correlation between PMRT and breast cancer-specific survival, in subgroups defined by tumor size and positive lymph nodes.

Results

The median follow-up was 60.1 months (interquartile range, 28.0 to 87.0). Among propensity-matched patients, multivariate analysis identified an association between PMRT and decreased breast cancer mortality (BCM; HR 0.637; 95 % CI 0.436–0.931; P = 0.020) in patient subset with three positive nodes and tumors 2–5 cm in size, and this benefit was limited to patients with three positive nodes and tumors 2–5 cm in size who did not receive chemotherapy. In patient subsets who received chemotherapy, no association between PMRT and BCM was found.

Conclusion

PMRT was not associated with BCM in older patients with T1-2N1 breast cancer who received chemotherapy. The benefit of PMRT was limited to those with three positive nodes and tumors 2–5 cm in size who did not receive chemotherapy.

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46.0 % older patients with T1-2N1 breast cancer received postmastectomy radiation therapy (PMRT).

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28.8 % older patients with T1-2N1 breast cancer received chemotherapy.

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PMRT was beneficial for those with three positive nodes and tumors 2–5 cm in size who did not receive chemotherapy.

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No correlation between PMRT and BCM was found in patients who received chemotherapy.

The Survival Effect of Chest Wall With or Without Regional Lymphatic Radiotherapy for Breast Cancer Patients With T3~4N0M0

Background

Peripheral lymphatic radiotherapy in patients with pT3N0M0 and pT4N0M0 breast cancer has been a matter of considerable debate among radiation oncologists. This is the first report in a non-Caucasian population.

Patients and Methods

The study included 165 pT3N0M0 and pT4N0M0 patients. Univariate, multivariate, propensity score matching (PSM), and Kaplan-Meier analyses were conducted to evaluate the survival of patients. We also review all the literature about regional lymph nodes radiation in T3-4N0M0 patients and summarize them with tables to compare with the present study.

Results

The median follow-up duration was 58.7 months. Multivariate analyses showed that advance T stage and grade were dependent poor prognostic factors for OS, DMFS, LRFS, and DFS between group A (chest wall radiation) and group B (chest wall and regional lymph nodes radiation). The overall survival (OS), disease-free survival (DFS), local relapse-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were not significantly different between group A and group B. The 5-year OS rate was 92.3% vs 89.7% for group A and group B, respectively (P=0.819). The 5-year LRFS rate was 94.9% vs 94.3% for group A and group B, respectively (P=0.852). Fifty-four pairs of patients were selected after propensity score matching (PSM) analysis was conducted. There was also no significant difference between group A and group B in regard to the OS, DFS, LRFS, and DMFS rates after PSM. The patients included in previous studies were all Caucasians, and our study was focused on non-Caucasians. The cases of previous studies were 10 to 20 years ago, but our study has more recent cases. The radiotherapy techniques of previous studies were conventional, and the techniques used in our study were three-dimensional conformal radiotherapy (3DCRT) or intensity modulated radiotherapy (IMRT).

Conclusion

Both our study and previous studies suggested that regional lymph nodes radiation cannot improve the survival rate for breast cancer patients with T3-4N0M0 in non-Caucasian population. Advance T stage and grade were the dependent poor prognostic factors for T3-4N0M0 patients.

Mastectomy alone for pT1-2 pN0-1 breast cancer patients: when postmastectomy radiotherapy is indicated

PURPOSE

To assess outcome of breast cancer (BC) stages pT1-2 N0-1 after mastectomy alone and to identify prognostic factors calling for the need of postmastectomy radiotherapy.

METHODS

Patients who were not eligible for breast conserving surgery (BCS) were operated on with mastectomy between 1998 and 2008. Locoregional (LRR), distant (DM) control and breast cancer specific survival (BCSS) were retrospectively evaluated. Cumulative incidence (CI) of events was estimated according to Kalbfleisch and Prentice while Gray's test tested difference. Kaplan-Meier method for survival and Cox proportional hazards model for univariable and multivariable analysis were used. A matched pair analysis between mastectomy alone and BCS plus whole breast irradiation (WBI), using the propensity score method, was performed.

RESULTS

1281 pT1-2 N0 and 1081 pT1-2 N1 were identified. Median follow-up was 8.2 years (9.2 years for survival). Overall, LRR rate was low for both N0 and N1 subgroups (10-year CI, 8.8% and 10.9%, respectively). Young age, lymphovascular invasion and Ki-67 ≥ 20% were proved to be statistically significant prognostic factors at multivariable analysis. The combination of ≥ 2 risk factors increased LRR rate to ≥ 15%. Risk factors combination weighed on LRR rate more than nodal status itself. DM rate doubled moving from negative to positive nodal status (10-year CI 10.5% versus 20.3%, respectively). BCSS remained high in both N0 and N1 subgroups (10-year CI 92.4% versus 84.5%, respectively). Remarkably, all the molecular subtypes except Luminal A significantly affected DM and BCSS both in the N0 and N1 subgroups. Nodes number significantly impacted on DM and BCSS but not on locoregional control. In the matched pair analysis, WBI decreased nodal recurrence rate and improved distant control, without affecting survival.

CONCLUSIONS

Selected patients, namely those with at least two additional risk factors, presented high enough LRR risk to support the use of postmastectomy radiotherapy in both N0 and N1 subgroups. Moreover, the observation that radiotherapy may provide benefits that go beyond local control deserves to be further investigated.

Clinical relevance of a degree of extracapsular extension in a sentinel lymph node in breast cancer patients: a single-centre study

In some breast cancer (BC) patients, an examination of lymph nodes dissected during sentinel lymph node biopsy (SLNB) demonstrates a presence of metastatic lesions and extracapsular extension (ECE) in a SLN. This study aimed to evaluate clinical relevance of ECE in BC patients. This is a retrospective analysis of 891 patients with cancer metastases to SLN, referred to supplementary axillary lymph node dissection (ALND), hospitalized between Jan 2007 and Dec 2017. Clinical and epidemiological data was evaluated. Long-term treatment outcomes were analysed. In 433 (48.6%) patients, cancer metastases were limited to the SLN (group I), in 61 (6.8%) patients the SLN capsule was exceeded focally (≤ 1 mm—group II). In 397 (44.6%) patients, a more extensive ECE was found (> 1 mm—group III). Metastases to non-sentinel lymph nodes (nSLNs) were diagnosed in 27.0% patients from group I, 44.3% patients from group II and in 49.6% patients from group III. No statistically significant differences were observed in long-term treatment outcomes for compared groups. The presence of ECE is accompanied by a higher stage of metastatic lesions in the lymphatic system. The differences in this respect were statistically significant, when compared to the group of ECE(−) patients. ECE, regardless of its extent, did not impact the long-term treatment results. ECE remains an indication for supplementary ALND and for other equivalent cancer treatment procedures, regardless of ECE size.

Lymph nodal radiotherapy in breast cancer: what are the unresolved issues?

Introduction: Sentinel lymph node biopsy (SLNB) is the gold standard in invasive breast cancer. Axillary dissection (ALND) is controversial in some presentations.Areas covered: Key questions were formulated and explored focused on four different scenarios in adjuvant axillary radiation management in early and locally advanced breast cancer. Answers to these questions were searched in MEDLINE, PubMed from June 1946 to August 2020. Clinical trials, retrospective studies, international guidelines, meta-analysis, and reviews were explored.Expert opinion: Analysis according to biological disease characteristics is necessary to establish the impact of ALND avoidance in unexpectedly positive SLNB (pN1) in cN0 patients. A low-risk probability of axillary recurrence was observed if axillary radiotherapy (ART) or ALND were offered without impact on outcomes. Adjuvant RNI in pT1-3 pN1 treated with mastectomy or BCS should be proposed in unfavorable disease and risk factors. In ycN0 after NACT, SLNB can be offered in selected cases or ALND should be performed. After SLNB post-NACT (ypN1), ALND and adjuvant radiotherapy are mandatory.

Utility of post mastectomy radiotherapy among patients with T1/ T2 N1 disease: A retrospective cohort study

Background

Pakistan has the highest incidence of breast cancer among Asian Countries but there is insufficient representation of local data addressing breast cancer treatment and outcome. We sought to determine the role of post-mastectomy radiotherapy (PMRT) in T1- T2 breast cancer with 1–3 positive axillary lymph nodes.

Methods

Data was reviewed retrospectively of total 755 patients out of which 291 received PMRT and 464 did not from two large breast cancer centres.

Results

With a median follow up of 78 months, 4 (4.5%) patients developed loco regional recurrence (LRR) in the PMRT group while a substantial number 74 (24.4%) recurred in the non PMRT group (p = 0.000). Loco regional free survival rate (LRFS) and overall survival rate (OS) was significantly better for PMRT patients than non-PMRT patients (P = <0.000). Multivariate analysis identified young age, lymphovascular invasion, extra capsular extension, triple negative and ER/PR negative were independent prognostic factors affecting loco regional free survival (LRFS).

Conclusion

Disease recurrence is a substantial issue in 1–3 node group despite early stage, PMRT has an instrumental effect in improving LRFS and OS.

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Disease recurrence is a significant concern in post mastectomy patients with T1-T2 N1 disease.

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Post mastectomy radiotherapy (PMRT) has a substantial effect in reducing disease recurrence in this subset of patients.

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PMRT improves disease free survival rate (DFS) and overall survival rate (OS).

Prognosis and Prophylactic Regional Nodal Irradiation in Breast Cancer Patients With the First Isolated Chest Wall Recurrence After Mastectomy

Background and Purpose

Optimal radiation target volumes for breast cancer patients with their first isolated chest wall recurrence (ICWR) after mastectomy are controversial. We aimed to analyze the regional failure patterns and to investigate the role of prophylactic regional nodal irradiation (RNI) for ICWR.

Materials and Methods

Altogether 205 patients with ICWR after mastectomy were retrospectively analyzed. Post-recurrence progression-free survival (PFS) and overall survival (OS) rates were calculated by Kaplan-Meier method and the differences were compared with Log-rank test. Competing risk model was used to estimate the subsequent regional recurrence (sRR) and locoregional recurrence (sLRR) rates, and the differences were compared with Gray test.

Results

The 5-year sRR rate was 25.2% with median follow-up of 88.6 months. Of the 52 patients with sRR, 30 (57.7%) recurred in the axilla, 29 (55.8%) in supraclavicular fossa (SC), and five (9.6%) in internal mammary nodes. Surgery plus radiotherapy was independently associated with better sLRR and PFS rates (p<0.001). The ICWR interval of ≤ 4 years was associated with unfavorable sRR (p=0.062), sLRR (p=0.014), PFS (p=0.001), and OS (p=0.005). Among the 157 patients who received radiotherapy after ICWR, chest wall plus RNI significantly improved PFS (p=0.004) and OS (p=0.021) compared with chest wall irradiation alone. In the 166 patients whose ICWR interval was ≤ 4 years, chest wall plus RNI provided the best PFS (p<0.001) and OS (p=0.022) compared with chest wall irradiation alone or no radiotherapy.

Conclusion

Patients with ICWR have a high-risk of sRR in SC and axilla. Chest wall plus RNI is recommended.

Discordance between Primary Breast Cancer and Ipsilateral Breast Cancer Tumor Recurrence as a Function of Distance

Background: Risk factors for ipsilateral breast cancer tumor recurrence (IBTR) are well established and include grading, nodal status, and receptor status. Little is known about the influence of the local distance between the primary tumor and recurrences on changes in tumor characteristics and prognosis. Methods: In a retrospective setting, we analyzed primary breast cancers and their recurrences. Localizations of primary and recurrent breast cancer were recorded to calculate the relative distance in pixels. Analysis was performed regarding tumor characteristics, relative distance between both, and their impact on breast cancer prognosis. Results: In a cohort of 142 patients with ipsilateral recurrence, no statistically significant difference could be shown in the change in tumor characteristics depending on distance. Progesterone receptor (PR) and estrogene receptor (ER) status changed in 22.7% and 14.9% of cases, respectively. human epidermal growth factor receptor 2 (ERBB2, HER2) status changed in 18.3% of cases. Survival was in accordance with the literature, with luminal-A-like tumors as best and triple negative breast cancers (TNBC) as worst prognosis. With a threshold of 162 pixels, the survival was significantly better in the group with shorter distance. Conclusion: Change in tumor characteristics from primary breast cancer to recurrence occurs more often in PR than ER. In contrast to other work, in this dataset, recurrences with a larger distance to the primary tumor had a worse prognosis in univariate analysis. A Cox model might indicate the possibility that this influence is independent of other risk factors.

Risk-Adapted Postmastectomy Radiotherapy Decision Based on Prognostic Nomogram for pT1-2N1M0 Breast Cancer: A Multicenter Study

PURPOSE

The aim of this study was to develop a widely accepted prognostic nomogram and establish a risk-adapted PMRT strategy based on locoregional recurrence for pT1-2N1M0 breast cancer.

METHODS AND MATERIALS

A total of 3,033 patients with pT1-2N1M0 breast cancer treated at 6 participating institutions between 2000 and 2016 were retrospectively reviewed. A nomogram was developed to predicted locoregional recurrence-free survival (LRFS). A propensity score-matched (PSM) analyses was performed in risk-adapted model.

RESULTS

With the median follow-up of 65.0 months, the 5-year overall survival (OS), disease free survival (DFS) and LRFS were 93.0, 84.8, and 93.6%, respectively. There was no significant difference between patients who received PMRT or not for the entire group. A nomogram was developed and validated to estimate the probability of 5-year LRFS based on five independent factors including age, primary tumor site, positive lymph nodes number, pathological T stage, and molecular subtype that were selected by a multivariate analysis of patients who did not receive PMRT in the primary cohort. According to the total nomogram risk scores, the entire patients were classified into low- (40.0%), moderate- (42.4%), and high-risk group (17.6%). The 5-year outcomes were significantly different among these three groups (P<0.001). In low-risk group, patients who received PMRT or not both achieved a favorable OS, DFS, and LRFS. In moderate-risk group, no differences in OS, DFS, and LRFS were observed between PMRT and no PMRT patients. In high-risk group, compared with no PMRT, PMRT resulted in significantly different OS (86.8 vs 83.9%, P = 0.050), DFS (77.2 vs 70.9%, P = 0.049), and LRFS (90.8 vs. 81.6%, P = 0.003). After PSM adjustment, there were no significant differences in OS, DFS, and LRFS in low-risk and moderate-risk groups. However, in the high-risk group, PMRT still resulted in significantly better OS, DFS and improved LRFS.

CONCLUSIONS

The proposed nomogram provides an individualized risk estimate of LRFS in patients with pT1-2N1M0 breast cancer. Risk-adapted PMRT for high-risk patients is a viable effective strategy.

Risk stratification for prediction of locoregional recurrence in patients with pathologic T1-2N0 breast cancer after mastectomy

Background

Previous studies have revealed that nearly 15–20% of selected high-risk T1–2N0 breast cancers developed LRR after mastectomy. This study is aim to indentify the risk factors of locoregional recurrence (LRR) in patients with pathologic T1–2N0 breast cancer after mastectomy in a real-world and distinguish individuals who warrant postmastectomy radiotherapy (PMRT).

Methods

Female patients treated from 1999 to 2014 in National Cancer Center of China were retrospectively reviewed. A competing risk model was developed to estimate the cumulative incidence of LRR with death treated as a competing event.

Results

A total of 4841 patients were eligible. All underwent mastectomy plus axillary nodes dissection or sentinel node biopsy without PMRT. With a median follow-up of 56.4 months (range, 1–222 months), the 5-year LRR rate was 3.9%.Besides treatment era, age ≤ 40 years old (p < 0.001, hazard ratio [HR] = 2.262), tumor located in inner quadrant (p < 0.001, HR = 2.236), T2 stage (p = 0.020, HR = 1.419), and negative expressions of estrogen receptor (ER) and progesterone receptor (PR) (p = 0.032, HR = 1.485), were patients-related independent risk factors for LRR. The 5-year LRR rates were 1.7, 3.5, and 15.0% for patients with zero, 1–2, and 3–4 risk factors (p < 0.001).

Conclusions

Risk Stratification based on age, T stage, ER/PR status and tumor location can stratify patients with pT1–2 N0 breast cancer into subgroups with different risk of LRR. PMRT might be suggested for patients with 3–4 risk factors.

Palpable Masses after Mastectomy: Differentiating Benign Postoperative Findings from Recurrent Disease

Due to postoperative changes, imaging evaluation of patients with palpable masses after mastectomy can be challenging. There is considerable overlap between the imaging characteristics of recurrent disease and benign postoperative findings in patients with or without breast reconstruction. US is the initial modality of choice for evaluating palpable masses in most patients after mastectomy. In cases where US findings are not classic, however, other modalities are useful in problem solving, including both mammography and MRI. It is imperative that radiologists are educated about benign and malignant imaging characteristics, further workup considerations, and appropriate management. In cases where findings are not characteristic across multiple imaging modalities, biopsy may be warranted.

Does Failure to Achieve Pathologic Complete Response with Neoadjuvant Chemotherapy Identify Node-Negative Patients Who Would Benefit from Postmastectomy Radiation or Regional Nodal Irradiation?

BACKGROUND

Postmastectomy radiation (PMRT) and regional nodal irradiation (RNI) improve outcomes for patients at high risk of locoregional recurrence (LRR). Node-negative patients with the triple-negative (TN) subtype and those who do not have a pCR with neoadjuvant chemotherapy (NAC) are at increased risk for LRR, but whether the absolute risk for LRR is high enough to justify PMRT/RNI is uncertain.

METHODS

Patients with cT1-T3N0 and pN0 disease treated with NAC who had residual disease in the breast were identified from a prospective database. Patients were eligible for the study if they had mastectomy or breast-conserving therapy with negative margins and whole-breast radiation. Those receiving PMRT or RNI were excluded. Actuarial rates were estimated using the cumulative incidence function.

RESULTS

The 227 patients in this study had a mean age was 51.4 ± 12.6 years, and 82 (36.1%) were TN. During a median follow-up period of 35 months, nine LRR events occurred. The overall crude and actuarial 3-year LRR rates were 4.4% and 5.9%, respectively. The crude LRR rate for the TN patients was 7.4%, and the 3-year actuarial rate was 10.1%. The hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-) patients had a crude LRR rate of 2.8% and a 3-year actuarial rate of 3.2%. The HER2+ patients had a crude LRR rate of 2.7% and a 3-year actuarial rate of 3.3%.

CONCLUSIONS

Locoregional recurrence is uncommon for patients with node-negative HR+/HER2- and HER2+ tumors who have residual disease in the breast; however, TN patients have LRR rates that approach 10% at 3 years, suggesting a possible role for PMRT/RNI for node-negative TN patients. Additional follow-up with more patients is needed for definitive conclusions.

Locoregional recurrence patterns in women with breast cancer who have not undergone post-mastectomy radiotherapy

Background

To analyze the patterns of locoregional recurrence in breast cancer patients after mastectomy.

Methods

The retrospective study included 7073 women with breast cancer without post-mastectomy radiotherapy: 4604 (65.1%) had pT1–2 N0 disease (low risk); 2042 (28.9%), pT1–2 N1 (intermediate risk); and 427 (6.0%), pT3–4 and/or pN2–3, or pT1–2 N1 after neoadjuvant chemotherapy (high risk). The distribution of cumulative locoregional recurrence was analyzed. The local recurrence and regional recurrence rates were estimated by the Kaplan-Meier method, and differences were compared with the log-rank test. Multivariate analysis was performed using Cox logistic regression analysis.

Results

In the median follow-up of 63.0 months, 469 patients had locoregional recurrence: chest wall recurrence in 238 (50.7%) cases, supraclavicular/infraclavicular nodes in 236 (50.3%) cases, axilla in 92 (19.6%), and internal mammary nodes in 50 (10.7%) cases. The 5-year local recurrence and regional recurrence rates were 2.5 and 4.4%, respectively. Subgroup analysis of the three risk groups and five molecular subtypes (luminal A, luminal B-Her2 negative, luminal B-Her2 positive, Her2-enriched, and triple negative) also showed that the chest wall and supraclavicular/infraclavicular nodes were the most common recurrence sites. Age, tumor location, T stage, N stage, and hormone receptor status were independent prognostic factors for both local recurrence and regional recurrence (p < 0.05).

Conclusions

The chest wall and supraclavicular/infraclavicular nodes are common sites of locoregional recurrence in breast cancer, irrespective of disease stage or molecular subtype, and the prognostic factors for local recurrence and regional recurrence are similar. Therefore, chest wall and supraclavicular/infraclavicular nodes irradiation should always be considered in post-mastectomy radiotherapy.

Patterns of Chest Wall Recurrence and Suggestions on the Clinical Target Volume of Breast Cancer: A Retrospective Analysis of 121 Postmastectomy Patients

Purpose

Radiotherapy is a powerful strategy to prevent chest wall recurrence (CWR) of postmastectomy breast cancer (BC). This retrospective study aims at analyzing patterns of CWR to explore the delineation of clinical target volume.

Patients and Methods

Detailed clinicopathological information of postmastectomy BC patients with CWR was collected from our single cancer center based on clear criteria. To describe recurrent positions more accurately, the chest wall was divided into three layers: skin layer (skin and subcutaneous tissues), pectoralis layer (pectoralis major and minor), and rib layer (rib and intercostal muscle). The frequency distribution of recurrence location and its association with clinical pathological factors were analyzed.

Results

A total of 121 postmastectomy BC with CWR were included in this study. The percentages of breast tumor located in the upper outer quadrant, upper inner quadrant, lower inner quadrant, lower outer quadrant, overlapping quadrant, and areola area were 31.0% (35/113), 26.5% (30/113), 12.4% (14/113), 5.3% (6/113), 21.1% (25/113), and 2.7% (3/113), respectively. HER2-positive BC (51/113, 45.1%) is the most common BC subtype. Analysis on the patterns of CWR showed that recurrences locating in the skin layer, pectoralis layer, rib layer, mixed layers, and incision periphery accounted for 58.6% (68/116), 9.5% (11/116), 1.7% (2/116), 30.2% (35/116), and 60.5% (46/76), respectively. Rates of recurrences located in the skin and/or pectoralis layers for all BC patients, patients with concomitant distance metastasis, and patients without concomitant distance metastasis were 82.8% (96/116), 85.9% (49/57), and 81.0% (47/58), respectively.

Conclusion

For BC patients receiving mastectomy, skin, subcutaneous tissues, pectoralis, and area around incision have a high risk of recurrence, which should be paid more attention in chest wall radiotherapy.

Locoregional recurrence risk after neoadjuvant chemotherapy: A pooled analysis of nine prospective neoadjuvant breast cancer trials

AIM

This pooled analysis aimed to evaluate locoregional recurrence (LRR) rates of breast cancer (BC) after neoadjuvant chemotherapy (NACT) and to identify independent LRR predictors.

METHODS

10,075 women with primary BC from nine neoadjuvant trials were included. The primary outcome was the cumulative incidence rate of LRR as the first event after NACT. Distant recurrence, secondary malignancy or death were defined as competing events. For identifying LRR predictors, surgery type, pathological complete response (pCR), BC subtypes and other potential risk factors were evaluated.

RESULTS

Median followup was 67 months (range 0-215), overall LRR rate was 9.5%, 4.1% in pCR versus 9.5% in non-pCR patients. Younger age, clinically positive lymph nodes, G3 tumours, non-pCR and TNBC but not surgery type were independent LRR predictors in multivariate analysis. Among BC subtypes, 5-year cumulative LRR rates were associated with higher risk in non-pCR versus pCR patients, which was significant for HR+/HER2- (5.9% vs 3.9%; HR = 2.32 [95%CI 1.22-4.43]; p = 0.011); HR-/HER2+ (14.8% vs 3.1%; HR = 4.26 [94%CI 2.35-7.71]; p < 0.001) and TNBC (18.5% vs 4.2%; HR = 4.10 [95%CI 2.88-5.82]; p < 0.001) but not for HR+/HER2+ (8.1% vs 4.8%; HR = 1.56 [95%CI 0.85-2.85]; p = 0.150). Within non-pCR subgroup, LRR risk was higher for HR-/HER2+ and TNBC vs HR+/HER2- (HR = 2.05 [95%CI 1.54-2.73]; p < 0.001 and HR = 2.77 [95%CI 2.27-3.39]; p < 0.001, respectively).

CONCLUSIONS

This pooled analysis demonstrated that young age, node-positive and G3 tumours, as well as TNBC, and non-pCR significantly increased the risk of LRR after NACT. Hence, there is a clear need to investigate better multimodality therapies in the post-neoadjuvant setting for high-risk patients.

The effect of post mastectomy radiation therapy on survival in breast cancer patients with N1mic disease

Background

The role of post mastectomy radiation therapy (PMRT) in patients with N1mic breast cancer has not been well defined. A retrospective analysis was performed using the SEER database to evaluate the impact of PMRT on survival in patients with N1mic breast cancer.

Materials and methods

Women with T1-T2, N1mic, M0 breast cancer who had undergone mastectomy were analyzed. Descriptive statistics were calculated for all variables. Univariate analysis to assess for differences in survival with respect to covariates was performed using the log rank test while multivariate analysis was performed with Cox proportional hazards regression. Sub-cohort analysis with propensity score matching was used to assess differences in survival among patients undergoing PMRT vs no PMRT. Comparisons were considered statistically significant at P < 0.05.

Results

Among 5878 patients, 1202 (20%) underwent PMRT. On univariate analysis, PMRT was a significant predictor of CSS, but not OS. There was no difference in either OS or CSS between the PMRT vs no PMRT groups on multivariate Cox regression analysis and after propensity score matching.

Conclusions

Among patients with T1-T2, N1mic, M0 breast IDC from the SEER database, there was no difference in either OS or CSS among patients who underwent PMRT vs no PMRT. These results suggest that PMRT does not impact survival among breast cancer patients with N1mic disease. However, additional prospective studies with longer follow up are necessary for further evaluation.

•

In women with N1mic breast cancer, there was no difference in overall survival with or without adjuvant radiation.

•

CSS was worse among women undergoing adjuvant radiation on univariate analysis, but not on multivariate analysis.

•

After propensity score matching, no significant difference was observed in survival between women undergoing PMRT vs no PMRT.

Multicentric breast cancer with heterogeneous histopathology: a multidisciplinary review

Multiple synchronous (multifocal or multicentric) ipsilateral breast cancers with heterogeneous histopathology are a rare clinical occurrence, however, their incidence is increasing due to the use of MRI for breast cancer screening and staging. Some studies have demonstrated poorer clinical outcomes for this pattern of breast cancer, but there is no evidence to guide clinical practice. In this multidisciplinary review, we reflect on pathology and molecular characteristics, imaging findings, surgical management including conservation and reconstructive options and approach to the axilla, and the role of chemotherapy and radiotherapy. Multidisciplinary discussions appear decisive in planning an appropriate surgical choice and defining the correct systemic treatment tailored to each clinical condition.

Prognostic validation and therapeutic decision-making of the AJCC eighth pathological prognostic staging for T3N0 breast cancer after mastectomy

BACKGROUND

T3N0 breast cancer might be a distinct clinical and biological entity, with higher heterogeneity and presenting diverse responses to locoregional and systemic therapy. The aim of the current study was to validate the prognostic effect and assess the treatment decision-making of the American Joint Committee on Cancer (AJCC) eighth pathological prognostic staging in T3N0 breast cancer after mastectomy.

METHODS

We retrospectively included 2465 patients with stage T3N0 breast cancer who had undergone mastectomy between 2010 and 2014 using the data from Surveillance, Epidemiology, and End Results program. The primary endpoint of this study was breast cancer-specific survival (BCSS).

RESULTS

Of the entire cohort, 76.0% of patients in the seventh AJCC staging system were restaged to the eighth AJCC pathological prognostic staging system. A total of 1431 (58.1%) and 1175 (47.7%) of them received chemotherapy and postmastectomy radiotherapy (PMRT), respectively. Pathological staging was an independent prognostic factor for BCSS. Using pathological prognostic stage IA as the reference, BCSS gradually became worse with increased hazard ratios. The 5-years BCSS was 96.9%, 95.5%, 91.1%, 85.6%, and 75.5% in pathological prognostic stage IA, IB, IIA, IIB, and IIIA breast cancers, respectively (P < .001). In pathological prognostic stage IA, IB, and IIA breast cancers, the receipt of PMRT or chemotherapy was not correlated with better BCSS. However, PMRT was correlated with better BCSS in pathological prognostic stage IIB disease (P = .006), but not in pathological prognostic IIIA disease. Moreover, chemotherapy was correlated with better BCSS in pathological prognostic stage IIIA disease (P = .006), but not in pathological prognostic stage IIB disease.

CONCLUSIONS

The eighth AJCC pathological prognostic staging system provides more risk stratification of T3N0 breast cancers after mastectomy and might affect individualized decision-making for chemotherapy and PMRT in this patient subset.

Postmastectomy radiotherapy in T1-2 patients with one to three positive lymph nodes - Past, present and future

PAST: The role of post-mastectomy radiotherapy (PMRT) in patients with tumor <5 cm and one to three positive lymph nodes after axillary dissection (ALND) is vigorously debated. Initial doubts over the efficacy and safety of PMRT in these patients were partially overcome by improvement in technology and systemic treatments. Several randomized controlled clinical trials confirmed benefit of PMRT in N1 patients, which were meta-analyzed by the Early Breast Cancer Trialists' Collaborative Group (EBCTCG). This meta-analysis provides the sole high-level evidence to guide clinical decision-making. PRESENT: Nevertheless, concerns have been evoked around these results, most notably concerning the patient selection bias and the era in which the patients were treated. More recent studies, albeit retrospective, are in contrast with this level I evidence, unequivocally reporting inferior recurrence rates in control arms than those of the EBCTCG meta-analysis. Taken together, these results suggest that one solution would not fit all N1 patients and that patient selection for PMRT shall be stratified upon risks factors. Most prominent of such factors identified are: patient age; number and ratio of positive lymph nodes; histological features such as lymphovascular invasion; and hormone receptor expression. FUTURE: A prospective randomized controlled trial SUPREMO will release its final results in 2023 and shed light onto the subject. Genomic tumor cell profiling will likely provide further guidelines in terms of risk stratification. SUPREMO translational sub-study will also offer material for genomic analyses. A cross-field tendency to forgo nodal dissection in favor of sentinel lymph node biopsy followed by nodal irradiation might eventually render the question of PMRT indication after ALND irrelevant.

Post Mastectomy Radiation for Stage II Breast Cancer Patients with T1/T2 Lesions

Objective

Post mastectomy radiation (PMR) is usually recommended for T3 or N2 breast cancer (BC). The role of PMR for stage II BC with T1/T2 lesions remains controversial. The aim of this study was to assess the role of PMR in this subgroup of patients.

Materials and Methods

A retrospective analysis of a prospectively collected database of all stage II BC patients treated with mastectomy at our institution between the years 2005-2008 was performed. Demographics, disease-free survival rates were compared between the patients receiving radiation vs. those who were not irradiated.

Results

Eighty-two patients underwent mastectomies for stage II disease with a T1/T2 lesion. Twenty-two of those (27%) received PMR. Loco regional recurrence (LRR) occurred only in the non -irradiated (NR) group. A Kaplan Meier analysis of time to LRR in the NR group was performed. Mean time to local failure was 78.9 months, 6% at 3 years and 13% at 5 years. The time to LRR was significantly lower in the estrogen receptor (ER) negative group compared to the ER positive group (64 vs. 82 months, p=0.029). LRR free rate at 5 years was 100% in low grade tumors vs. 53% in high grade tumors, (p=0.001). In a Cox regression multivariate analysis none of those factors maintained significance.

Conclusion

ER negative status, high grade and node negativity were associated with LRR. A prospective trial randomizing stage II BC patients with T1/T2 lesions, negative hormone receptors and high-grade tumors to PMR following mastectomy arm vs. no radiation arm is recommended.

Local Cancer Recurrence: The Realities, Challenges, and Opportunities for New Therapies

Locoregional recurrence negatively impacts both long-term survival and quality of life for several malignancies. For appropriate-risk patients with an isolated, resectable, local recurrence, surgery represents the only potentially curative therapy. However, oncologic outcomes remain inferior for patients with locally recurrent disease even after macroscopically complete resection. Unfortunately, these operations are often extensive, with significant perioperative morbidity and mortality. This review highlights selected malignancies (mesothelioma, sarcoma, lung cancer, breast cancer, rectal cancer, and peritoneal surface malignancies) in which surgical resection is a key treatment modality and local recurrence plays a significant role in overall oncologic outcome with regard to survival and quality of life. For each type of cancer, the current, state-of-the-art treatment strategies and their outcomes are assessed. The need for additional therapeutic options is presented given the limitations of the current standard therapies. New and emerging treatment modalities, including polymer films and nanoparticles, are highlighted as potential future solutions for both prevention and treatment of locally recurrent cancers. Finally, the authors identify additional clinical and research opportunities and propose future research strategies based on the various patterns of local recurrence among the different cancers.

No association between tumor laterality and cardiac-related mortality in breast cancer patients after radiotherapy: a population-based study

Introduction

To assess the effect of tumor laterality to cardiac-related deaths of breast cancer in the current radiation practices using a large modern population-based study.

Methods

Women diagnosed with breast cancer from 2000 to 2008 were included using the current Surveillance, Epidemiology, and End Results database. The primary outcome of this study was the cardiac-related mortality. Multivariate analysis was performed using the Cox proportional hazards model to analyze the cardiac-related mortality including demographic, clinicopathologic, and treatment factors.

Results

We identified 168,761 breast cancer patients, including 85,006 (50.4%) patients with left-sided tumors and 83,755 (49.6%) patients with right-sided tumors. The median follow-up period was 8.8 years. The 10-year cardiac-related mortality was 2.3% and 2.3% in left- and right-sided tumors, respectively (P=0.685). The results indicated that patients with older age, non-Hispanic Black, receipt of mastectomy, and married status were the independent adverse factors for cardiac-related mortality. However, left-sided tumors were not associated to a higher risk of cardiac-related mortality than right-sided tumors following postoperative radiotherapy (right vs left, hazard ratios 1.025, 95% CI 0.856–1.099, P=0.484). The risk of cardiac-related mortality in the entire cohort was increased with the extension of follow-up time. However, there was still not significantly different between left- and right-sided tumors. Subgroup analysis also found no association between tumor laterality and cardiac-related mortality after postoperative radiotherapy based on various demographics and treatment factors.

Conclusion

With a median follow-up of 8.8 years, no significant differences were found in cardiac-related mortality between left- and right-sided tumors under current radiation practices of breast cancer patients.

Lymphovascular invasion and extranodal tumour extension are risk indicators of breast cancer related lymphoedema: an observational retrospective study with long-term follow-up

Background

Breast cancer related lymphoedema (BCRL) occurs in a substantial proportion of breast cancer survivors and is a major contributor to patients’ disability. Regrettably, there are no validated predictive biomarkers, diagnostic tools, and strong evidence-supported therapeutic strategies for BCRL. Here, we provide an integrative characterization of a large series of women with node-positive breast cancers and identify new bona fide predictors of BCRL occurrence.

Methods

Three hundred thirty-two cases of surgically-treated node-positive breast cancers were retrospectively collected (2–10.2 years of follow-up). Among them, 62 patients developed BCRL. To identify demographic and clinicopathologic features related to BCRL, Fisher’s exact test or Chi-squared test were carried out for categorical variables; the Wilcoxon rank-sum was employed for continuous variables. Factors associated with BCRL occurrence were assessed using a Cox proportional hazards regression model.

Results

En-bloc dissection of the axillary lymph nodes but not the type of breast surgery impacted on BCRL development. Most of BCRL patients had a Luminal A-like neoplasm. The median number of lymph nodes involved by metastatic deposits was significantly higher in BCRL compared to the control group (p = 0.04). Both peritumoral lymphovascular invasion (LVI) and extranodal extension (ENE) of the metastasis had a negative impact on BCRL-free survival (p = 0.01). Specifically, patients with LVI and left side localization harboured 4-fold higher risk of developing BCRL, while right axillary nodes metastases with ENE increased the probability of BCRL compared to ENE-negative patients.

Conclusions

Assessment of LVI and ENE should be integrated with clinical and surgical data to improve BCRL risk stratification.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4851-2) contains supplementary material, which is available to authorized users.

Clinical decision making in postmastectomy radiotherapy in node negative breast cancer

For decades, postmastectomy radiotherapy (PMRT) has been recommended for node positive [N(+)] breast cancer patients; nevertheless, the beneficial effect of PMRT for treatment of node negative [N(−)] disease remains under discussion. Nowadays, the biology of breast cancer and the risk factors (RFs) for locoregional failure (LRF) must be included in the decision on whether or not to carry out PMRT. For these reasons, the present review aims to evaluate the rationale use of PMRT in N(−) patients and discuss which subgroups may further benefit from the treatment in present times where the decision must be personalised, according to the RFs of locoregional recurrence (LRR). To perform the analysis, we ponder that LRR of over 10% should be considered unacceptable due to the fact that LRRs generate great morbidity in patients. For this purpose, we consider that routine RT in these patients is not recommended, although there are subgroups of patients with high LRR, in which PMRT could be beneficial.

Comparison of survival outcomes of locally advanced breast cancer patients receiving post-mastectomy radiotherapy with and without immediate breast reconstruction: a population-based analysis

Objective

To compare the survival outcomes in locally advanced breast cancer (LABC) patients receiving post-mastectomy radiotherapy (PMRT) with and without immediate breast reconstruction.

Methods

We used the Surveillance, Epidemiology, and End Results program to include LABC patients who were treated/not treated with immediate breast reconstruction followed by PMRT between 2003 and 2010. Statistical analysis was performed using the chi-squared test, Kaplan–Meier survival analysis, and Cox regression analysis. A 1:1 propensity score matching method was performed to decrease the selection bias.

Results

We identified 1,732 patient-pairs that were completely matched. In the unmatched population, 8,198 and 1,802 patients received mastectomy only and immediate breast reconstruction, respectively. Patients who received immediate breast reconstruction had better breast cancer-specific survival (BCSS) (hazard ratio [HR] 0.880, 95% CI 0.783–0.989, P = 0.032) and overall survival (OS) (HR 0.846, 95% CI 0.758–0.943, P = 0.003) than patients who underwent mastectomy alone. However, in the matched population, there was comparable BCSS and OS between patients who received immediate breast reconstruction and mastectomy alone. Subset analysis in the matched population found that immediate breast reconstruction was associated with better BCSS (HR 0.750, 95% CI 0.614–0.917, P = 0.005) and OS (HR 0.779, 95% CI 0.644–0.942, P = 0.010) compared to patients aged <50 years who received mastectomy alone.

Conclusion

There are comparable survival outcomes in LABC patients who received immediate breast reconstruction or mastectomy alone followed by PMRT. However, patients aged <50 years had a survival advantage after immediate breast reconstruction.

Management of In-Breast Tumor Recurrence

The management of isolated in-breast tumor recurrence is complex, requiring careful consideration of prior local therapies to plan future multimodality treatment. Options for surgical management have evolved from standard salvage mastectomy with axillary clearance and now include repeat breast conservation with axillary staging in select patients. Reattempting sentinel lymph node biopsy may avoid the morbidity of extensive axillary surgery and has been shown to be feasible in clinically node-negative patients with oncologically safe outcomes. In the adjuvant setting, partial breast irradiation has emerged as a valuable means to improve local control rates with limited associated toxicity and acceptable overall cosmesis. Furthermore, results from prospective trials are now available to support the use of chemotherapy in hormone-receptor negative subgroups, which is associated with improvements in long-term, disease-free, and overall survival.

Factors Influencing Axillary Node Metastasis in Breast Cancer

Aims and Background

The status of the axillary lymph nodes at the time of diagnosis has been accepted as one of the most important prognostic factors for the overall and disease-free survival of patients with breast cancer. The aim of our study was to determine which factors influence axillary node involvement in invasive breast cancer.

Methods

The data presented here were obtained from 344 patients who were treated for invasive breast cancer at the Department of Radiation Oncology, Uludag University Medical College, Bursa, Turkey. Possible prognostic factors were categorized as patient related and tumor related. The Mann-Whitney U test was used for univariate analysis and logistic regression was used for multivariate analysis.

Results

In univariate analysis, a familial cancer history (P = 0.0042), age <40 years (P = 0.0276), higher T stage (P <0.0000), nipple involvement (P = 0.0345), skin involvement (P = 0.0270), perineural invasion (P = 0.0231), and lymphatic vessel invasion (P <0.0000) were correlated with increased axillary node involvement. A higher incidence of ≥4 involved lymph nodes was associated with higher T stage (P = 0.0004), nipple involvement (P = 0.0292), presence of an extensive intraductal component (P = 0.0023), skin involvement (P = 0.0008), perineural invasion (P = 0.0523), and lymphatic vessel invasion (P <0.0000) in univariate analysis. In multivariate analysis, age <40 years (P = 0.0454), cancer history within the family (P = 0.0024), higher T stage (P = 0.0339), lymphatic vessel invasion (P = 0.0003), and perineural invasion (P = 0.0408) were found to be independent factors for axillary lymph node positivity. Age <40 years (P = 0.0221), perineural invasion (P = 0.0408), and an extensive intraductal component (P = 0.0132) were associated with an increased incidence of ≥4 involved nodes in the logistic regression analysis. In patients with breast cancer, the incidence of axillary lymph node involvement was independently influenced by age <40 years, presence of cancer history within the family, higher T stage, lymphatic vessel invasion, and perineural invasion.

Conclusions

In conclusion, absence of familial cancer history, presence of lymphatic vessel invasion, higher T stage, and age below 40 years independently increased the risk of axillary node involvement. Presence of perineural invasion and lymphatic vessel invasion, age below 40, and an extensive intraductal component of more than 25% independently affected the risk of having ≥4 nodes involved. Patients characterized by these factors may be classified into a higher risk group for nodal involvement, but more data are needed to define factors that can help in the decision-making regarding the omission of axillary treatment.

Most Breast Cancer Patients with T1-2 Tumors and One to Three Positive Lymph Nodes Do Not Need Postmastectomy Radiotherapy

BACKGROUND/OBJECTIVE

Guidelines concur that postmastectomy radiation therapy (PMRT) in T1-2 tumors with one to three positive (+) lymph nodes (LNs) decreases locoregional recurrence (LRR) but advise limiting PMRT to patients at highest risk to balance against potential harms. In this study, we identify the risks of LRR after mastectomy in patients with T1-2N1 disease, treated with modern chemotherapy, and identify predictors of LRR when omitting PMRT.

METHODS

Patients with T1-2N1 breast cancer undergoing mastectomy between 1995 and 2006 were categorized by receipt of PMRT. The Chi square test compared the clinicopathologic features between both groups, and Kaplan-Meier and Cox regression analysis was used to determine the rates of LRR, recurrence-free survival (RFS), and overall survival (OS).

RESULTS

Overall, 1087 patients (924 no PMRT, 163 PMRT) were included in the study, with a median follow-up of 10.8 years (range 0-21). We identified 63 LRRs (56 no PMRT, 7 PMRT), and 10-year rates of LRR with and without PMRT were 4.0% and 7.0%, respectively. Patients receiving PMRT were younger (p = 0.019), had larger tumors (p = 0.0013), higher histologic grade (p = 0.029), more positive LNs (p < 0.0001), lymphovascular invasion (LVI) (p < 0.0001), extracapsular nodal extension (p < 0.0001), and macroscopic LN metastases (p < 0.0001). There was no difference in LRR, RFS, or OS between groups. On multivariate analysis, age < 40 years (p < 0.0001) and LVI (p < 0.0001) were associated with LRR in those not receiving PMRT.

CONCLUSION

Consistent with the guidelines, 85% of patients with T1-2N1 were spared PMRT at our center, while maintaining low LRR. Age < 40 years and the presence of LVI are significantly associated with LRR in those not receiving PMRT.

Should all breast cancer patients with four or more positive lymph nodes who underwent modified radical mastectomy be treated with postoperative radiotherapy? A population-based study

Postmastectomy radiotherapy (PMRT) has become a standard adjuvant postoperative therapy for breast cancer patients with four or more positive lymph nodes. However, some studies have demonstrated that some subgroups of the breast cancer patients with four or more positive lymph nodes did not benefit substantially from PMRT. Therefore, it is of great necessity to identify whether all breast cancer patients with four or more positive lymph nodes who underwent modified radical mastectomy be treated with PMRT. In our study, we first established a prognostic model using the Surveillance Epidemiology and End Results (SEER) database between 1998 and 2001. Univariate and multivariate Cox models were used to assess the prognostic factors, and five risk factors individually associated with prognosis including AJCC stage, AJCC T, Grade, ER status, PR status. Prognostic index of PMRT were defined as the number of risk factor (NRF). The NRF scores correlated well with overall survival of PMRT even if the patients were in the sub-poor prognosis group. Then the prognostic model was validated using the SEER database between 2006 and 2009, and the same results were obtained. In conclusion, different from others studies, our study demonstrated that all patients with four or more positive lymph nodes after modified radical mastectomy need to be treated with PMRT ever if the patients belonged to AJCC T4 in a poor prognosis group.

Postmastectomy Radiation Therapy in Women with T1-T2 Tumors and 1 to 3 Positive Lymph Nodes: Analysis of the Breast International Group 02-98 Trial

PURPOSE

To analyze the impact of postmastectomy radiation therapy (PMRT) for patients with T1-T2 tumors and 1 to 3 positive lymph nodes enrolled on the Breast International Group (BIG) 02-98 trial.

METHODS AND MATERIALS

The BIG 02-98 trial randomized patients to receive adjuvant anthracycline with or without taxane chemotherapy. Delivery of PMRT was nonrandomized and performed according to institutional preferences. The present analysis was performed on participants with T1-T2 breast cancer and 1 to 3 positive lymph nodes who had undergone mastectomy and axillary nodal dissection. The primary objective of the present study was to examine the effect of PMRT on risk of locoregional recurrence (LRR), breast cancer-specific survival, and overall survival.

RESULTS

We identified 684 patients who met the inclusion criteria and were included in the analysis, of whom 337 (49%) had received PMRT. At 10 years, LRR risk was 2.5% in the PMRT group and 6.5% in the no-PMRT group (hazard ratio 0.29, 95% confidence interval 0.12-0.73; P = .005). Lower LRR after PMRT was noted for patients randomized to receive adjuvant chemotherapy with no taxane (10-year LRR: 3.4% vs 9.1%; P = .02). No significant differences in breast cancer-specific survival (84.3% vs 83.9%) or overall survival (81.7% vs 78.3%) were observed according to receipt of PMRT.

CONCLUSION

Our analysis of the BIG 02-98 trial shows excellent outcomes in women with T1-T2 tumors and 1 to 3 positive lymph nodes found in axillary dissection. Although PMRT improved LRR in this cohort, the number of events remained low at 10 years. In all groups, 10-year rates of LRR were relatively low compared with historical studies. As such, the use of PMRT in women with 1 to 3 positive nodes should be tailored to individual patient risks.

Randomized controlled trial of late-course concurrent versus sequential chemoradiotherapy after mastectomy and axillary surgery in locally advanced breast cancer

BACKGROUND

Concurrent chemoradiotherapy could increase the local control rate in patients with high recurrence risk after breast-conserving surgery, but the effect of concurrent chemoradiotherapy after mastectomy and axillary dissection is not clear. The aim of the study was to compare the effects of late-course concurrent chemoradiotherapy (CCRT) versus sequential therapy (SCRT) after mastectomy and axillary surgery in locally advanced breast cancer.

METHODS

This was a randomized controlled trial of 155 patients with stage pT3-4p N1-3c M0 or pAnyT pN2-3c M0 breast cancer undergoing 5-fluorouracil+epirubicin+cyclophosphamide followed by docetaxel (FEC-D) chemotherapy after mastectomy and axillary dissection. Patients were randomized to the CCRT group (intensity-modulated radiation therapy was performed concurrently with docetaxel) or to the SCRT group (radiotherapy after chemotherapy). Recurrences, adverse reactions, and short-term effects were observed.

RESULTS

All the patients completed the planned therapy. The median follow-up was 39 (range, 16-62) months. Compared with SCRT, the 3-year local-regional recurrence-free survival (LRFS) in the CCRT group was improved (81.8% vs 92.3%, P = .046). There was no significant difference in 3-year disease-free survival (DFS) and overall survival (OS). In the pT3-4 pN1-3 cM0 subgroup, the 3-year local recurrence-free survival and DFS were significantly improved in the CCRT group (69.4% vs 88.2%, P = .036; and 41.7% vs 72.6%, P = .049, respectively). No significant difference was observed adverse reactions between the 2 groups.

CONCLUSION

LRFS of patients with locally advanced invasive breast cancer after mastectomy and axillary surgery was better with CCRT than with SCRT and with similar profiles of adverse reactions. The DFS of patients staged pT3-4 pN1-3 cM0 was also improved.