Supraclavicular lymph node dissection with radiotherapy versus radiotherapy alone for operable breast cancer with synchronous ipsilateral supraclavicular lymph node metastases: a real-world cohort study

Clinical outcomes after post-operative radiotherapy for breast cancer patients presenting with ipsilateral supraclavicular metastasis: considerations on the cranial border of irradiation field

BACKGROUND

Disease recurrence at lower neck adjacent to ipsilateral supraclavicular (SCV) region represents a concern in locally advanced breast cancer patients presenting with SCV metastasis at diagnosis. This study aims to report the outcomes following post-operative radical radiation therapy and discuss the reasonable cranial border of the irradiation field for N3c patients.

METHODS

Between July 2016 and January 2022, a total of 268 patients were eligible for analysis. The endpoints included in-field and out-field cervical failures, local-regional recurrence-free survival (LRRFS), SCV recurrence-free survival (SRFS), distant metastasis-free survival (DMFS), relapse-free survival (RFS), and overall survival (OS).

RESULTS

During a median follow-up of 37 months (range 3-89 months), 17 patients (6.3%) developed local-regional recurrence as the first recurrence event, with 13 having concomitant distant-metastasis (DM); 56 patients (20.9%) had DM alone. The 3-year rates of LRRFS, SRF, DMFS, RFS, and OS were 92.3%, 94.5%, 74.5%, 73.0%, and 90.0%, respectively. 89.2% of patients received RT with the cranial border at the top of hyoid bone, and 95.1% of patients received a boost not exceeding the level of cricoid cartilage. A total of 11 patients (4.1%) developed ipsilateral SCV failure, and 3 patients (1.1%) experienced cervical failure, including 2 in-field failures and 1 out-field failure. Neoadjuvant systemic therapy (NST) was administered to 234 patients (87.3%). In the multivariate analysis, non-ypN0, triple-negative subtype and cT4 at diagnosis were predictors of worse SRFS and RFS in NST subgroup.

CONCLUSION

Our findings suggest that radical RT with cranial border of irradiation field at the hyoid bone level lead to excellent local-regional control, and out-field cervical failure was rare. The irradiation field might not extend to mastoid process.

Comparing supraclavicular surgery with radiotherapy versus radiotherapy alone in breast cancer patients with ipsilateral supraclavicular lymph node metastasis: a two-center retrospective cohort study

BACKGROUND

This study aimed to assess combined supraclavicular lymph node dissection (SLND) and radiotherapy (RT) versus standalone radiotherapy for efficacy in newly diagnosed breast cancer patients with ipsilateral supraclavicular lymph node metastasis (ISLNM).

METHODS

Totally 143 ISLNM patients treated between 2014 and 2021 in two medical institutions were examined retrospectively. Patients were divided into two groups to undergo combined SLND and radiotherapy (surgery + RT, n = 73) or radiotherapy alone (RT, n = 70). The effects of SLND on disease-free survival (DFS), breast cancer-specific survival (BCSS), and overall survival (OS) were assessed by Kaplan-Meier analysis and Cox regression models.

RESULTS

During a median follow-up of about 35 months, 18.2% of patients died. Five-years OS, BCSS, and DFS rates in the RT and surgery + RT groups were 79.2% and 69.4% (P = 0.21), 82.2% and 79.4% (P = 0.29), and 56.1% and 53.1% (P = 0.70), respectively. In multivariable analysis, SLND didn't significantly impact these outcomes, a finding consistent across multiple subgroups. However, Estrogen receptor expression, the presence of vascular cancer emboli, and surgical approach differentially affected DFS, BCSS, and OS. Furthermore, patients with residual supraclavicular lymph node tumors post-surgery had lower DFS (43.7% vs. 73.2%) and OS (68.7% vs. 90.2%) rates compared with counterparts without residual lymph nodes. Residual supraclavicular lymph node tumor was an independent risk factor for DFS (HR = 4.191, 95%CI 1.755-10.007; p = 0.001) and OS (HR = 3.781, 95%CI 1.025-13.486; p = 0.046) in breast cancer patients with ISLNM.

CONCLUSIONS

Breast cancer patients with synchronous ISLNM may not benefit from SLND. The clinical decision-making for ISLNM patients should be carefully considered. Prospective studies are needed to validate the results.

Predicting ipsilateral supraclavicular lymph node pathological complete response: nomogram based on the inflammatory markers

Background

The prediction of ISLN pCR after neoadjuvant chemotherapy (NAC) based on inflammatory markers and its prognostic value have rarely been investigated.

Methods

Patients diagnosed with ISLN-involved breast cancer who received NAC in West China Hospital between September 2009 and December 2020 were enrolled in the derivation cohort for model construction and survival analysis, and patients with the same criteria between January 2021 and July 2024 were involved in validation cohort for external validation. After randomly dividing patients into training and testing groups at 7:3 ratio, a nomogram predicting ISLN pCR was constructed based on logistic regression in training group. Internal validation was performed in the testing group and external validation was performed in the independent validation cohort. The ROC curves were applied to validate the accuracy of the model. Survival analysis was performed using Kaplan-Meier plots.

Results

A total of 120 eligible patients were involved in the derivation cohort to establish the nomogram (84 patients in training group and 36 patients in testing group), and 45 patients were involved in the independent validation cohort for external validation of the nomogram. Pretreatment NLR and hormone receptor (HR) status, as well as preoperative SII, CEA, CA15-3 and anti-HER2 therapy were included in the nomogram predicting ISLN pCR. The AUC were 0.906 (95% CI 0.837-0.975, P<0.001), 0.888 (95% CI 0.751-1.000, P<0.001) and 0.828 (95% CI 0.703-0.953, P< 0.001) in training, testing groups and the validation cohort respectively. ISLN pCR was significantly associated with better prognosis (all P<0.05).

Conclusion

Inflammatory factors combined with tumor makers, hormone receptor status and anti-HER2 therapy could predict ISLN pCR effectively, which was significantly associated with improved survival outcomes.

Incidence and severity of acute radiation induced toxicities among breast cancer patients treated with adjuvant radiotherapy at a major cancer treatment center in Ghana

BACKGROUND

Adjuvant radiotherapy after mastectomy or breast conserving surgery (BCS) is the standard of care for majority of patients with breast cancer. This is however associated with mucosal and epidermal toxicity of organs at risk (OARs). Breast cancer patients are exposed to a plethora of wrong perceptions, misinformation and myths concerning the usefulness and adverse effects of radiotherapy. There is paucity of literature on the incidence and severity of radiation-induced acute toxicities experienced by patients with breast cancer in Ghana.

AIM

To assess the occurrence and severity of four main acute radiation-induced toxicities among female breast cancer patients treated with external beam radiotherapy at a major cancer treatment centre in Ghana.

METHODS

Data on the occurrence of acute toxicities among patients was collected from patients' medical records, through a semi-structured questionnaire and via weekly clinical assessments. The Common Terminology Criteria for Adverse Events (CTCAE) grading scale (version 4.0) was used to grade the severity of these toxicities. Descriptive and inferential statistics using an independent two-sampled t-test (two-tailed), one-way analysis of variance (ANOVA), Pearson's Chi-square and Fisher's exact tests were performed.

RESULTS

Dermatitis, fatigue, pharyngitis, and breast (chest) pain were the radiation toxicities found among the breast cancer patients undergoing treatment on the two machines. The mean predominant radiation doses associated with the onset of dermatitis, fatigue, pharyngitis, and chest pain in the breast cancer patients were 22.32 Gy, 22.48 Gy, 13.59 Gy, and 19.27 Gy respectively for treatment with a statistically significant (p = 0.0173). Radiation dermatitis was the most dominant acute radiation toxicity recorded, and its incidence and severity. The range of Fisher's p-values (0.689-0.999) between the acute radiation toxicities with both machines revealed no statistical significance.

CONCLUSION

Radiation dermatitis was the dominant acute toxicity, both in incidence and severity for patients treated. There was no statistical significance in the incidence and severity of acute radiation side effects.

Role of aggressive locoregional surgery in treatment strategies for ipsilateral supraclavicular lymph node metastasis of breast cancer: a real-world cohort study

Background: Breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastases (ISLNM) have unfavorable prognoses. The role of supraclavicular lymph node dissection (SLND) as a surgical intervention in the treatment of this condition remains controversial. In this study, we aimed to evaluate the prognostic factors associated with breast cancer with ISLNM and to assess the potential impact of aggressive locoregional surgical management on patient outcomes. Methods: We conducted a retrospective analysis of 250 breast cancer patients with ISLNM who were treated with curative intent at our institution between 2000 and 2020. The cohort was stratified into groups based on the extent of axillary surgery. The first group, comprising 185 patients, underwent level I/II axillary dissection. The second group, consisting of 65 patients, underwent aggressive locoregional surgery, including levels I/II/III (infraclavicular) dissection in 37 patients and levels I/II/III + SLND in 28 patients. Our study evaluated overall survival (OS) and disease-free survival (DFS) as primary endpoints, and locoregional recurrence-free survival (LRRFS) and distant metastasis-free survival (DMFS) as secondary endpoints. Results: The median follow-up time among all patients was 5.92 years (1.05-15.36 years). The 5-year OS rate was 71.89%, while the DFS rate, LRRFS rate, and DMFS rates were 59.25%, 66.38%, and 64.98%, respectively. A significant difference in OS, DFS, LRRFS, and DMFS was observed between the second group and the first group (p < 0.01). No beneficial impact on recurrence, metastasis, or survival outcomes was observed in the levels I/II/III + SLND group compared to the levels I/II/III dissection group. Multivariate logistic regression analysis revealed that levels I/II/III ± SLND surgery and T stage were associated with OS (p = 0.006 and p = 0.026), while levels I/II/III ± SLND surgery, ER+/HER2-, and histologic grade were associated with DFS (p = 0.032, p = 0.001, p = 0.032). Conclusion: Breast cancer with ISLNM may be considered a locoregional disease, requiring a combination of systemic and local therapies. Aggressive locoregional surgery has been shown to positively impact recurrence, metastasis, and survival outcomes. This approach may provide improved management of the ISLNM for breast cancer patients.

Nodal response to primary systemic therapy predicts prognosis of cN3c breast cancer patients receiving multimodality therapy

AIM

To investigate the survival outcomes, patterns and risks of recurrence in cN3c breast cancer patients after multimodality therapy, as well as the predictors of candidates for ipsilateral supraclavicular (SCV) area boosting.

METHOD

Consecutive cN3c breast cancer patients from January 2009 to December 2020 were retrospectively reviewed. Based on nodal response to primary systemic therapy (PST), patients were categorized into three groups: clinical complete response (cCR) not achieved in SCV lymph nodal (SCLN, Group A), SCLN cCR but axillary node (ALN) did not achieve pathological complete response (pCR, Group B), cCR in SCLN and pCR in ALN (Group C).

RESULTS

The median follow-up time was 32.7 months. The 5-year overall survival (OS) and recurrence-free survival (RFS) were 64.6% and 43.7% respectively. Multivariate analysis showed cumulative SCV dose and ypT stage, ALN response and SCV response to PST were significantly associated with OS and RFS respectively. Compared with Group A or B, Group C showed significantly improved 3 y-RFS (53.8% vs 73.6% vs 100%, p = 0.003), and the lowest rate of DM as first failure (37.9% vs 23.5% vs 0%, p = 0.010). In Group A, the 3 y-OS for patients receiving the cumulative SCV dose of ≥60 Gy versus <60 Gy was 78.0% versus 57.3% (p = 0.029).

CONCLUSION

Nodal response to PST is an independent prognostic factor for survival and pattern of failure. A cumulative SCV dose of ≥60 Gy is positively associated with improved OS, especially in Group A. Our data supports the perspective of optimizing radiotherapeutic strategy based on nodal response.

Comparison of supraclavicular surgery plus radiotherapy versus radiotherapy alone in breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastasis: a multicenter retrospective study

PURPOSE

To evaluate and compare the outcomes of supraclavicular lymph node dissection plus radiotherapy (RT) and RT alone for patients with synchronous ipsilateral supraclavicular lymph node metastasis.

METHODS

In all, 293 patients with synchronous ipsilateral supraclavicular lymph node metastasis across three centers were included. Of these, 85 (29.0%) received supraclavicular lymph node dissection plus RT (Surgery + RT) and 208 (71.0%) received RT alone. All patients received preoperative systemic therapy followed by mastectomy or lumpectomy and axillary dissection. Supraclavicular recurrence-free survival (SCRFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were evaluated by using the Kaplan-Meier method and multivariate Cox models. Multiple imputation was used for missing data.

RESULTS

The median follow-up duration of the RT and Surgery + RT groups were 53.7 and 63.5 months, respectively. For the RT and Surgery + RT groups, the 5-year SCRFS rates were 91.7% vs. 85.5% (P=0.522), LRRFS rates were 79.1% vs. 73.1% (P=0.412), DMFS rates were 60.4 vs. 58.8% (P=0.708), DFS rates were 57.6% vs. 49.7% (P=0.291), and OS rates were 71.9% vs. 62.2% (P=0.272), respectively. There was no significant effect on any outcome when comparing Surgery +RT versus RT alone in the multivariate analysis. Based on four risk factors of DFS, patients were classified into three risk groups: the intermediate- and high-risk groups had significantly lower survival outcomes than the low-risk group. Surgery +RT did not improve outcomes of any risk group compared with RT alone.

CONCLUSIONS

Patients with synchronous ipsilateral supraclavicular lymph node metastasis may not benefit from supraclavicular lymph node dissection. Distant metastasis remained the major failure pattern, especially for intermediate- and high-risk groups.

Long-term Oncologic Outcomes in Patients with Inflammatory Breast Cancer with Supraclavicular Nodal Involvement

BACKGROUND

Inflammatory breast cancer (IBC) is a rare and aggressive subtype of breast cancer characterized by rapid progression and early metastasis, often with advanced nodal locations, including the supraclavicular (SCV) nodal basin. Previously considered M1 disease, ipsilateral clinical supraclavicular node involvement (N3c) disease is now considered locally advanced disease and warrants treatment with intent to cure. The objective of this study was to evaluate the long-term outcomes of patients with IBC and N3c disease.

PATIENTS AND METHODS

This study was conducted using a prospectively collected database of all patients with IBC treated at a dedicated cancer center from 2007 to 2019. Surgical patients with SCV nodal involvement and complete follow-up were identified. Our primary outcome was 5-year overall survival (OS). Multivariate Cox proportional hazards models were used to determine predictors for survival. Event-free survival (EFS) and OS were calculated using the Kaplan-Meier method.

RESULTS

There were 70 patients who met inclusion criteria. All patients underwent comprehensive trimodality therapy. The majority of patients had complete (66.2%) radiologic response in the SCV nodal basins following neoadjuvant therapy. Six patients (8.6%) had a locoregional recurrence, with two (2.9%) occurring in the supraclavicular fossa. The 5-year OS was 60.2% [95% confidence interval (CI) 47.7-72.7%]. Increasing age (hazard ratio 2.7; p = 0.03) and triple-negative subtype (hazard ratio 4.9; p = 0.03) were associated with poor OS. The 5-year EFS was 56.1% (95% CI 40.9-68.8%). The presence of more than ten positive axillary nodes on final surgical pathology (hazard ratio 5.5; p = 0.01) predicted poor EFS.

CONCLUSIONS

With comprehensive trimodality therapy and multidisciplinary team approach, patients with IBC with supraclavicular nodal involvement experience excellent locoregional control and favorable survival.

Supraclavicular and Contralateral Axillary Lymph Node Involvement in Breast Cancer Patients

Ipsilateral supraclavicular disease was reclassified from Stage IV, distant metastatic disease, to Stage IIIC, locally advanced breast cancer 20 years ago. Treatment with curative intent with multimodality therapy has led to improved outcomes over time. In contrast, metastatic disease to contralateral axillary lymph nodes remains as Stage IV distant disease. Despite this, in the absence of other distant metastases, many patients with contralateral axillary disease are treated more aggressively than other Stage IV patients. Outcomes of patients with contralateral axillary disease treated with curative intent are more like patients with ipsilateral supraclavicular disease and other locally advanced breast cancers than patients with de novo distant metastases elsewhere. Therefore, some favor reclassification of contralateral axillary metastases without distant metastasis from Stage IV to Stage III breast cancer similar to ipsilateral supraclavicular metastases.

Contemporary Outcomes After Multimodality Therapy in Patients With Breast Cancer Presenting With Ipsilateral Supraclavicular Node Involvement

PURPOSE

Patients with breast cancer and ipsilateral supraclavicular (SCV) node involvement at the time of diagnosis (TNM cN3c) have historically had poor outcomes. Radiation therapy (RT) has an important role because SCV nodes are not routinely surgically dissected. However, optimal locoregional management, contemporary outcomes, and prognostic factors are not well defined.

METHODS AND MATERIALS

We reviewed the data of patients with cN3c breast cancer treated at our institution between 2014 and 2019 with curative intent, including neoadjuvant chemotherapy, surgery, and adjuvant RT. All patients received comprehensive regional RT, including to the SCV nodes. Institutional guidelines recommend a 10-Gy or 16-Gy boost to resolved and unresolved N3 nodes, respectively. Overall survival (OS), recurrence-free survival (RFS), locoregional recurrence-free survival (LRRFS), and supraclavicular recurrence-free survival (SCRFS) were analyzed.

RESULTS

Data from 173 consecutive patients were analyzed with a median follow-up time of 2.8 years. The median age was 54 years, 76 patients (44%) were estrogen receptor positive/human epidermal growth factor receptor 2 negative, 100 patients (58%) had T3/4 disease, and 10 patients (6%) underwent a neck dissection. In addition, 156 patients (90%) received a cumulative SCV dose of ≥60 Gy. The 5-year OS, SCRFS, LRRFS, and RFS rates were 73%, 95%, 86%, and 50%, respectively. The 5-year OS rate for a cumulative SCV dose of ≥60 Gy versus <60 Gy was 75% versus 39% (P = .04). In the multivariable analysis, a cumulative SCV dose of ≥60 Gy, extranodal extension, receptor status, and Eastern Cooperative Oncology Group performance status were associated with OS. The 5-year SCRFS rates with and without neck dissection were 100% versus 95% (P = .57). Among patients with a postchemotherapy SCV node size of ≥1 cm without neck dissection, the 5-year SCRFS rate was 83%.

CONCLUSIONS

In one of the largest series of patients with cN3c breast cancer, multimodality therapy using adjuvant RT with a SCV boost resulted in a 5-year LRRFS rate of 86%. There is a limited role for neck dissection as the 5-year SCRFS rate was 95% overall and 83% for residual SCV disease ≥1 cm after chemotherapy with RT alone. A cumulative SCV dose of ≥60 Gy was associated with improved OS, but not SCRFS, LRRFS, or RFS. A SCV boost should be considered in these patients as treatment was well-tolerated. Despite advances in systemic therapy, nearly half of patients developed distant metastases, highlighting the need for close observation after treatment.

Impact of Ipsilateral Supraclavicular Lymph Node Dissection (ISLND) for Breast Cancer Patients and a Nomogram for Predicting Ipsilateral Supraclavicular Pathological Complete Response (ispCR)

BACKGROUND

The purpose of this study was to evaluate the impact of ipsilateral supraclavicular lymph node dissection (ISLND) on the outcomes of breast cancer patients with ipsilateral supraclavicular lymph node metastasis (ISLNM), and to evaluate the prognostic value of ipsilateral supraclavicular pathological complete response (ispCR). Meanwhile, a nomogram was constructed to predict ispCR.

METHODS

We retrospectively reviewed the medical documents of 353 patients with ISLNM but no distant metastasis at presentation. Based on whether ISLND was performed, patients were divided into radiotherapy (RT) and ISLND + RT groups. The impact of ISLND was evaluated after propensity score matching, and the prognostic value of ispCR was also analyzed. A nomogram to predict the probability of ispCR was constructed based on clinicopathologic variables.

RESULTS

After propensity score matching, we found that the use of ISLND was associated with a higher rate of ipsilateral supraclavicular relapse-free survival (ISRFS; p < 0.0001). Among 307 patients who underwent ISLND, ispCR was associated with a higher rate of ISRFS and disease-free survival (p = 0.018 and p = 0.00033, respectively). Furthermore, the nomogram constructed with number of axillary lymph node metastases, breast pCR, size of the ipsilateral supraclavicular lymph nodes after neoadjuvant chemotherapy (NAC), number of NAC cycles, and Ki67 level showed a good fit for predicting ispCR.

CONCLUSION

For breast cancer patients with ISLNM but no distant metastasis, ISLND may be beneficial in some certain subtypes, and ispCR indicated a better prognosis. Our nomogram is well-fitted to predict the probability of achieving ispCR.

Combined Therapy Can Improve the Outcomes of Breast Cancer with Isolated Supraclavicular Lymph Node Involvement

Purpose

This study aimed to evaluate the efficacy of systemic combined with local therapies in isolated metachronous ipsilateral supraclavicular lymph node metastasis (mISLM) breast cancer patients.

Patients and Methods

We reviewed the data of mISLM patients admitted by Breast Disease Center of the Affiliated Hospital of Qingdao University, from January 2009 to July 2019. Ninety-nine patients were included and were divided into two groups: the systemic group, which referred to patients who received only systemic therapy, and the combined group, which referred to patients who received systemic therapy plus local therapy (including neck radiotherapy (RT) and/or supraclavicular lymph node dissection surgery). In the combined group, patients were further divided into systemic therapy plus: 1) neck RT, 2) supraclavicular lymph node dissection surgery, and 3) neck RT and supraclavicular lymph node dissection surgery.

Results

The median duration of follow-up was 36 months. The median PFS was 15 months, and the median OS was 35 months. Local control rates of 1 year, 2 years and 3 years were 92.9%, 86.9% and 84.8%, respectively. The combined group (n=56) had a significantly better PFS (P<0.001) and OS (P=0.001) than the systemic group (n=43). Compared with Group B (n=13) and Group C (n=14), Group A (n=29) had a significantly better PFS (P=0.007). Higher dose and conventional dose showed no significant differences regarding the local control rate (P=1.000), PFS (P=0.787) or OS (P=0.690) in the patients who received RT. In multivariate analysis, pN3 stage and combined therapy (systemic therapy plus local therapy) for mISLM affected PFS (P<0.001 and P=0.002, respectively). Neck RT was an independent parameter affecting OS (P=0.002).

Conclusion

In breast cancer patients with mISLM, systemic therapy combined with local therapy could improve PFS and OS. Based on systemic therapy, RT had a better effect on survival than surgery. However, more aggressive methods, such as systemic therapy combined with both RT and surgery or a higher dose of RT, may not be associated with improved PFS or OS in these patients.