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Rao SS, Nair NS, Wadasadawala T, Mokal S, Pathak R, Sarin R, Parmar V, Joshi S, Badwe RA. A Questionnaire Survey of Current Practice in the Management of Internal Mammary Lymph Nodes in Breast Cancer. South Asian J Cancer 2024; 13:85-89. [PMID: 38919667 PMCID: PMC11196148 DOI: 10.1055/s-0043-1763251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Nita S. NairBackground Radiotherapy (RT) is an important modality in the management of breast cancers (BC). Large randomized trials have suggested that prophylactic regional nodal irradiation inclusive of internal mammary lymph nodes (IMLN) reduces BC-related mortality. However, the adoption of IMLN-RT has been variable due to relative benefits and toxicity concerns. Methods A survey was emailed to radiation oncologists (ROs) across the country wherein they were asked about their practice regarding IMLN-RT in BC. Results We received 128 responses, which included radiation oncologists across both private institutions (PIs) and government institutions (GIs). Fifty-six (43.8%) routinely offer prophylactic(p) IMLN-RT and an additional 15 (11.71%) suggested they would have offered it in the absence of logistic constraints. Almost all, 121 (94.5%) radiate the IMLN in case of radiologically positive lymph nodes (LNs). Fifty-six ROs (43.8%) offered prophylactic IMLN-RT in node-negative disease. Among those who did not offer IMLN-RT, most (84.72%) felt the clinical evidence was equivocal. Of the 56 who offered pIMLN-RT, 34/56 (60.71%) offered to locally advanced tumors, 20/56 (35.71%) offered to all inner and central tumors (ICQT), 29/56 (51.78%) to > 4 axillary LN-positive and 9/56 (16.07%) to any axillary LN-positive. The majority, i.e., 36/56 (64.28%) radiated upper three intercostal spaces, 9 (16.07%) radiated upper five intercostal spaces, and 6 (10.9%) decided based on tumor location, while 5 (9%) irradiated one space below the involved space. Overall, simulation-based planning was undertaken in 99% of PIs as opposed to 89% of GIs ( p = 0.03). The majority of ROs, i.e., 92 (72.4%) preferred IMRT to IMLN-RT. In addition, the surgical approach to IMLN was practiced by surgeons at 18 (14%) centers, of which 13 (72.22%) operated the IMLN when radiologically evident. The IMLN dissection was preferentially performed for second and third intercostal spaces as suggested in 10 (55.55%) responses, while 8 (44.44%) performed thoracoscopic dissection of the IMLN chain. The distribution of prophylactic, definitive IMLN-RT, and IMLN dissection did not differ significantly between GI and PI ( p = NS). Conclusion pIMLN-RT is still not the standard protocol in most centers citing equivocal evidence in the literature. Logistics, though different in GIs and PIs, did not impact the decision of pIMLN-RT. Further efforts would be required to standardize practice in IMLN across India.
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Affiliation(s)
- Smitha S. Rao
- Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nita S. Nair
- Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tabassum Wadasadawala
- Breast Disease Management Group, Department of Radiation Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Smruti Mokal
- Department of Biostatistics, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rima Pathak
- Breast Disease Management Group, Department of Radiation Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rajiv Sarin
- Cancer Genetics Unit, Breast Disease Management Group, Department of Radiation Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vani Parmar
- Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shalaka Joshi
- Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rajendra A. Badwe
- Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Adam R, Duong TQ, Hodges L, Lu J, Maldjian T. Internal mammary lymph nodal response to neoadjuvant chemotherapy on imaging and breast cancer prognosis. Ann Med Surg (Lond) 2022; 84:104900. [PMID: 36536730 PMCID: PMC9758323 DOI: 10.1016/j.amsu.2022.104900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/06/2022] [Accepted: 11/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background Pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) is an important prognostic indicator in breast cancer. Internal mammary lymph node involvement is not currently included in pCR determination, as sampling at the time of surgery is not routinely performed. Methods Pre and post neoadjuvant chemotherapy MRI or PET/CT imaging response of the internal mammary lymph node chain was utilized as a surrogate to pCR and imaging data was correlated with patient outcomes. Results Internal mammary lymph node response to NAC was associated with disease free survival over the course of this study, regardless of whether axillary nodal pCR was achieved. Conclusion Internal mammary lymph nodal response to NAC is an important prognostic indicator. Potential use of internal mammary lymph node resolution as an imaging data input for AI models that predict pCR post-NAC may improve accuracy and other metrics in pCR prediction.
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Affiliation(s)
- Richard Adam
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Tim Q Duong
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Laura Hodges
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Jinyu Lu
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Takouhie Maldjian
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
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Li L, Zhang H, Wang L, Xie C, Zhou Y, Zhong Y. A retrospective analysis on metastatic rate of the internal mammary lymph node and its clinical significance in adjuvant radiotherapy of breast cancer patients. BMC Cancer 2020; 20:153. [PMID: 32093638 PMCID: PMC7041175 DOI: 10.1186/s12885-020-6642-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 02/17/2020] [Indexed: 12/18/2022] Open
Abstract
Background There is a discrepancy about the metastatic rate of internal mammary lymph nodes (IMNs) between clinical and pathologic findings. We aimed to investigate the metastatic rate of IMNs and to provide recommendations on target volume delineation of IMNs for adjuvant radiotherapy in breast cancer patients. Methods We retrospectively analyzed data from 114 breast cancer patients treated with surgery without adjuvant radiotherapy who developed local and/or regional lymph node recurrence/metastasis at our institute from January 2015 to January 2019. Patients with widely lung or pleural metastases were excluded. We first analyzed the recurrence rate with the chest wall, the metastatic rate of internal mammary/anterior mediastinal, ipsilateral axillary and supraclavicular lymph nodes, and then investigated the distribution of the IMNs. Results Among the 114 included patients, the recurrence rate with the chest wall, metastatic rate of IMNs, IMNs/anterior mediastinal lymph nodes, ipsilateral axillary lymph nodes, and the ipsilateral supraclavicular lymph nodes was 43, 37.7, 59.6, 12.3, and 22.8%, respectively. The metastatic IMNs were mainly located from the first to the second intercostal space. However, metastatic lymph nodes could also be observed above the upper edge of the first rib. Conclusions The metastatic rate is high in the IMNs and irradiation of the internal mammary lymphatic chain is required. It is suggested that the upper bound of the internal mammary lymphatic chain should be up to the subclavian vein with a 5-mm margin, thus connecting to the caudal border of supraclavicular clinical target volume in breast cancer patients at high risk of recurrence.
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Affiliation(s)
- Li Li
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Cancer Clinical Study Center, Wuhan, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Wuhan, China
| | - Hongyan Zhang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Cancer Clinical Study Center, Wuhan, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Wuhan, China
| | - Linwei Wang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Cancer Clinical Study Center, Wuhan, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Wuhan, China
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Cancer Clinical Study Center, Wuhan, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Wuhan, China
| | - Yunfeng Zhou
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China.,Hubei Cancer Clinical Study Center, Wuhan, China.,Hubei Key Laboratory of Tumor Biological Behaviors, Wuhan, China
| | - Yahua Zhong
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China. .,Hubei Cancer Clinical Study Center, Wuhan, China. .,Hubei Key Laboratory of Tumor Biological Behaviors, Wuhan, China.
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Qingqing H, Jian Z, Dayong Z, Ziyi F, Luming Z, Peng Z, Fang Y, Gaofeng N, Xuefeng D, Meng W, Dan W, Lei H, Xiaolei L, Tao Y. Robot-Assisted Internal Mammary Lymph Node Chain Dissection for Breast Cancer. Clin Breast Cancer 2018; 18:e441-e445. [PMID: 29752223 DOI: 10.1016/j.clbc.2018.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/07/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
Affiliation(s)
- He Qingqing
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China.
| | - Zhu Jian
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Zhuang Dayong
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Fan Ziyi
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Zheng Luming
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Zhou Peng
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Yu Fang
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Ni Gaofeng
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Dong Xuefeng
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Wang Meng
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Wang Dan
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Hou Lei
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Li Xiaolei
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Yue Tao
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
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