Selecting breast cancer patients with T1-T2 tumors and one to three positive axillary nodes at high postmastectomy locoregional recurrence risk for adjuvant radiotherapy

Present-day locoregional control in patients with t1 or t2 breast cancer with 0 and 1 to 3 positive lymph nodes after mastectomy without radiotherapy

BACKGROUND

We sought to determine present-day locoregional recurrence (LRR) rates to better understand the role of postmastectomy radiotherapy (PMRT) in women with 0 to 3 positive lymph nodes.

METHODS

Clinical and pathologic factors were identified for 1019 patients with pT1 or pT2 tumors and 0 (n = 753), 1 (n = 176), 2 (n = 69), or 3 (n = 21) positive lymph nodes treated with mastectomy without PMRT during 1997 to 2002. Total LRR rates were calculated by Kaplan-Meier analysis and compared between subgroups by the log rank test.

RESULTS

After a median follow-up of 7.47 years, the overall 10-year LRR rate was 2.7%. The only independent predictor of LRR was younger age (P = 0.004). Patients ≤40 years old had a 10-year LRR rate of 11.3 vs. 1.5% for older patients (P < 0.0001). The 10-year rate of LRR in patients with 1 to 3 positive nodes was 4.3% (94.4% had systemic therapy), which was not significantly different from the 10-year risk of contralateral breast cancer development (6.5%; P > 0.5). Compared with the 10-year LRR rate among patients with node-negative disease (2.1%), patients with 1 positive node had a similar 10-year LRR risk (3.3%; P > 0.5), and patients with 2 positive nodes had a 10-year LRR risk of 7.9% (P = 0.0003). Patients with T2 tumors with 1 to 3 positive nodes had a 10-year LRR rate of 9.7%.

CONCLUSIONS

In patients with T1 and T2 breast cancer with 0 to 3 positive nodes, LRR rates after mastectomy are low, with the exception of patients ≤40 years old. The indications for PMRT in patients treated in the current era should be reexamined.

Effect of nodal irradiation and fraction size on cardiac and cerebrovascular mortality in women with breast cancer treated with local and locoregional radiotherapy

PURPOSE

To determine whether the adjuvant breast cancer radiation volume or fraction size (>2 Gy vs. ≤2 Gy) affected the risk of fatal cardiac or cerebrovascular (CCV) events and to determine whether the addition of regional radiotherapy (RT) increased the risk of fatal cerebrovascular events compared with breast/chest wall RT alone.

METHODS AND MATERIALS

Overall survival was compared for patients receiving breast/chest wall RT alone or breast/chest wall plus regional node RT (BRCW+NRT) in a population-based cohort of women with early-stage breast cancer who had undergone RT between 1990 and 1996. The effect of laterality, age, systemic therapy, radiation volume, and fraction size on the risk of fatal CCV events was analyzed using a competing risk method.

RESULTS

A total of 4,929 women underwent adjuvant RT. The median follow-up was 11.7 years. BRCW+NRT was associated with an increased risk of CCV death at 12 years (5% for BRCW+NRT vs. 3.5% for breast/chest wall RT alone; p = .004), but the fraction size was not (3.92% for a fraction size >2 Gy vs. 3.54% for a fraction size <2 Gy; p = .83). The 12-year absolute risk of death from stroke alone did not differ for either radiation volume (1.17% for BRCW+NRT vs. 0.8% for breast/chest wall RT alone; p = .22) or fraction size (p = .59).

CONCLUSION

Regional RT was associated with a small (1.5% at 12 years), but statistically significant, increased risk of death from a CCV event. The addition of regional RT did not significantly increase the risk of death from stroke, although the number of events was small. An increased fraction size was not significantly associated with a greater risk of fatal CCV events. These data support the continued use of hypofractionated adjuvant regional RT.

Postmastectomy locoregional recurrence and recurrence-free survival in breast cancer patients

Background

One essential outcome after breast cancer treatment is recurrence of the disease. Treatment decision is based on assessment of prognostic factors of breast cancer recurrence. This study was to investigate the prognostic factors for postmastectomy locoregional recurrence (LRR) and survival in those patients.

Methods

114 patients undergoing mastectomy and adjuvant radiotherapy in Cancer Institute of Tehran University of Medical Sciences were retrospectively reviewed between 1996 and 2008. All cases were followed up after initial treatment of patients with breast cancer via regular visit (annually) for discovering the LRR. Cumulative recurrence free survival (RFS) was determined using the Kaplan-Meier method, with univariate comparisons between groups through the log-rank test. The Cox proportional hazards model was used for multivariate analysis.

Result

The median follow up time was 84 months (range 2-140). Twenty-three (20.2%) patients developed LRR. Cumulative RFS rate at 2.5 years and 5 years were 86% (95%CI, 81-91) and 82.5% (95%CI, 77-87) respectively. Mean RFS was 116.50 ± 4.43 months (range, 107.82 - 125.12 months, 95%CI). At univariate and multivariate analysis, factors had not any influence on the LRR.

Conclusion

Despite use of adjuvant therapies during the study, we found a LRR rate after mastectomy of 20.2%. Therefore, for patients with LRR without evidence of distant disease, aggressive multimodality therapy is warranted.

Prognostic factors affecting the outcome of salvage radiotherapy for isolated locoregional recurrence after mastectomy

OBJECTIVES

To evaluate the prognostic factors affecting the outcome of salvage radiotherapy for isolated locoregional recurrence after mastectomy.

METHODS

Between May 1988 and April 2002, 65 breast cancer patients underwent radiotherapy as a component of salvage treatment for isolated locoregional recurrence after mastectomy. The sites of failure were as follows: chest wall in 37 patients, regional lymph nodes (LNs) in 23 patients, and combined chest wall and LNs in 5 patients. None of the patients had previously been treated with radiation. Thirty-nine patients had surgical resection, and 55 patients received systemic chemotherapy and/or hormonal therapy for recurrent disease. In 51 cases (78.5%), the chest wall and ipsilateral regional lymphatics including supraclavicular, axillary, and internal mammary LNs were irradiated. Median dose was 50.4 Gy (range: 50-71.5). Median duration of follow-up was 52 months (range: 2-206).

RESULTS

The 5-year overall survival rate was 48.1%. On multivariate analysis, patients without initial nodal involvement had better overall survival (P = 0.0118). The 5-year locoregional progression-free survival rate was 69.8%, and time to recurrence (>36 months vs. < or =36 months) had an influence on the outcome with borderline significance (P = 0.0775). The 5-year distant metastasis-free survival rate was 42.1%. Lack of systemic therapy after recurrence (P = 0.0089) and age <50 years at recurrence (P = 0.0145) were significant prognostic factors predicting poor distant metastasis-free survival.

CONCLUSIONS

Radiotherapy for isolated locoregional relapse after mastectomy achieved locoregional control in about two-thirds of patients. Major pattern of failure was distant relapse, and systemic therapy is warranted to prevent secondary dissemination.

Therapeutic benefit of radiotherapy after surgery in patients with T1–T2 breast tumour

Purpose: To look for the therapeutic benefit of radiotherapy after surgery in patients with T1–T2 breast tumour.

Methodology: From 1990 to 2000, 915 patients with T1–T2 breast tumour who underwent mastectomy or conservative breast surgery (CBS) with or without radiotherapy were analysed retrospectively for age, disease stage, radiation therapy technique, dose, the use of chemotherapy or hormonal therapy and other clinical and/or pathologic characteristics. The Kaplan–Meier method was used to estimate locoregional recurrence-free survival (LRRFS) and overall survival (OS). The Cox proportional hazard regression model was used to determine significant prognostic factors affecting LRRFS and OS.

Results: At a median follow up of 74 months, LRR rate was 5.3% and distant metastases rate was 19%. Disease-free survival (DFS) and OS at 10 year was 72% and 76%, respectively. LRR in patients with CBS followed with radiation was 3% as compared to 33% without radiation. LRR in patients with post-mastectomy radiation was 3% as compared to 19% without radiation. In patients with N0 nodes, LRR was 4% with radiation and 20% without radiation. Worst case was in patients with CBS-N0 who were not given radiation. LRR in such patients was 32% as compared to 5% in those who were given radiation post-CBS. In patients with mastectomy with N0 status, LRR was 3% with radiation as compared to 18% with out radiation. On univariate analysis factors affecting LRRFS were type of surgery, nodal involvement, radiotherapy and hormonal therapy. Factors affecting OS were nodal involvement, grade, lymphovascular invasion (LVI), ductal carcinoma in situ (DCIS), extracapsular extension (ECE), chemotherapy and radiotherapy. On multivariate analysis factors affecting LRRFS were type of surgery, nodal involvement, radiotherapy and hormonal therapy. Factors affecting OS were nodal involvement, LVI, DCIS, ECE, chemotherapy and radiotherapy.

Conclusion: Radiation use offered a therapeutic advantage for all patients with T1–T2 breast cancer.

Prognostic value of nodal ratios in node-positive breast cancer: a compiled update

The number of positive axillary nodes is a strong prognostic factor in breast cancer, but is affected by variability in nodal staging technique yielding varying numbers of excised nodes. The nodal ratio of positive to excised nodes is an alternative that could address this variability. Our 2006 review found that the nodal ratio consistently outperformed the number of positive nodes, providing strong arguments for the use of nodal ratios in breast cancer staging and management. New evidence has continued to accrue confirming the prognostic significance of nodal ratios in various worldwide population settings. This review provides an updated summary of available data, and discusses the potential application of the nodal ratio to breast cancer staging and prognostication, its role in the context of modern surgical techniques such as sentinel node biopsy, and its potential correlations with new biologic markers such as circulating tumor cells and breast cancer stem cells.

Are mastectomy resection margins of clinical relevance? A systematic review

Although some guidelines support the use of post-mastectomy radiotherapy where the resection margin is involved or close, the scientific basis of this practice is not established. This systematic review explores the relationship between margin status and subsequent relapse. Pooled data from 22 studies (18,863 women) identified an involved post-mastectomy margin in 2.5%, a close margin in 8.0% and muscle or fascia invasion in 7.2% of patients. In a meta-analysis of five studies of non-inflammatory breast cancer without radiotherapy, local recurrence was increased by an involved or close margin (relative risk 2.6; P<0.00001). The effect of muscle or fascia invasion was of borderline significance (relative risk 1.7; P=0.04). In two separate meta-analyses, risk of relapse was related to margin status in women with inflammatory breast cancer (relative risk 3.1; P<0.0001) but not in those undergoing skin-sparing mastectomy (relative risk 2.1; P=0.16).

D-dimer as a possible prognostic marker of operable hormone receptor-negative breast cancer

BACKGROUND

Breast cancer is the most common cause of death in women by neoplasia. The mechanisms related to recurrence are unclear, specially the hemostatic alterations that occur during the development of the disease. Plasma D-dimer is a hypercoagulability and fibrinolytic system marker and is increased in patients with various solid tumors. The purpose of this study was to evaluate the hemostatic status assessed by plasma D-dimer in operable breast cancer patients and to investigate its value as a prognostic marker.

MATERIALS AND METHODS

The study comprised 32 patients with operable hormone receptor-negative breast cancer and a control group with 43 healthy women. Variables included presence and absence of breast cancer, clinical and histopathology findings, and overall survival.

RESULTS

Plasma D-dimer level was normal in the control group and significantly higher in breast cancer patients (P = 0.001), as well as in nonsurvivors compared with survivors (P = 0.025). The results showed that plasma D-dimer levels were not correlated with clinical and histopathology findings (P > 0.213).

CONCLUSIONS

The results taken together indicate the presence of a hypercoagulability state in women with operable hormone receptor-negative breast cancer given the increased levels of D-dimer in this group. Therefore, considering higher levels of D-dimer in patients with a poor outcome, its evaluation may be a promising tool for prognosis in women with operable hormone receptor-negative breast cancer.

Prospective multicenter comparison of models to predict four or more involved axillary lymph nodes in patients with breast cancer with one to three metastatic sentinel lymph nodes

PURPOSE

Three models have been developed to predict four or more involved axillary lymph nodes (ALNs) in patients with breast cancer with one to three involved sentinel lymph nodes (SLNs). Two scores were developed by Chagpar et al (Louisville scores excluding or including method of detection), and a nomogram was developed by Katz et al. The purpose of our investigation was to compare these models in a prospective, multicenter study.

PATIENTS AND METHODS

Our study involved a cohort of 536 patients having one to three involved SLNs who underwent ALN dissection. We evaluated the area under the receiver operating characteristic curve (AUC), calibration (for the Katz nomogram only), false-negative (FN) rate, and clinical utility of the three models. Results were compared with the optimal logistic regression (OLR) model that was developed from the validation cohort.

RESULTS

Among the 536 patients, 57 patients (10.6%) had > or = four involved ALNs. The AUC for the Katz nomogram was 0.84 (95% CI, 0.81 to 0.86). The Louisville score excluding method of detection was 0.75 (95% CI, 0.72 to 0.78). The Louisville score including method of detection was 0.77 (95% CI, 0.74 to 0.79). The FN rates were 2.5% (eight of 321 patients), 1.8% (two of 109 patients), and 0% (zero of 27 patients) for the Katz nomogram and the Louisville scores excluding and including method of detection, respectively. The Katz nomogram was well calibrated. Optimism-corrected bootstrap estimate AUC of the OLR model was 0.86. Using this result as a reasonable target for an external model, the performance of the Katz nomogram was remarkable.

CONCLUSION

We validated the three models for their use in clinical practice. The Katz nomogram outperformed the two other models.

Radiation therapy and breast reconstruction: a critical review of the literature

BACKGROUND

The optimal timing and technique of breast reconstruction in patients who may require postmastectomy radiation therapy are controversial. To help surgeons make the best decisions, the authors reviewed the recent literature on this topic.

METHODS

The authors searched the MEDLINE database for studies of radiation therapy and breast reconstruction with most patients treated after 1985 and mean follow-up of more than 1 year. Forty-nine articles were reviewed.

RESULTS

Even with the latest prosthetic materials and modern radiation delivery techniques, the complication rate for implant-based breast reconstruction in patients undergoing postmastectomy radiation therapy is greater than 40 percent, and the extrusion rate is 15 percent. Modified sequencing of two-stage implant reconstruction, such that the expander is exchanged for the permanent implant before postmastectomy radiation therapy, results in higher rates of capsular contracture and is not generally feasible after neoadjuvant chemotherapy. Current evidence suggests that postmastectomy radiation therapy also adversely affects autologous tissue reconstruction. Even with modern radiation delivery techniques, immediate implant-based or autologous tissue breast reconstruction can distort the chest wall and limit the ability to treat the targeted tissues without excessive exposure of the heart and lungs. In patients for whom postmastectomy radiation therapy appears likely but may not be required, "delayed-immediate reconstruction," in which tissue expanders are placed at mastectomy, avoids the difficulties associated with radiation delivery after immediate reconstruction and preserves the opportunity for the aesthetic benefits of skin-sparing mastectomy.

CONCLUSIONS

In patients who will receive or have already received postmastectomy radiation therapy, the optimal approach is delayed autologous tissue reconstruction after postmastectomy radiation therapy. If postmastectomy radiation therapy appears likely but may not be required, delayed-immediate reconstruction may be considered.

Breast cancer in young women and its impact on reproductive function

BACKGROUND

Breast cancer is the most common cancer in women in developed countries, and 12% of breast cancer occurs in women 20-34 years. Survival from breast cancer has significantly improved, and the potential late effects of treatment and the impact on quality of life have become increasingly important. Young women constitute a minority of breast cancer patients, but commonly have distinct concerns and issues compared with older women, including queries regarding fertility, contraception and pregnancy. Further, they are more likely than older women to have questions regarding potential side effects of therapy and risk of relapse or a new primary. In addition, many will have symptoms associated with treatment and they present a management challenge. Reproductive medicine specialists and gynaecologists commonly see these women either shortly after initial diagnosis or following adjuvant therapy and should be aware of current management of breast cancer, the options for women at increased genetic risk, the prognosis of patients with early stage breast cancer and how adjuvant systemic treatments may impact reproductive function.

METHODS

No systematic literature search was done. The review focuses on the current management of breast cancer in young women and the impact of treatment on reproductive function and subsequent management. With reference to key studies and meta-analyses, we highlight controversies and current unanswered questions regarding patient management.

RESULTS

Chemotherapy for breast cancer is likely to negatively impact on reproductive function. A number of interventions are available which may increase the likelihood of future successful pregnancy, but the relative safety of these interventions is not well established. For those who do conceive following breast cancer, there is no good evidence that pregnancy is detrimental to survival. We review current treatment; effects on reproductive function; preservation of fertility; contraception; pregnancy; breastfeeding and management of menopausal symptoms following breast cancer.

CONCLUSION

This paper provides an update on the management of breast cancer in young women and is targeted at reproductive medicine specialists and gynaecologists.

[Evidence-based radiotherapy in the treatment of early-stage invasive breast cancer: traditional clinical features and biomarkers]

Adjuvant radiotherapy after modified radical mastectomy and breast-conserving surgery for early-stage invasive breast cancer substantially reduces the risk of locoregional failure and is evidence-based. Using traditional clinical and pathological factors, patients can be classified into subgroups by the risk of locoregional recurrence. In the high-risk groups the absolute benefit of irradiation is larger. However, the patients are over-treated in every subgroup. Substantial proportion of the patients remains free of locoregional recurrence even in the absence of irradiation, and some patients develop locoregional recurrence despite postoperative irradiation. Molecular markers may provide sufficient information to allow accurate individual risk assessment to identify patients who might benefit from irradiation. Despite of hundreds of reports on tumor markers, results are controversial and the number of validated markers for clinical practice is small. Prognostic and predictive factors commonly used in radiotherapy practice are ER, PgR and HER-2. Adjuvant radiotherapy not only reduces locoregional recurrence rates but also improves cancer-specific survival in patients receiving systemic therapy. The highest mortality reduction is observed in mastectomy patients with good prognostic factors (<4 positive nodes, tumor size <2 cm, Grade 1 malignancy, ER- and PgR-positive, HER-2-negative). After mastectomy the chest wall, and after breast conserving surgery the ipsilateral breast are the sites at greatest risk of recurrence. The risk of axillary recurrence is low in patients undergoing axillary dissection. Axillary and supraclavicular recurrences generally forecast a grim prognosis, and they are indicators of distant dissemination. Improvement in survival resulting from the use of irradiation is more related to the prevention of local recurrences. Post-irradiation local recurrence increases the risk of mortality, but with good prognostic factors the 10-year survival is 80-90%. Patients with </=2 cm ipsilateral breast recurrence might receive a second conservative surgery. The radiation dose to the lung and heart can be significantly reduced by individualized CT-based treatment planning. The rate of Grade 3 atrophic dermatitis and fibrosis is 3-4%. The estimated incidence of ipsilateral breast angiosarcoma is less than 0.2%, but the mortality rate is high.

Chest wall radiotherapy: middle ground for treatment of patients with one to three positive lymph nodes after mastectomy

PURPOSE

To evaluate the outcomes for patients with Stage II breast cancer and one to three positive lymph nodes after mastectomy who were treated with observation or adjuvant radiotherapy to the chest wall (CW) with or without the regional lymphatics.

METHODS AND MATERIALS

We retrospectively analyzed 238 patients with Stage II breast cancer (one to three positive lymph nodes) treated with mastectomy at the Massachusetts General Hospital between 1990 and 2004. The estimates of locoregional recurrence (LRR), disease-free survival (DFS), and overall survival were analyzed according to the delivery of radiotherapy and multiple prognostic factors.

RESULTS

LRR and DFS were significantly improved by postmastectomy radiotherapy (PMRT), with a 5- and 10-year LRR rate without PMRT of 6% and 11%, respectively and, with PMRT, of 0% at both 5 and 10 years (p = .02). The 5- and 10-year DFS rate without PMRT was 85% and 75%, respectively, and, with PMRT, was 93% at both 5 and 10 years (p = .03). A similar benefit was found for patients treated with RT to the CW alone. The LRR, DFS, and overall survival rate for patients treated to the CW only was 0%, 96%, and 95% at 10 years, respectively.

CONCLUSION

Our data suggest that adjuvant PMRT to the CW alone provides excellent disease control for patients with breast cancer <5 cm with one to three positive lymph nodes.

[Risk factors for tumor recurrence after breast conserving therapy: about 254 cases]

OBJECTIVES

To retrospectively study our risk factors of recurrence of infiltrating breast cancers treated by conservative therapy in Saint-Etienne university hospital.

MATERIALS AND METHODS

From 1997 to 2000, 254 patients were treated by conservative treatment. Through a univariate then multivariate analysis we identified factors of locoregional and metastatic recurrences.

RESULTS

The global rate of recurrence is 21.6%. There is 9.8% of local recurrence, 2.3% of node recurrence and 14.9% of metastatic one. Plurifocality OR: 3.7, tumoral type OR: 2.93, lymphovascular invasion OR: 3.6 and young age are factors of locoregional recurrence. For distant metastases, the recurrences factors are the tumoral size, the node status, the absence of estrogens receptors, the SBR rank, the locoregional recurrence, the rise of CA 15-3 and the addition of chemotherapy but only the SBR rank OR: 2.56 appears in multivariate analysis.

CONCLUSION

On one hand, this study revealed known risk factors already used to decide on the adjuvant therapy. On the other hand, plurifocality and lobular cancer must be taken into consideration before a conservative therapy. The surgery will probably be more extensive under these conditions.

Effect of postmastectomy radiotherapy in patients <35 years old with stage II-III breast cancer treated with doxorubicin-based neoadjuvant chemotherapy and mastectomy

PURPOSE

Postmastectomy radiotherapy (PMRT) improves locoregional control (LRC) in patients with high-risk features after mastectomy. Young age continues to evolve as a potentially important risk factor. The objective of this study was to assess the benefits of PMRT in patients <35 years old treated with doxorubicin-based neoadjuvant chemotherapy for Stage II-III breast cancer.

PATIENTS AND METHODS

We retrospectively analyzed 107 consecutive breast cancer patients <35 years old with Stage IIA-IIIC disease treated at our institution with doxorubicin-based neoadjuvant chemotherapy and mastectomy, with or without PMRT. The treatment groups were compared in terms of LRC and overall survival.

RESULTS

Despite more advanced disease stages, the patients who received PMRT (n = 80) had greater rates of LRC (5-year rate, 88% vs. 63%, p = 0.001) and better overall survival (5-year rate, 67% vs. 48%, p = 0.03) than patients who did not receive PMRT (n = 27).

CONCLUSION

Among breast cancer patients <35 years old at diagnosis, the use of PMRT after doxorubicin-based neoadjuvant chemotherapy and mastectomy led to a statistically greater rate of LRC and overall survival compared with patients without PMRT. The benefit seen for PMRT in young patients provides valuable data to better tailor adjuvant, age-specific treatment decisions after mastectomy.

Postmastectomy radiotherapy in breast cancer with high risk of relapse: current and future approaches

Postmastectomy radiotherapy in patients with breast cancer remains controversial in oncology . The major risk factor for local-regional recurrence is the tumor size and the number of lymph node metastases. The common sites of postmastectomy recurrence are the chest wall and the supraclavicle fossa. Postmastectomy radiotherapy decreases local-regional recurrence and improves survival in selected patients . This article presents a short overview of this issue based on the author's professional medical experience and reviews the literature.

Postmastectomy radiation therapy: indications and controversies

The indications and benefits of postmastectomy radiation therapy (PMRT) continue to evolve. Advances in systemic adjuvant therapy and targeted therapy for breast cancer are likely to play an increasingly important role in control of locoregional as well as distant disease. Ongoing scrutiny of patterns of chest wall failure will be required to define the net benefit derived from PMRT. This article discusses the 2001 American Society of Clinical Oncology guidelines for PMRT and current practices using PMRT in selected groups of patients who have breast cancer.

The Ratio of Positive to Excised Nodes Identifies High-risk Subsets and Reduces Inter-Institutional Differences in Locoregional Recurrence Risk Estimates in Breast Cancer Patients With 1–3 Positive Nodes: An Analysis of Prospective Data From British Columbia and the M. D. Anderson Cancer Center

PURPOSE

To examine the power of the nodal ratio (NR) of positive/excised nodes in predicting postmastectomy locoregional recurrence (LRR) in patients with 1-3 positive nodes (N+) and in identifying cohorts at similar risk across independent data sets.

METHODS AND MATERIALS

Data from 82 patients with 1-3 N+ treated without postmastectomy radiotherapy (PMRT) in the British Columbia (BC) randomized trial were compared with data from 462 patients treated without PMRT in prospective chemotherapy trials at the M. D. Anderson Cancer Center (MDACC). Kaplan-Meier LRR curves were compared between centers using the absolute number of N+ and nodal ratios.

RESULTS

The median number of excised nodes was 10 in BC and 16 in MDACC (p < 0.001). Examining LRR by number of N+, the 10-year LRR rate for patients with 1-3 N+ was higher in BC compared with MDACC (21.5% vs. 12.6%; p = 0.02). However, when examining LRR using NR, no differences were found between institutions. In patients with NR < or = 0.20, the 10-year LRR rate was 17.7% BC vs. 10.9% MDACC (p = 0.27). In patients with NR > or = 0.20, the 10-year LRR rate was 28.7% BC vs. 22.7% MDACC (p = 0.32). On Cox regression analysis, NR was a stronger prognostic factor compared with number of N +.

CONCLUSIONS

In patients with 1-3 N+, evaluating nodal positivity using NR reduced inter-institutional differences in LRR estimates that may exist due to variations in numbers of nodes excised. Nodal ratio >0.20 was associated with LRR >20%, warranting PMRT consideration. Nodal ratio may be useful for extrapolating data from prospective trials to clinical practices in which axillary staging extent vary.

Supraclavicular nodal failure in patients with one to three positive axillary lymph nodes treated with breast conserving surgery and breast irradiation, without supraclavicular node radiation

The purpose of this study was to evaluate the risk factors associated with supraclavicular nodal failure (SCF) in patients with one to three positive axillary nodes treated with breast conserving surgery and axillary dissection without supraclavicular node radiation (S/C RT) to aid in the selection of patients for S/C RT. Two hundred two breast conservation patients with one to three positive axillary nodes on axillary dissection treated with breast irradiation without S/C RT and 20 patients with S/C RT between August 1985 and May 2002 were identified and retrospectively evaluated. The Kaplan-Meier method was used to determine SCF-free and overall survival curves. Risk factors for SCF were examined. The median follow-up from surgery was 72 months (range: 4-195). Nine of 202 patients (4%) failed in the ipsilateral breast, 4 (2%) in the ipsilateral supraclavicular lymph nodes, 4 (2%) in the ipsilateral axillary and/or internal mammary nodes and 30 (15%) distantly. The 5- and 10-year SCF-free survival was 97.92%. The overall survival at 5, 10, and 15 years was 91.35%, 75.58%, and 67.18%, respectively. SCFs were associated with high grade or ER negative cancers, but not with number of positive nodes. Two of the four SCFs were associated with distant metastases, and two with local failures. One patient with a SCF was salvaged and is disease-free at 134 months. The overall low incidence of SCF in patients with one to three positive nodes treated with breast radiation alone after breast conserving surgery and adequate axillary dissection suggests that additional S/C RT is unnecessary in this cohort. When it occurs, supraclavicular nodal failure is often associated with distant metastases.

Post-mastectomy radiation therapy: Translating local benefits into improved survival

Several randomized trials and the most recent meta-analysis from the Oxford Overview have confirmed the efficacy of post-mastectomy radiation therapy (PMRT) in improving local control and long-term survival. The survival advantage of PMRT has been established in patients with a 10% risk of local regional recurrence. Patients with four or more positive lymph nodes fall in this category, even with effective systemic therapy. However, it remains difficult to identify the subset of patients with 1-3 positive lymph nodes at highest risk of local recurrence, who would most likely demonstrate a survival benefit with PMRT. When PMRT is used, careful treatment planning, particularly with regard to cardiac dose, is critical to minimizing serious late effects of treatment. Further developments in pathologic stratification of these patients, guided by expression profiles or novel biologic markers, are required to enable individualized assessment of long-term therapeutic risks and benefits.

Predicting Patients at Low Probability of Requiring Postmastectomy Radiation Therapy

BACKGROUND

Postmastectomy radiation therapy (PMRT) is recommended for patients with four or more positive lymph nodes (LN+). Given the ramifications of PMRT for immediate reconstruction, we sought to create a model using preoperative and intraoperative factors to predict which patients with a positive sentinel lymph node will have less than four LN+.

METHODS

The database from a prospective multicenter study of 4,131 patients was used for this analysis. Patients with one to three positive sentinel lymph nodes (SLN) and tumors < 5 cm (n = 1,133) in size were randomly divided into a training set (n = 580) and a test set (n = 553). Multivariate logistic regression was used on the training set to create a prediction rule that was subsequently validated in the test set.

RESULTS

Median patient age was 57 (range, 27-100) years, and median tumor size was 2.0 (range, 0.2-4.8) cm. In the training set, factors associated with having four or more LN+ on multivariate analysis were: tumor size [odds ratio (OR) = 2.087; 95% confidence interval (CI): 1.307-3.333, P = 0.002), number of positive SLN (P < 0.0005), and proportion of positive SLN (OR = 3.602; 95% CI: 2.100-6.179, P < 0.005). A predictive model was established with a point assigned to each positive SLN, T2 (vs. T1), and if proportion of positive SLN was > 50%, for a maximum of five points. In both the training and test sets, patients with one point had a low probability of having four or more LN+ (3.8% and 3.3%, respectively).

CONCLUSION

Tumor size, number of positive SLN, and the proportion of positive SLN influence whether patients will have four or more LN+. A simple model can predict the probability of requiring PMRT.

Postmastectomy radiotherapy in intermediate-risk patients: the gray zone

Postmastectomy radiotherapy continues to be one of the most controversial issues in breast radiotherapy. At the crux of the controversy lies the lack of conclusive studies that specifically address the risk-benefit ratio of postmastectomy radiotherapy for patients at intermediate risk of developing locoregional recurrence. A well-designed phase III trial was initiated, but the trial failed to accrue and was closed prematurely, leaving the issue unresolved. Recent data confirm that postmastectomy radiotherapy yields a clear benefit in breast cancer-specific survival. Furthermore, the risk of cardiac morbidity that historically has offset the benefit of postmastectomy radiotherapy appears to be lessening with modern radiotherapy approaches. However, newer, more efficacious systemic therapy regimens may decrease the risk of locoregional recurrence and increase the risk of toxicity from combined-modality therapy. Recent studies attempt to better stratify patients into risk categories based on disease factors and to estimate the benefit of postmastectomy radiotherapy when traditional risk estimates, such as nodal status, are obscured by neoadjuvant systemic therapy. Nonetheless, a clear consensus on the role of postmastectomy radiotherapy remains elusive for patients who are at intermediate risk of locoregional recurrence after mastectomy.

The impact of the number of excised axillary nodes and of the percentage of involved nodes on regional nodal failure in patients treated by breast-conserving surgery with or without regional irradiation

PURPOSE

After breast-conserving surgery, recommendations for regional nodal radiotherapy are usually based on the number of positive nodes. This number is dependent on the number of nodes removed during the axillary dissection. This study examines whether the percentage of positive nodes may help to select patients for regional radiotherapy.

METHODS AND MATERIALS

A retrospective study was conducted on 1,372 T1-T2 node-positive breast cancer patients treated at L'Hôtel-Dieu de Québec Hospital between 1972 and 1997.

RESULTS

Among the patients who did not receive regional radiotherapy, the percentage of involved nodes was significantly associated with axillary failure. Ten-year axillary control rates were 97% and 91% when the percentage of involved nodes was <50% and > or =50%, respectively (p = 0.007). In addition, regional radiotherapy is always significantly associated with a decrease in overall regional failure (axillary and/or supraclavicular), regardless of the percentage of involved nodes. However, regional radiotherapy reduced the axillary failure rate (2% vs. 9%, p = 0.007) only when more than a specific percentage of nodes was involved (> or =40% if N1-3 and > or =50% if N>3 nodes).

CONCLUSIONS

The percentage of involved nodes should be taken into consideration in selecting patients for regional radiotherapy. Irradiation of the axilla should be reserved for patients with a specific ratio: >40% involved nodes if N1-3 and > or =50% involved nodes if N>3 nodes.

Study of failure pattern among high-risk breast cancer patients with or without postmastectomy radiotherapy in addition to adjuvant systemic therapy: long-term results from the Danish Breast Cancer Cooperative Group DBCG 82 b and c randomized studies

PURPOSE

Postmastectomy radiotherapy (RT) in high-risk breast cancer patients can reduce locoregional recurrences (LRRs) and improve disease-free and overall survival. The aim of this analysis was to examine the overall disease recurrence pattern among patients randomly assigned to receive treatment with or without RT.

PATIENTS AND METHODS

A long-term follow-up was performed among the 3,083 patients from the Danish Breast Cancer Cooperative Group 82 b and c trials, except in those already recorded with distant metastases (DM) or contralateral breast cancer (CBC). The end points were LRR, DM, and CBC, and the follow-up continued until DM, CBC, emigration, or death. Information was selected from medical records, general practitioners, and the National Causes of Death Registry. The median potential follow-up time was 18 years.

RESULTS

The 18-year probability of any first breast cancer event was 73% and 59% (P < .001) after no RT and RT, respectively (relative risk [RR], 0.68; 95% CI, 0.63 to 0.75). The 18-year probability of LRR (with or without DM) was 49% and 14% (P < .001) after no RT and RT, respectively (RR, 0.23; 95% CI, 0.19 to 0.27). The 18-year probability of DM subsequent to LRR was 35% and 6% (P < .001) after no RT and RT, respectively (RR, 0.15; 95% CI, 0.11 to 0.20), whereas the probability of any DM was 64% and 53% (P < .001) after no RT versus RT, respectively (RR, 0.78; 95% CI, 0.71 to 0.86).

CONCLUSION

Postmastectomy RT changes the disease recurrence pattern in high-risk breast cancer patients; fewer patients have LRR as first site of recurrence, and overall fewer patients have DM.

Quantitative molecular diagnosis of axillary drainage fluid for prediction of locoregional failure in patients with one to three positive axillary nodes after mastectomy without adjuvant radiotherapy

PURPOSE

A quantitative multiple-marker reverse transcriptase (RT)-polymerase chain reaction (PCR) assay for sensitive detection of cancer cells in axillary drainage fluid was developed to examine whether the presence of cancer cells in axillary drainage fluid can be used as a predictor of locoregional recurrence (LRR) in patients with breast cancer who had T1/2 primary tumors and one to three positive axillary lymph nodes treated with modified radical mastectomy without adjuvant radiotherapy.

METHODS AND MATERIALS

Axillary drainage fluid was collected from 126 patients with invasive ductal carcinoma of the breast who were treated with modified radical mastectomy and were found to have one to three positive axillary nodes. Cancer cells in axillary drainage fluid were detected by RT-PCR assay using primers specific for carcinoembryonic antigen (CEA) and cytokeratin-19 (CK-19) together with numerous clinicopathologic and treatment-related factors and were analyzed for their impact on LRR.

RESULTS

A total of 38 patients suffered LRR during follow-up and the multimarker RT-PCR assays for CEA and CK-19 in the axillary drainage fluid both were positive in 34 patients (27.0%), of which 29 patients had LRR. In univariate analysis, the 5-year LRR-free survival showed higher rates in patients with PCR-negative findings in axillary drainage fluid (p<0.0001), age>or=40 years old (p<0.0001), tumor size<2.5 cm (p<0.0001), negative lymph-vascular space invasion (p=0.026), and T1 status (<0.0001); in multivariate analysis, PCR-positive findings together with age and tumor size were found to be independent predictors of LRR (all p<0.05).

CONCLUSION

Multiplex RT-PCR assay for CEA and CK-19 was highly sensitive for detection and might be useful for prediction of LRR in such subgroup breast cancer patients.