Local recurrence in breast carcinoma patients with T1–2 and 1–3 positive nodes: Indications for radiotherapy

Post-mastectomy Radiation Therapy in Triple-Negative Breast Cancer Patients: Analysis of the BEATRICE Trial

PURPOSE

Post-mastectomy radiation therapy (PMRT) improves locoregional control and overall survival in patients with breast cancer. With the evolution of systemic therapy, the benefit of PMRT in patients with triple-negative disease requires further evaluation.

PATIENTS AND METHODS

BEATRICE is a phase III randomized clinical trial that examined the efficacy of bevacizumab in patients with triple-negative breast cancer (TNBC). The current study is a retrospective analysis of data on patients enrolled and treated with mastectomy and systemic therapy. The primary endpoint was determining the effect of PMRT on locoregional recurrence rates (LRR). Hazard ratios were estimated using Cox regression, and LRR curves were generated by the Kaplan-Meier method.

RESULTS

In total, 940 patients were included in our analysis, of whom 359 (38.2%) received PMRT while 581 (61.8%) did not. At median follow-up of 5 years, no significant difference in LRR was noted between the PMRT and no PMRT groups in node-negative patients (HR = 1.09). Patients with N1 disease had 5-year LRR-free survival of 96% for PMRT versus 91% for no PMRT (HR = 0.46). Most N2 patients received PMRT and had 5-year LRR-free survival of 76%.

CONCLUSION

PMRT benefit in TNBC patients treated with modern systemic therapy is lower than historical reports. Delivery of PMRT in patients with N1 disease enrolled in the BEATRICE trial was not shown to improve local control. As this might be due to patient selection for PMRT, future randomized controlled trials are required to assess the role of PMRT in this patient population.

Analysis of Breast Cancer Patients with T1-2 Tumors and 1-3 Positive Lymph Nodes Treated with or without Postmastectomy Radiation Therapy

The use of postmastectomy radiation therapy (PMRT) has been recommended for patients with 4 or more positive lymph nodes, however, its role in patients with 1-3 positive lymph nodes remains unclear. The purpose of this study is to evaluate oncological outcomes for breast cancer patients with T1-2 tumors and 1-3 positive lymph nodes after undergoing PMRT. We performed a single-institution retrospective investigation that evaluated the association between PMRT and outcomes in breast cancer patients with T1-2 tumors and 1-3 positive lymph nodes, who underwent mastectomy from 2004 to 2015. Multivariable Cox proportional hazards regression was used to evaluate the association of PMRT with disease-free survival and overall survival. A total of 379 patients met inclusion criteria, of which 204 (54%) received PMRT while 175 (46%) did not receive PMRT following mastectomy and were followed over a median of 5.2 years (25^th–75^th percentile: 2.8–8.4 years). Recurrence was similar in patients receiving PMRT compared to those that did not: locoregional (0 vs 3, P = 0.061), distant (9 vs 3, P = 0.135) and any recurrence (11 vs 7, P = 0.525). After adjustment for potential confounding variables, PMRT was not associated with a statistically significant difference in disease-free survival (HR: 0.93; 95% CI: 0.48, 1.79) or overall survival (HR: 0.91; 95% CI: 0.45, 1.85). PMRT was not associated with improved oncological outcomes in patients with T1-2 breast cancer and 1-3 positive lymph nodes at our institution.

Axillary management for young women with breast cancer varies between patients electing breast-conservation therapy or mastectomy

PURPOSE

Axillary treatment strategies for the young woman with early-stage, clinically node-negative breast cancer undergoing upfront surgery found to have 1-3 positive sentinel lymph nodes (SLNs) differ significantly after BCT and mastectomy. Here we compare axillary lymph node dissection (ALND) and regional nodal irradiation (NRI) rates between women electing breast-conservation therapy (BCT) versus mastectomy.

METHODS

From 2010 to 2016, women age < 50 years with clinical T1-T2N0 breast cancer having upfront surgery and found to have a positive SLN were identified. ALND and/or NRI receipt were compared between groups.

RESULTS

192 women undergoing BCT and 165 undergoing mastectomy were identified (median age: 44 years). 5.2% (10/192) of women undergoing BCT had an ALND versus 87% (144/165) of women undergoing mastectomy (p < 0.01). NRI was given to 48% (78/165) of mastectomy patients compared to 30% (57/192) of BCT patients (p < 0.01). Of the 75 mastectomy patients with 1-2 total positive lymph nodes after completion ALND, 44% received NRI. Women undergoing mastectomy were significantly more likely to receive both ALND and NRI than women undergoing BCS (45% vs 6%, p < 0.01).

CONCLUSION

Young cT1-2N0 breast cancer patients found to have 1-3 SLN metastases received ALND, NRI, and combined ALND/NRI more frequently if they elected mastectomy over BCT. Use of both ALND and postmastectomy radiotherapy (PMRT) in this population could be reduced in the future by omitting ALND in patients for whom the need for PMRT is clear with the finding of 1-2 SLN metastases.

Location and Frequency of Residual Breast Tissue after Mastectomy

Introduction

Residual breast tissue after mastectomy is a problem since breast cancer can arise from it. The aim of this study was to investigate the incidence and location of residual breast tissue following modified radical mastectomy.

Methods

111 consecutive breast cancer patients who underwent mastectomy were enrolled in this study. During surgery, after removal of the breast tissue and before skin closure, a 1-cm² tissue sample was obtained from each quadrant under the skin flaps. These samples were evaluated histopathologically for the presence of any residual breast tissue.

Results

Residual breast tissue was detected in the tissue samples of 12/111 (10.8%) patients. 4 of these patients had residual breast tissue in all 4 quadrants. 6 patients had residual tissue in a single quadrant. With 9 positive biopsy results, the upper medial quadrant was the most frequently involved location. The other quadrants had 6 positive biopsy results each. At the end of a median of 20 months of follow-up, none of these patients developed breast cancer recurrences.

Conclusion

Mastectomy has a high probability of residual breast tissue being left behind. Physicians should be aware of this and act accordingly when planning surgical or follow-up treatment.

Multidisciplinary Management of the Axilla in Patients with cT1-T2 N0 Breast Cancer Undergoing Primary Mastectomy: Results from a Prospective Single-Institution Series

BACKGROUND

The after mapping of the axilla: radiotherapy or surgery (AMAROS) trial concluded that for patients with cT1-2 N0 breast cancer and one or two positive sentinel lymph nodes (SLNs), axillary radiotherapy (AxRT) provides equivalent locoregional control and a lower incidence of lymphedema compared with axillary lymph node dissection (ALND). The study prospectively assessed how often ALND could be replaced by AxRT in a consecutive cohort of patients undergoing mastectomy for cT1-2 N0 breast cancer.

METHODS

In November 2015, our multidisciplinary group agreed to omit routine intraoperative SLN evaluation for cT1-2 N0 patients undergoing upfront mastectomy and potentially eligible for postmastectomy radiation therapy (PMRT), including those 60 years of age or younger and those older than 60 years with high-risk features. Patients with one or two positive SLNs on final pathology were reviewed to determine whether PMRT including the full axilla was an appropriate alternative to ALND.

RESULTS

From November 2015 to December 2016, 154 patients met the study criteria, and 114 (74%) formed the final study cohort. Intraoperative SLN evaluation was omitted for 76 patients (67%). Of these patients, 20 (26%) had one or two positive SLNs, and 14 of these patients received PMRT + AxRT as an alternative to ALND. Three patients returned for ALND, and three patients were observed. On univariate analysis, tumor size, LVI, number of positive lymph nodes, and receipt of chemotherapy were associated with receipt of PMRT.

CONCLUSIONS

For the majority of patients with one or two positive SLNs, ALND was avoided in favor of PMRT + AxRT. With appropriate multidisciplinary strategies, intraoperative evaluation of the SLN and immediate ALND can be avoided for patients meeting the AMAROS criteria and eligible for PMRT.

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.

Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

PURPOSE

A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT).

METHODS

A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data.

RECOMMENDATIONS

The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.

Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

Purpose A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT). Methods A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data. Recommendations The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.

Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT).

METHODS

A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data.

RECOMMENDATIONS

The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.

Dosimetric analysis of the brachial plexus among patients with breast cancer treated with post-mastectomy radiotherapy to the ipsilateral supraclavicular area: report of 3 cases of radiation-induced brachial plexus neuropathy

Background

The purpose of this study was to evaluate the brachial plexus (BP) dose of postmastectomy radiotherapy (PMRT) to the ipsilateral supraclavicular (ISCL) area, and report the characteristics of radiation-induced brachial plexus neuropathy (RIBPN).

Methods

The BP dose of 31 patients who received adjuvant PMRT to the ISCL area and chest wall using three-dimensional conformal radiotherapy (3DCRT) and the records of 3 patients with RIBPN were retrospectively analyzed based on the standardized Radiation Therapy Oncology Group-endorsed guidelines. The total dose to the ISCL area and chest wall was 50 Gy in 25 fractions.

Results

Patients with a higher number of removed lymph nodes (RLNs) had a higher risk of RIBPN (hazard ratio [HR]: 1.189, 95% confidence interval [CI]: 1.005-1.406, p = 0.044). In 31 patients treated with 3DCRT, the mean dose to the BP without irradiation to the ISCL area was significantly less than that with irradiation to the ISCL area (0.97 ± 0.20 vs. 44.39 ± 4.13 Gy, t = 136.75, p <0.001). In the 3DCRT plans with irradiation to the ISCL area and chest wall, the maximum dose to the BP was negatively correlated with age (r = −0.40, p = 0.026), body mass index (BMI) (r = −0.44, p = 0.014), and body weight (r = −0.45, p = 0.011). Symptoms of the 3 patients with RIBPN occurred 37–65 months after radiotherapy, and included progressive upper extremity numbness, pain, and motor disturbance. After treatment, 1 patient was stable, and the other 2 patients’ symptoms worsened.

Conclusions

The incidence of RIBPN was higher in patients with a higher number of RLNs after PMRT. The dose to the BP is primarily from irradiation of the ISCL area, and is higher in slim and young patients. Prevention should be the main focus of managing RIBPN, and the BP should be considered an organ-at-risk when designing a radiotherapy plan for the ISCL area.

Prognostic significance of lymphatic invasion in lymph node-positive breast carcinoma: findings from a large case series with long-term follow-up using immunohistochemical endothelial marker

The poor prognostic significance of lymphatic invasion (LI) in breast carcinoma (BC) as a whole and in lymph node (LN)-negative patients in particular has been recognized in several studies; however, its prognostic role in LN-positive patients is still questionable. Aim of the current study was to assess prognostic role of LI in LN-positive BC specimens. Sections from non-selected 557 LN-positive BC specimens were stained with antibody to podoplanin/D2-40. LI was identified and correlated with clinicopathological features and patients' outcome. Twenty-year overall survival (OS), disease-free interval (DFI), and development of distant metastasis (DM) or recurrence were known for all patients. LI was detected in 262/557 (47%) of specimens ranging from 1 to 350 lesion per tumor section. Its presence was associated with higher grade tumors (P<0.0001), negative hormonal receptors (P<0.0001), high HER-2 expression (P=0.006), and with increased number of positive LNs (P=0.019). In the whole LN-positive BC, presence of LI was a poor prognostic factor for OS, DFI, and development of DM both in univariate and in multivariate analysis. In further stratification of patients, LI was associated with poorer prognosis in patients with single positive LN and not in patients with >1 positive LN. In T1N1 stage, LI was highly associated with poor OS (P=0.002), DFI (P<0.0001), and DM (P<0.0001). In T2N1 patients, LI was associated only with poorer DFI (P=0.037) but not with death or DM. In the two former patient groups, LI lost significance in multivariate analysis. In conclusion, LI is a poor prognostic factor in LN-positive BC particularly for patients having single positive LN. LI therefore would add further prognostic significance when considered in treatment in those patients. We recommend incorporation of LI in breast carcinoma staging and in prognostic indices.

Post-mastectomy radiotherapy can improve survival in breast cancer patients aged 35 years or younger with four or more positive nodes but not in one to three positive nodes

Introduction

This retrospective study investigated the clinical value of post-mastectomy radiotherapy (PMRT) in female Chinese breast cancer patients aged 35 years or younger with positive axillary lymph nodes after mastectomy.

Methods

We performed an analysis of clinical pathological data from 221 female Chinese breast cancer patients aged 35 years or younger treated between 1998 and 2007. Patients were diagnosed with positive axillary lymph nodes and underwent mastectomy. PMRT was delivered to 92 patients.

Results

The median follow-up was 61 months. The 5-year locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were 84.1%, 65.2%, 61.4%, and 77.2%, respectively. Univariate survival analysis (P=0.003) and multivariate analysis (P<0.001) both suggested that PMRT is an independent prognostic factor of LRFS. PMRT positively affected LRFS (P=0.003), but had no significant impact on DMFS (P=0.429), DFS (P=0.146), and OS (P=0.750). PMRT improved LRFS (P=0.001), DFS (P=0.017), and OS (P=0.042) in patients with four or more positive nodes, but no survival benefit was observed in patients with one to three positive nodes (P>0.05).

Conclusion

PMRT can improve survival in breast cancer patients aged 35 years or younger with four or more positive nodes but not in those with one to three positive nodes.

Post-mastectomy radiotherapy benefits subgroups of breast cancer patients with T1-2 tumor and 1-3 axillary lymph node(s) metastasis

Background

To determine the role of postmastectomy radiotherapy (PMRT) in breast cancer patients with T1–2 and N1 disease.

Patients and methods.

A total of 207 postmastectomy women were enrolled. The 5-year Kaplan-Meier estimates of locoregional recurrence rate (LRR), distant recurrence rate (DRR) and overall survival (OS) were analyzed by different tumor characteristics. Multivariate analyses were performed using Cox proportional hazards modeling.

Results

With median follow-up 59.5 months, the 5-year LRR, DRR and OS were 9.1%, 20.3% and 84.4%, respectively. On univariate analysis, age < 40 years old (p = 0.003) and Her-2/neu over-expression (p = 0.016) were associated with higher LRR, whereas presence of LVI significantly predicted higher DRR (p = 0.026). Negative estrogen status (p = 0.033), Her-2/neu overexpression (p = 0.001) and LVI (p = 0.01) were significantly correlated with worse OS. PMRT didn’t prove to reduce 5-year LRR (p = 0.107), as well as 5-year OS (p = 0.918). In subgroup analysis, PMRT showed significant benefits of improvement LRR and OS in patients with positive LVI.

Conclusions

For patients with T1–2 and N1 stage breast cancer, PMRT can decrease locoregional recurrence and increase overall survival only in patients with lymphovascular invasion.

Analysis in early stage triple-negative breast cancer treated with mastectomy without adjuvant radiotherapy: patterns of failure and prognostic factors

BACKGROUND

The objective of this study was to evaluate and identify patterns of failure and prognostic factors for locoregional recurrence (LRR) that could justify postmastectomy radiotherapy after modified radical mastectomy in patients with early stage triple-negative breast cancer.

METHODS

Between January 2000 and July 2007, the authors retrospectively analyzed 390 patients who had triple-negative breast cancer with T1/T2 tumors and from zero to 3 positive lymph nodes (pathologic T1-T2N0-N1) who underwent modified radical mastectomy without postmastectomy radiotherapy at the author's institution. The 5-year cumulative incidence for events was calculated using Kaplan-Meier analysis, and subgroups were compared using the log-rank test. Multivariate analysis was performed using a Cox proportional hazards model.

RESULTS

Overall, 86.4% of patients received chemotherapy. At a median follow-up of 60.5 months, the 5-year cumulative rates of local recurrence, regional recurrence, LRR, and distant metastasis were 5.4%, 4.7%, 8%, and 13.4%, respectively. On multivariate analysis, age <50 years, the presence of lymphovascular invasion, grade 3 tumor, and 3 involved lymph nodes were associated significantly with an increased risk of LRR. The 5-year LRR rate for patients who had 0 or 1 risk factor, 2 risk factors, and 3 or 4 risk factors was 4.2%, 25.2%, and 81% (P < .0001), respectively. The presence of lymphovascular invasion and having 3 involved lymph nodes were statistically significant predictors of regional recurrence, and the patients who had regional recurrence had a significantly greater risk of distant metastases compared with patients who had local recurrence (59.1% vs 20.9%; P < .0001).

CONCLUSIONS

Several risk factors were identified in this study that correlated independently with a greater incidence of LRR in patients who had early stage triple-negative breast cancer. The current results indicated that postmastectomy radiotherapy should be considered for those patients who have 2 or more of these factors.

Comparison of clinical outcome of breast cancer patients with T1-2 tumor and one to three positive nodes with or without postmastectomy radiation therapy

OBJECTIVE

The value of postmastectomy radiation therapy for breast cancer patients with T1-2 tumor and one to three positive nodes remains controversial. The purpose of this retrospective study was to compare the clinical outcomes of breast cancer patients with T1-2 and one to three positive nodes with and without postmastectomy radiation therapy.

METHODS

Between May 1990 and June 2008, of 318 breast cancer patients with T1-2 and one to three positive nodes who had undergone modified radical mastectomy, 163 received postmastectomy radiation therapy and 155 did not. The clinico-pathologic characteristics were analyzed for clinical outcomes including loco-regional recurrence, distant metastasis, disease-free survival and overall survival.

RESULTS

During the median follow-up period of 102 months, the clinical outcomes in postmastectomy radiation therapy versus no-postmastectomy radiation therapy groups were as follows: loco-regional recurrence rate (3.1 versus 11.0%, P= 0.006); distant metastasis rate (20.9 versus 27.7%, P= 0.152); 10-year disease-free survival rate (73.8 versus 61.3%, P= 0.001); and 10-year overall survival rate (82.1 versus 76.1%, P= 0.239). Through a multivariate analysis, a positive nodal ratio of ≥25% (hazard ratio= 4.571, P= 0.003) and positive lymphovascular invasion (hazard ratio= 2.738, P= 0.028) were found to be independent poor prognostic predictors of loco-regional recurrence. The reduction in loco-regional recurrence (hazard ratio= 0.208, P= 0.004) by postmastectomy radiation therapy was found to be significant.

CONCLUSIONS

On the basis of our results, postmastectomy radiation therapy is highly recommended for breast cancer patients with T1-2 and one to three positive nodes, especially for high-risk subgroups with a positive nodal ratio of ≥25% and positive lymphovascular invasion, not only for reducing loco-regional recurrence but also for improving disease-free survival.

Prognostic Significance of the Number of Removed and Metastatic Lymph Nodes and Lymph Node Ratio in Breast Carcinoma Patients with 1-3 Axillary Lymph Node(s) Metastasis

We evaluated the prognostic significance of lymph node ratio (LNR), number of metastatic lymph nodes divided by number of removed nodes in 924 breast carcinoma patients with 1-3 metastatic axillary lymph node(s). The most significant LNR threshold value separating patients in low- and high-risk groups with significant survival difference was 0.20 for disease-free survival (P < 0.001), 0.30 for locoregional recurrence-free survival (P < 0.001), and 0.15 for distant metastasis-free survival (P < 0.001), and the patients with lower LNR had better survival. All three LNR threshold values had independent prognostic significance in Cox analysis (P < 0.001 for all three of them). In conclusion, LNR is a useful tool in separating breast carcinoma patients with 1-3 metastatic lymph node(s) into low- and high-risk prognostic groups.

Triple negative phenotype and N-ratio are important for prognosis in patients with stage IIIB non-inflammatory breast carcinoma

BACKGROUND AND OBJECTIVES

The aim is to evaluate novel prognostic factors such as triple negative (TN) phenotype and ratio between positive nodes and total dissected lymph nodes (N-ratio) in stage IIIB breast carcinoma patients.

METHODS

In this retrospective study, primary endpoints were local recurrence (LR), distant recurrence (DR), and overall survival (OS). Univariate and multivariate prognostic factor analyses were carried out using Cox and Kaplan-Meier methods in the data of 185 patients.

RESULTS

The median observation time was 36 (range 16-86) months. Pathological tumor size (continuous [cont.], P = 0.002; Hazard ratio [HR], 1.2; 95% confidence interval [CI], 1.1-1.3) and N-ratio (cont., P < 0.0001; HR, 1.02; CI, 1.01-1.03) were strongly associated with LR. Tumor phenotype (triple vs. non-triple, P = 0.002; HR, 2.6; CI, 1.4-4.7), N-ratio (cont., P = 0.01; HR, 1.02; CI, 1.01-1.03) and pathological tumor size (cont., P = 0.003; HR, 1.2; CI, 1.1-1.3) for DR, and also tumor phenotype (triple vs. non-triple, P < 0.0001; HR, 3.7; CI, 1.8-7.5), N-ratio (cont., P = 0.03; HR, 1.02; CI, 1.01-1.03) and pathological tumor size (cont., P = 0.006; HR, 1.3; CI, 1.2-1.4) for OS were the most important prognostic factors.

CONCLUSIONS

N-Ratio and TN phenotype were the most important prognostic factors for stage IIIB breast carcinoma patients.

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.

Locoregional recurrence in breast carcinoma patients

AIMS

To assess the risk of locoregional recurrence (LRR) after mastectomy and to identify predictive and treatment factors that affect the risk of LRR.

METHODS

The primary endpoint was local recurrence. Univariate and multivariate Cox regression analyses were carried out in the data from 1217 patients.

RESULTS

The median follow-up was 74 months, and 63 (5.2%) patients experienced a LRR in their follow-up period. In the multivariate analysis, age group (< or =35 years vs. >35 years, p<0.0001; Hazard Ratio [HR], 5.0; 95% Confidence Interval [95% CI], 3.0-8.3), tumour size (>2 cm vs. < or =2 cm, p=0.03; HR, 2.2; 95% CI, 1.2-4.7) and LVI (yes vs. no, p<0.0001; HR, 3.2; 95% CI,1.9-5.2) were the independent prognostic factors for LRR. This analysis, in the final model, indicated that adjuvant radiotherapy and adjuvant tamoxifen were associated with a reduced risk of LRR by 90% and 75%, respectively, across the follow-up period, whereas age group remained as an important risk factor (p=0.002; HR, 3.0; 95% CI, 1.5-6.2).

CONCLUSIONS

Although adjuvant therapies reduce the risk of LRR, young age is an independent risk factor for LRR.