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Alamoodi M. Does Post-Mastectomy Radiotherapy Confer Survival Benefits on Patients With 1-3 Clinically Positive Lymph Nodes Rendered Pathologically Negative After Neoadjuvant Systemic Chemotherapy: Consensus from A Pooled Analysis? Eur J Breast Health 2024; 20:81-88. [PMID: 38571693 PMCID: PMC10985578 DOI: 10.4274/ejbh.galenos.2024.2023-12-14] [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: 12/29/2023] [Accepted: 02/16/2024] [Indexed: 04/05/2024]
Abstract
The advent of taxane-based chemotherapy has revolutionized breast cancer care. This advance has helped improve the response to downstaging tumors that might otherwise be inoperable. It has also helped in rendering clinically (cN+) positive lymph nodes (LNs) pathologically negative (ypN0). The standard of care for cN+ patients included post-mastectomy radiotherapy (PMRT), regardless of the response to neoadjuvant chemotherapy. However, PMRT in patients with 1-3 positive LNs still lacks definitive guidelines. Numerous retrospective results have been inconclusive about the benefit of PMRT on survival in patients with 1-3 positive LNs. This pooled analysis attempts to reach a consensus. The PubMed database was searched through October 2023. The search yielded 27 papers, of which 11 satisfied the inclusion criteria. The locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), and overall survival (OS) for each study were tabulated when given, and two groups were created, the PMRT and NO PMRT, respectively. The results were then pooled for analysis. The total number of patients was 8340, 4136 in the PMRT group, and 4204 in the NO PMRT group, respectively. The LRRFS, DFS, and OS were 96.9%, 82.1%, and 87.3% for the PMRT group and 93.2%, 79.6%, and 84.8% for the NO PMRT group, respectively. There was no statistical significance in LRRFS, DFS, or OS between the two groups (p = 0.61, p = 0.61, and p = 0.38, respectively). PMRT does not seem to confer survival benefits in patients with pN1 rendered ypN0 for stages T1-3. This pooled analysis's findings should be confirmed prospectively with a longer period of follow-up.
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Affiliation(s)
- Munaser Alamoodi
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Novick K, Chadha M, Daroui P, Freedman G, Gao W, Hunt K, Park C, Rewari A, Suh W, Walker E, Wong J, Harris EE. American Radium Society Appropriate Use Criteria Postmastectomy Radiation Therapy: Executive Summary of Clinical Topics. Int J Radiat Oncol Biol Phys 2024; 118:458-465. [PMID: 37478956 DOI: 10.1016/j.ijrobp.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To conduct an appropriate use criteria expert panel update on clinical topics relevant to current clinical practice regarding postmastectomy radiation therapy (PMRT). METHODS AND MATERIALS An analysis of the medical literature from peer-reviewed journals was conducted from May 4, 2010 to May 4, 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to search the PubMed database to retrieve a comprehensive set of relevant articles. A well-established methodology (modified Delphi) was used by the expert panel to rate the appropriate use of procedures. RESULTS Evidence for key questions in PMRT regarding benefit in special populations and technical considerations for delivery was examined and described. Risk factors for local-regional recurrence in patients with intermediate-risk disease that indicate benefit of PMRT include molecular subtype, age, clinical stage, and pathologic response to neoadjuvant chemotherapy. Use of hypofractionated radiation in PMRT has been examined in several recent randomized trials and is under investigation for patients with breast reconstruction. The use of bolus varies significantly by practice region and has limited evidence for routine use. Adverse effects occurred with both PMRT preimplant and postimplant exchange in 2-staged breast reconstruction. CONCLUSIONS Most patients with even limited nodal involvement will likely benefit from PMRT with significant reduction in local-regional recurrence and potential survival. Patients with initial clinical stage III disease and/or any residual disease after neoadjuvant chemotherapy should be strongly considered for PMRT. Growing evidence supports the use of hypofractionated radiation for PMRT with equivalent efficacy and decreased acute side effects, but additional evidence is needed for special populations. There is limited evidence to support routine use of bolus in all patients. Timing of PMRT regarding completion of 2-staged breast reconstruction requires a discussion of increased risks with radiation postimplant exchange compared with increased risk of failure of reconstruction or surgical complications with radiation preimplant exchange.
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Affiliation(s)
- Kristina Novick
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Manjeet Chadha
- Department of Radiation Oncology, Mount Sinai, New York, New York
| | - Parima Daroui
- Department of Radiation Oncology, Southern California Permanente Medical Group, Los Angeles, California
| | - Gary Freedman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wendy Gao
- Tacoma Valley Radiation Oncology Centers, Tacoma, Washington
| | - Kelly Hunt
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Catherine Park
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Amar Rewari
- Department of Radiation Oncology, Ann Arundel Medical Center, Annapolis, Maryland
| | - Warren Suh
- Department of Radiation Oncology, Ridely Tree Cancer Center, Santa Barbara, California
| | - Eleanor Walker
- Department of Radiation Oncology, Henry Ford Health, Detroit, Michigan
| | - Julia Wong
- Department of Radiation Oncology, Dana Farber Brigham Cancer Center, Boston, Massachusetts
| | - Eleanor E Harris
- Department of Radiation Oncology, St. Luke's University Health Network, Easton, Pennsylvania
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Qi WX, Cao L, Zheng S, Xu C, Cai R, Xu H, Cai G, Chen J. IMNI PRECISION trial protocol: a phase II, open-label, non-inferior randomized controlled trial of tailoring omission of internal mammary node irradiation for early-stage breast cancer. BMC Cancer 2022; 22:1356. [PMID: 36575421 PMCID: PMC9795778 DOI: 10.1186/s12885-022-10454-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/15/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Since the publication of MA-20 and EORTC-22922 trials, chest wall (CW)/ whole breast (WB) irradiation + comprehensive regional nodal irradiation (RNI) with internal mammary node irradiation (IMNI) has been the standard adjuvant treatment for early-stage breast cancer (BC). However, one size does not fit all BC, and the risk of recurrence significantly varies among this patient population. In addition, whether all BC patients presented with one to three positive lymph nodes (pN1) could benefit from IMNI remains controversial. Thus, the optimal adjuvant RNI volume for early-stage BC with T1-2N1 remains undetermined. METHODS The IMNI PRECISION trial is a single institute, open-labeled, non-inferior, randomized controlled trial. A total of 214 clinically "high risk" BC patients which is characterized as having at least two of the five clinically adverse factors (age ≤ 40, three positive LN, T2 stage, grade 3 and Ki-67 index ≥ 14%), but genomic score "low risk" (the genomic score ≤ 44) N1 breast cancers are randomly assigned to omitting IMNI group (experimental group) or with IMNI (control group) with a 1:1 ratio. The primary endpoint of this trial is event-free survival, and secondary endpoints include overall survival and locoregional recurrence-free survival. DISCUSSION The IMNI PRECISION design allows promising clinical-genomic model to stratify the individualized risk of developing recurrence and guides the optimal RNI treatment for early-stage (pT1-2N1) BC patients. We anticipate that our results would provide high-level evidence to tailor IMNI according to individualized recurrence risk of BC. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT04517266 . Date of registration: August 18, 2020. Status: Recruiting.
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Affiliation(s)
- Wei-Xiang Qi
- grid.412277.50000 0004 1760 6738Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lu Cao
- grid.412277.50000 0004 1760 6738Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Siyue Zheng
- grid.412277.50000 0004 1760 6738Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Cheng Xu
- grid.412277.50000 0004 1760 6738Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rong Cai
- grid.412277.50000 0004 1760 6738Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haoping Xu
- grid.412277.50000 0004 1760 6738Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Gang Cai
- grid.412277.50000 0004 1760 6738Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiayi Chen
- grid.412277.50000 0004 1760 6738Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Kim N, Park W, Cho WK, Kim HY, Choi DH, Nam SJ, Kim SW, Lee JE, Yu J, Chae BJ, Lee SK, Ryu JM, Mun GH, Pyon JK, Jeon BJ. Suggestion for the omission of post-mastectomy chest wall radiation therapy in patients who underwent skin-sparing/nipple-sparing mastectomy. Breast 2022; 66:54-61. [PMID: 36179501 PMCID: PMC9526229 DOI: 10.1016/j.breast.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/24/2022] [Accepted: 09/19/2022] [Indexed: 12/27/2022] Open
Abstract
AIM Both skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) have been widely adopted. Although postmastectomy radiation therapy (PMRT) can improve clinical outcomes, it can worsen cosmesis following reconstruction. Therefore, identifying risk factors of ipsilateral breast tumor recurrence (IBTR) could help de-escalate PMRT after NSM/SSM in patients with pT1-2 disease. METHODS We retrospectively reviewed patients treated with SSM (N = 400) and NSM (N = 156) in patients with pT1-2N0-1 disease between 2009 and 2016. Seventy-four patients received PMRT with 50-50.4 Gy in 25-28 fractions. The Cox proportional hazards model was used to analyze the prognostic factors of IBTR. RESULTS With a median follow-up of 66.2 months, 17 IBTR events were observed, with 5-year IBTR-free rate of 97.2%. Although only one IBTR was observed after PMRT, there was no statistical difference in the 5-year IBTR-free rate (PMRT vs. no PMRT, 98.6% vs. 97.0%, p = 0.360). Multivariable analyses demonstrated that age ≤45 years and lymphovascular invasion (LVI) were adverse features of IBTR. The low-risk group (0 risk factor) showed a better 5-year IBTR-free rate than the high-risk group (≥1 risk factor) (100.0% vs. 95.8%, p = 0.003). In the high-risk group, PMRT slightly improved 5-year IBTR-free rate compared with no PMRT (98.6% vs. 95.2%, p = 0.166). In addition, PMRT increased 5-year cumulative incidence of reconstruction failure (10.0% vs. 2.8%, p = 0.001). CONCLUSION We identified risk factors (age and LVI) related to IBTR following upfront SSM/NSM with pT1-2 disease. As a hypothesis-generating study, de-escalation of PMRT by omitting chest wall irradiation in selective patients could improve reconstruction-related complications without compromising oncologic outcomes.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,Corresponding author. Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hae Young Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seok Jin Nam
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seok Won Kim
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Eon Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jonghan Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung Joo Chae
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Se Kyung Lee
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jai Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jai-Kyong Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung-Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Tesch ME, Partridge AH. Treatment of Breast Cancer in Young Adults. Am Soc Clin Oncol Educ Book 2022; 42:1-12. [PMID: 35580291 DOI: 10.1200/edbk_360970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although breast cancer is rare and understudied in adults age 40 and younger, recent epidemiologic data show an increasing incidence of breast cancer among young women in the United States and ongoing inferior long-term outcomes. Given breast cancers arising at a young age are more likely to present at advanced stages and to have aggressive biology, multimodal treatments are often indicated. Elevated local recurrence risks and greater propensity for germline cancer predisposition mutations can impact local therapy choices. Recently, escalated systemic therapy regimens for triple-negative breast cancer incorporating immunotherapy, de-escalated anti-HER2 therapy, and emerging targeted agents, including CDK4/6 inhibitors and PARP inhibitors, for early-stage disease may be employed in younger and older patients alike, with some special considerations. Prognostic genomic signatures can spare low-risk young women with hormone receptor-positive breast cancer adjuvant chemotherapy, but management of intermediate-risk patients remains controversial. Ovarian function suppression and extended endocrine therapy are improving outcomes in hormone receptor-positive breast cancer, but treatment adherence is a particular problem for young patients. Young women may also face greater challenges in long-term survivorship, including impaired fertility, difficulties in psychosocial adjustment, and other treatment-related comorbidities. Consideration of these age-specific issues through dedicated multidisciplinary strategies is necessary for optimal care of young women with breast cancer.
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Post-Mastectomy Radiation Therapy: Applications and Advancements. CURRENT BREAST CANCER REPORTS 2022. [DOI: 10.1007/s12609-022-00449-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Zangouri V, Nasrollahi H, Taheri A, Akrami M, Arasteh P, Hamedi SH, Johari MG, Karimaghaee N, Ranjbar A, Karami MY, Tahmasebi S, Mosalaei A, Talei A. Intraoperative radiation therapy for early stage breast cancer. BMC Surg 2022; 22:26. [PMID: 35081942 PMCID: PMC8793207 DOI: 10.1186/s12893-021-01427-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 12/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background and objective We report our experiences with Intraoperative radiation therapy (IORT) among breast cancer (BC) patients in our region. Methods All patients who received radical IORT from April 2014 on to March 2020 were included in the study. Patient selection criteria included: Age equal or older than 45 years old; All cases of invasive carcinomas (in cases of lobular carcinomas only with MRI and confirmation); Patients who were 45–50 years old with a tumor size of 0–2 cm, 50–55 years old with a tumor size of < 2.5 cm, and those who were ≥ 55 years old with a tumor size of < 3 cm; Invasive tumors only with a negative margin; Negative nodal status (exception in patients with micrometastasis); A positive estrogen receptor status. Primary endpoints included death and recurrence which were assessed using the Kaplan–Meier method. Results Overall, 252 patients entered the study. Mean (SD) age of patients was 56.43 ± 7.79 years. In total, 32.9% of patients had a family history of BC. Mean (SD) tumor size was 1.56 ± 0.55 cm. Mean (IQR) follow-up of patients was 36.3 ± 18.7 months. Overall, 8 patients (3.1%) experienced recurrence in follow-up visits (disease-free-survival of 96.1%), among which four (1.5%) were local recurrence, two (0.8%) were regional recurrence and two patients (0.8%) had metastasis. Median (IQR) time to recurrence was 46 (22, 53.7) months among the eight patient who had recurrence. Overall, one patient died due to metastasis in our series. Eleven patients (4.3%) with DCIS in our study received IORT. All these patients had free margins in histopathology examination and none experienced recurrence. Conclusion Inhere we reported our experience with the use of IORT in a region where facilities for IORT are limited using our modified criteria for patient selection. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01427-5.
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Affiliation(s)
- Vahid Zangouri
- Surgical Oncology Division, General Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran.,Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Nasrollahi
- Radiation Oncology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Taheri
- Trauma Research Center, Rajaei Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Majid Akrami
- Surgical Oncology Division, General Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Arasteh
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Hassan Hamedi
- Radiation Oncology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Nazanin Karimaghaee
- Core Medical Trainee, Northumbria Healthcare NHS Foundation /Trust, Newcastle Upon Tyne, UK
| | - Aliye Ranjbar
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Yasin Karami
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sedigheh Tahmasebi
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Ahmad Mosalaei
- Shiraz Institute for Cancer Research, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdolrasoul Talei
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Luo C, Zhong X, Fan Y, Wang C, Wang Y, Luo T. The effect of postmastectomy radiation therapy on high-risk patients with T1-2N0 breast cancer. Breast 2021; 60:1-5. [PMID: 34455226 PMCID: PMC8399378 DOI: 10.1016/j.breast.2021.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/01/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The prognostic impact of postmastectomy radiation therapy (PMRT) on high-risk patients with T1-2N0 breast cancer is controversial. We aimed to investigate the effect of PMRT on high-risk patients with T1-2N0 breast cancer. METHODS A total of 3439 patients diagnosed with T1-2N0 breast cancer who received mastectomy between 2000 and 2016 in our institute were retrospectively analyzed. Leveraging the Fine and Gray competing risks regression in unirradiated patients, risk factors of locoregional recurrence (LRR) were identified. All patients were stratified into high-risk (3 or 4 risk factors) and low-risk (no more than 2 risk factors) groups. The prognostic effect of PMRT was estimated in two subgroups. This subgroup analysis was also performed in patients with T2N0 breast cancer. RESULTS The median follow-up was 89 months. The 5-year cumulative incidence of LRR was 2.2% in unirradiated patients. Tumor size, estrogen receptor (ER) status, histologic grade and lymphovascular invasion (LVI) were identified as independent risk factors of LRR. In the high-risk group, PMRT was correlated with a 8.3% risk reduction of 5-year LRR, 7.8% risk reduction of 5-year distant recurrence (DR), and 6.4% risk reduction of 5-year breast cancer mortality (BCM), whereas it was not correlated with LRR, DR, or BCM in low-risk group. In patients with T2N0 breast cancer, PMRT was associated with decreased LRR, DR and BCM in high-risk group, other than low-risk group. CONCLUSIONS PMRT presented heterogenous effect on patients with T1-2N0 breast cancer. Patients at high risk of LRR were more likely to benefit from PMRT.
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Affiliation(s)
- Chuanxu Luo
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaorong Zhong
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Fan
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
| | - Chengshi Wang
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Wang
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Luo
- Department of Head, Neck and Mammary Gland Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
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Kim SW, Cho WK, Choi DH, Kim H, Cho O, Park W, Chun M. What Is High-risk Breast Cancer With Pathologically Negative Lymph Nodes for Regional Recurrence? Int J Radiat Oncol Biol Phys 2021; 111:992-998. [PMID: 34280967 DOI: 10.1016/j.ijrobp.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/01/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study aimed to identify high-risk factors for regional recurrence in patients with breast cancer with pathologically negative lymph nodes. METHODS AND MATERIALS We retrospectively analyzed 3800 patients with stage pT1-pT3 breast cancer and pathologically negative lymph nodes between 2004 and 2012. All patients underwent upfront surgery with curative intent. Adjuvant systemic treatments were administered to most patients (96.7%) based on contemporary guidelines. RESULTS After a median follow-up of 83 months (range, 7-175 months), the estimated 10-year cumulative incidence rate of regional recurrence was 2.0%. Multivariate competing risk analysis revealed that high histologic grade, positive lymphovascular invasion, and stage pT2-3 were significant risk factors for any regional recurrence. Patients with ≥2 risk factors showed a significantly higher 10-year cumulative incidence rate of any regional recurrence than those with 1 or no risk factors (5.5% vs 1.2%; P < .001). When the number of retrieved lymph nodes was less than 10, the difference in the incidence rate of regional recurrence between patients with ≥2 risk factors and those with 1 or no risk factors was greater (6.6% vs 1.3%, respectively; P < .001). The 10-year disease-free survival was worse in patients with ≥2 risk factors than in those with 1 or no risk factors (84.7% vs 90.0%, respectively; P < .001). Patients with ≥2 risk factors also showed worse 10-year overall survival than did those with 1 or no risk factors (91.3% vs 97.0%, respectively; P < .001). CONCLUSIONS Overall, the cumulative incidence rate of any regional recurrence was low at 10 years. However, patients with ≥2 risk factors showed an increased risk of any regional recurrence and worse disease-free survival, particularly when the number of retrieved lymph nodes was less than 10.
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Affiliation(s)
- Sang-Won Kim
- Department of Radiation Oncology, Konyang University College of Medicine, Daejeon, Republic of Korea; Myunggok Medical Research Institute, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Oyeon Cho
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Mison Chun
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, Republic of Korea.
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Mastectomy alone for pT1-2 pN0-1 breast cancer patients: when postmastectomy radiotherapy is indicated. Breast Cancer Res Treat 2021; 188:511-524. [PMID: 33905020 DOI: 10.1007/s10549-021-06227-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/09/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE To assess outcome of breast cancer (BC) stages pT1-2 N0-1 after mastectomy alone and to identify prognostic factors calling for the need of postmastectomy radiotherapy. METHODS Patients who were not eligible for breast conserving surgery (BCS) were operated on with mastectomy between 1998 and 2008. Locoregional (LRR), distant (DM) control and breast cancer specific survival (BCSS) were retrospectively evaluated. Cumulative incidence (CI) of events was estimated according to Kalbfleisch and Prentice while Gray's test tested difference. Kaplan-Meier method for survival and Cox proportional hazards model for univariable and multivariable analysis were used. A matched pair analysis between mastectomy alone and BCS plus whole breast irradiation (WBI), using the propensity score method, was performed. RESULTS 1281 pT1-2 N0 and 1081 pT1-2 N1 were identified. Median follow-up was 8.2 years (9.2 years for survival). Overall, LRR rate was low for both N0 and N1 subgroups (10-year CI, 8.8% and 10.9%, respectively). Young age, lymphovascular invasion and Ki-67 ≥ 20% were proved to be statistically significant prognostic factors at multivariable analysis. The combination of ≥ 2 risk factors increased LRR rate to ≥ 15%. Risk factors combination weighed on LRR rate more than nodal status itself. DM rate doubled moving from negative to positive nodal status (10-year CI 10.5% versus 20.3%, respectively). BCSS remained high in both N0 and N1 subgroups (10-year CI 92.4% versus 84.5%, respectively). Remarkably, all the molecular subtypes except Luminal A significantly affected DM and BCSS both in the N0 and N1 subgroups. Nodes number significantly impacted on DM and BCSS but not on locoregional control. In the matched pair analysis, WBI decreased nodal recurrence rate and improved distant control, without affecting survival. CONCLUSIONS Selected patients, namely those with at least two additional risk factors, presented high enough LRR risk to support the use of postmastectomy radiotherapy in both N0 and N1 subgroups. Moreover, the observation that radiotherapy may provide benefits that go beyond local control deserves to be further investigated.
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Qi WX, Cao L, Xu C, Zhao S, Chen J. Established and Validated Novel Nomogram for Predicting Prognosis of Post-Mastectomy pN0-1 Breast Cancer without Adjuvant Radiotherapy. Cancer Manag Res 2021; 13:3517-3527. [PMID: 33935517 PMCID: PMC8079251 DOI: 10.2147/cmar.s292233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 03/15/2021] [Indexed: 12/24/2022] Open
Abstract
Aim To establish and validate a nomogram for predicting prognosis of breast cancer patients with pN0-1 who were treated with mastectomy and without adjuvant radiotherapy. Material and Methods The LASSO regression was performed to identify predictors of breast cancer-specific survival (BCSS), local regional recurrence (LRR) and distant metastasis (DM). Model performance was evaluated by the concordance index (C-index) and calibration plot. Results The 5-year BCSS, LRR and DM rates for the entire cohort were 98%, 2% and 4%, respectively. LASSO regression analysis found that pathological T stage, number of positive LN, grade and Ki-67 were significant predictors for both BCSS and DM-free survival, while number of resected LN and PR status were predictors for DM-free survival. In addition, number of positive LN was the only significant predictor for developing LRR. The C-indexes for the 5-year BCSS and DM nomograms were 0.81 and 0.78 in the training data set, 0.65 and 0.70 in the testing set and 0.72 and 0.69 in the external validation set, respectively. Conclusion Our prognostic nomograms accurately predict 5-year BCSS and DM-free survival in post-mastectomy breast cancer without adjuvant radiotherapy, which provides a useful tool to identify high-risk patients who could benefit from additional adjuvant therapy.
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Affiliation(s)
- Wei-Xiang Qi
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Lu Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Cheng Xu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Shengguang Zhao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Jiayi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
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Bundred J, Michael S, Bowers S, Barnes N, Jauhari Y, Plant D, Maishman T, Cutress R, Holleczek B, Dodwell D, Bundred N. Do surgical margins matter after mastectomy? A systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:2185-2194. [PMID: 32907774 DOI: 10.1016/j.ejso.2020.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/04/2020] [Accepted: 08/18/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND No consensus exists regarding adequacy of margins after mastectomy. To determine if pathological margin proximity is associated with local (LR) or distant recurrence after mastectomy for early invasive breast cancer or ductal carcinoma in situ. METHODS A systematic review of literature published from 1980 to 2019 and meta-analysis was conducted. Unpublished data were sought from authors (PROSPERO (CRD42019127541)). Thirty-four studies comprising 34,833 breast cancer patients were included in the quantitative synthesis. Eligible studies reported on patients undergoing curative mastectomy for cancer allowing estimation of outcomes in relation to margin status/width. The association between pathological margin status and local (LR) and distant recurrence was considered using random effects modelling. PRISMA guidelines were followed. RESULTS Positive margins were associated with increased LR on multivariable analyses (HR, 2·64, (95%CI 2·01-3·46)) and LR was higher regardless of the distance of tumour from the margin defined as positive. After skin-sparing mastectomy, positive margins were associated with increased LR (HR 3·40, (95%CI 1·9-6·2)). In the 4 studies reporting distant recurrence, patients with involved margins had a higher risk (HR 1·53, (95%CI 1·03-2·25)). CONCLUSIONS Failure to achieve clear margins after mastectomy may increase the risks of local and distant recurrence. Adequate margin clearance should be recommended to minimize recurrence after mastectomy in National and International Guidelines.
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Affiliation(s)
- James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sarah Michael
- Manchester University NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, UK; University of Manchester, Manchester, M13 9PT, UK
| | - Sarah Bowers
- Manchester University NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, UK; University of Manchester, Manchester, M13 9PT, UK
| | | | - Yasmin Jauhari
- Clinical Effectiveness Unit, Royal College of Surgeons, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
| | - Dafydd Plant
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Thomas Maishman
- University of Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ramsey Cutress
- University of Southampton, Tremona Road, Southampton, SO16 6YD, UK; University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Bernd Holleczek
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), INF 581, 69120, Heidelberg, Germany; Saarland Cancer Registry, Präsident Baltz-Straße 5, 66119, Saarbrücken, Germany
| | - David Dodwell
- Nuffield Dept. of Population Health,University of Oxford, OX3 7LF, UK
| | - Nigel Bundred
- Manchester University NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, UK; University of Manchester, Manchester, M13 9PT, UK.
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Risk stratification for prediction of locoregional recurrence in patients with pathologic T1-2N0 breast cancer after mastectomy. BMC Cancer 2020; 20:1132. [PMID: 33228588 PMCID: PMC7685539 DOI: 10.1186/s12885-020-07594-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 10/30/2020] [Indexed: 01/19/2023] Open
Abstract
Background Previous studies have revealed that nearly 15–20% of selected high-risk T1–2N0 breast cancers developed LRR after mastectomy. This study is aim to indentify the risk factors of locoregional recurrence (LRR) in patients with pathologic T1–2N0 breast cancer after mastectomy in a real-world and distinguish individuals who warrant postmastectomy radiotherapy (PMRT). Methods Female patients treated from 1999 to 2014 in National Cancer Center of China were retrospectively reviewed. A competing risk model was developed to estimate the cumulative incidence of LRR with death treated as a competing event. Results A total of 4841 patients were eligible. All underwent mastectomy plus axillary nodes dissection or sentinel node biopsy without PMRT. With a median follow-up of 56.4 months (range, 1–222 months), the 5-year LRR rate was 3.9%.Besides treatment era, age ≤ 40 years old (p < 0.001, hazard ratio [HR] = 2.262), tumor located in inner quadrant (p < 0.001, HR = 2.236), T2 stage (p = 0.020, HR = 1.419), and negative expressions of estrogen receptor (ER) and progesterone receptor (PR) (p = 0.032, HR = 1.485), were patients-related independent risk factors for LRR. The 5-year LRR rates were 1.7, 3.5, and 15.0% for patients with zero, 1–2, and 3–4 risk factors (p < 0.001). Conclusions Risk Stratification based on age, T stage, ER/PR status and tumor location can stratify patients with pT1–2 N0 breast cancer into subgroups with different risk of LRR. PMRT might be suggested for patients with 3–4 risk factors.
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Zhao X, Tang Y, Wang S, Yang Y, Fang H, Wang J, Jing H, Zhang J, Sun G, Chen S, Jin J, Song Y, Liu Y, Chen B, Qi S, Li N, Tang Y, Lu N, Ren H, Li Y. Locoregional recurrence patterns in women with breast cancer who have not undergone post-mastectomy radiotherapy. Radiat Oncol 2020; 15:212. [PMID: 32887640 PMCID: PMC7487762 DOI: 10.1186/s13014-020-01637-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 08/06/2020] [Indexed: 12/16/2022] Open
Abstract
Background To analyze the patterns of locoregional recurrence in breast cancer patients after mastectomy. Methods The retrospective study included 7073 women with breast cancer without post-mastectomy radiotherapy: 4604 (65.1%) had pT1–2 N0 disease (low risk); 2042 (28.9%), pT1–2 N1 (intermediate risk); and 427 (6.0%), pT3–4 and/or pN2–3, or pT1–2 N1 after neoadjuvant chemotherapy (high risk). The distribution of cumulative locoregional recurrence was analyzed. The local recurrence and regional recurrence rates were estimated by the Kaplan-Meier method, and differences were compared with the log-rank test. Multivariate analysis was performed using Cox logistic regression analysis. Results In the median follow-up of 63.0 months, 469 patients had locoregional recurrence: chest wall recurrence in 238 (50.7%) cases, supraclavicular/infraclavicular nodes in 236 (50.3%) cases, axilla in 92 (19.6%), and internal mammary nodes in 50 (10.7%) cases. The 5-year local recurrence and regional recurrence rates were 2.5 and 4.4%, respectively. Subgroup analysis of the three risk groups and five molecular subtypes (luminal A, luminal B-Her2 negative, luminal B-Her2 positive, Her2-enriched, and triple negative) also showed that the chest wall and supraclavicular/infraclavicular nodes were the most common recurrence sites. Age, tumor location, T stage, N stage, and hormone receptor status were independent prognostic factors for both local recurrence and regional recurrence (p < 0.05). Conclusions The chest wall and supraclavicular/infraclavicular nodes are common sites of locoregional recurrence in breast cancer, irrespective of disease stage or molecular subtype, and the prognostic factors for local recurrence and regional recurrence are similar. Therefore, chest wall and supraclavicular/infraclavicular nodes irradiation should always be considered in post-mastectomy radiotherapy.
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Affiliation(s)
- Xuran Zhao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Shulian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China.
| | - Yong Yang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Jianyang Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Jianghu Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Guangyi Sun
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Siye Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Yongwen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Yueping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Shunan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Ningning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Hua Ren
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China
| | - Yexiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuannanli, Chaoyang District, Beijing, 100021, China.
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The effect of post mastectomy radiation therapy on survival in breast cancer patients with N1mic disease. Breast 2020; 51:50-56. [PMID: 32213441 PMCID: PMC7375567 DOI: 10.1016/j.breast.2020.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 02/16/2020] [Accepted: 02/25/2020] [Indexed: 11/22/2022] Open
Abstract
Background The role of post mastectomy radiation therapy (PMRT) in patients with N1mic breast cancer has not been well defined. A retrospective analysis was performed using the SEER database to evaluate the impact of PMRT on survival in patients with N1mic breast cancer. Materials and methods Women with T1-T2, N1mic, M0 breast cancer who had undergone mastectomy were analyzed. Descriptive statistics were calculated for all variables. Univariate analysis to assess for differences in survival with respect to covariates was performed using the log rank test while multivariate analysis was performed with Cox proportional hazards regression. Sub-cohort analysis with propensity score matching was used to assess differences in survival among patients undergoing PMRT vs no PMRT. Comparisons were considered statistically significant at P < 0.05. Results Among 5878 patients, 1202 (20%) underwent PMRT. On univariate analysis, PMRT was a significant predictor of CSS, but not OS. There was no difference in either OS or CSS between the PMRT vs no PMRT groups on multivariate Cox regression analysis and after propensity score matching. Conclusions Among patients with T1-T2, N1mic, M0 breast IDC from the SEER database, there was no difference in either OS or CSS among patients who underwent PMRT vs no PMRT. These results suggest that PMRT does not impact survival among breast cancer patients with N1mic disease. However, additional prospective studies with longer follow up are necessary for further evaluation. In women with N1mic breast cancer, there was no difference in overall survival with or without adjuvant radiation. CSS was worse among women undergoing adjuvant radiation on univariate analysis, but not on multivariate analysis. After propensity score matching, no significant difference was observed in survival between women undergoing PMRT vs no PMRT.
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Montero A, Ciérvide R, García-Aranda M, Rubio C. Postmastectomy radiation therapy in early breast cancer: Utility or futility? Crit Rev Oncol Hematol 2020; 147:102887. [PMID: 32018127 DOI: 10.1016/j.critrevonc.2020.102887] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/08/2020] [Accepted: 01/27/2020] [Indexed: 01/31/2023] Open
Abstract
Postmastectomy radiation therapy (PMRT) has been shown to reduce the risk of locoregional recurrence (LRR), in patients with locally advanced breast cancer who are considered of high-risk because of large tumors (>5 cm) or presence of axillary lymph-node involvement, as well as to reduce breast cancer mortality. However, controversy still remains with respect to indication of PMRT in case of early-stages invasive tumors. This review aims to analyze the impact that PMRT has on final results in women with breast tumors in different scenarios that would otherwise be considered as early breast cancer, such as extensive DCIS, tumors without axillary lymph-node involvement or with minimal microscopic nodal-involvement. The existence of risk factors including young age, premenopausal status, and presence of lymphovascular invasion (LVI), high grade or tumor size >2 cm has been associated with an increased risk of LRR in these patients at early-stages and advises to consider PMRT in selected cases.
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Affiliation(s)
- Angel Montero
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, Centro Integral Oncológico Clara Campal (CIOCC), Madrid, Spain; Breast Cancer Unit, Hospital Universitario HM Sanchinarro, Madrid, Spain.
| | - Raquel Ciérvide
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, Centro Integral Oncológico Clara Campal (CIOCC), Madrid, Spain; Breast Cancer Unit, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - Mariola García-Aranda
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, Centro Integral Oncológico Clara Campal (CIOCC), Madrid, Spain; Breast Cancer Unit, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - Carmen Rubio
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, Centro Integral Oncológico Clara Campal (CIOCC), Madrid, Spain; Breast Cancer Unit, Hospital Universitario HM Sanchinarro, Madrid, Spain
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Torres MA. Implications of ARTIC: Is This the Beginning of a Climate Change? J Clin Oncol 2019; 37:3329-3332. [PMID: 31618130 DOI: 10.1200/jco.19.02100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mylin A Torres
- Glenn Family Breast Center, Winship Cancer Institute, Emory University, Atlanta, GA
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Can a subgroup at high risk for LRR be identified from T1-2 breast cancer with negative lymph nodes after mastectomy? A meta-analysis. Biosci Rep 2019; 39:BSR20181853. [PMID: 31484798 PMCID: PMC6753322 DOI: 10.1042/bsr20181853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 04/24/2019] [Accepted: 07/10/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose: To identify a subgroup at high risk for loco-regional recurrence (LRR) from T1-2 breast cancer with negative lymph nodes (N0) after mastectomy by using a meta-analysis.Methods and materials: Published studies on the relationship between clinical features and LRR of breast cancer were identified from public databases, including PubMed, EMBASE, and the Cochrane Library. High-risk features for LRR in this patient population were defined based on the pooled results of meta-analysis.Results: For the meta-analysis, a total of 11244 breast cancers with pT1-2N0 after mastectomy from 20 publications were included for analysis. The pooled results indicated that age (hazard ratio (HR) 1.77, P=0.001), lymphovascular invasion (LVI) (HR 2.23, P<0.001), histologic grade (HR 1.66, P<0.001), HER2 status (HR 1.65, P=0.027), menopausal status (HR 1.36, P=0.015), and surgical margins (HR 2.56, P=0.014) were associated with a significantly increased risk of developing LRR in this patient population group, but not for tumor size (HR 1.32, P=0.23), systematic therapy (HR 1.67, P=0.20), and hormonal receptor status (HR 1.04, P=0.73).Conclusion: In the current study, patients with young age, positive LVI, high histologic grade, HER-2 positive, premenopausal, and positive surgical margins have an increased risk of developing LRR. Further prospective trials are needed to clearly define the role of adjuvant postmastectomy radiotherapy in T1-2N0 breast cancer at high risk of developing LRR.
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Radiotherapy after skin-sparing mastectomy with immediate breast reconstruction in intermediate-risk breast cancer. Strahlenther Onkol 2019; 195:949-963. [DOI: 10.1007/s00066-019-01507-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
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Cho WK, Park W, Choi DH, Kim YB, Kim JH, Kim SS, Kim K, Kim JH, Ahn SJ, Lee SY, Lee J, Kim SW, Kwon J, Ahn KJ. The Benefit of Post-Mastectomy Radiotherapy in ypN0 Patients after Neoadjuvant Chemotherapy According to Molecular Subtypes. J Breast Cancer 2019; 22:285-296. [PMID: 31281730 PMCID: PMC6597409 DOI: 10.4048/jbc.2019.22.e25] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 03/20/2019] [Indexed: 12/02/2022] Open
Abstract
PURPOSE The benefit of post-mastectomy radiation therapy (PMRT) in patients with breast cancer who achieve ypN0 following neoadjuvant chemotherapy (NAC) has not yet been established. This study aimed to identify the role of PMRT in patients who achieve ypN0 according to molecular subtype. METHODS We identified patients initially suspected with axillary disease who achieved ypN0 following NAC. From 13 institutions of the Korean Radiation Oncology Group between 2005 and 2011, a total of 189 patients were included in the analysis. Effects of PMRT on loco-regional control (LRC), disease-free survival (DFS), and overall survival (OS) were evaluated for different molecular subtypes. RESULTS In all patients, the prognostic effect of PMRT on LRC, DFS, or OS was not significant. Subgroups analysis showed that the effect of PMRT on LRC was different according to molecular subtype (p for interaction = 0.019). PMRT was associated with greater LRC in the luminal subtype (p = 0.046), but not in other subtypes. CONCLUSION In patients who achieve ypN0 following NAC and mastectomy, PMRT shows no additional survival benefits for any molecular subtype.
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Affiliation(s)
- Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Sun Young Lee
- Department of Radiation Oncology, Chonbuk National University Medical School, Jeonju, Korea
| | - Jeongshim Lee
- Department of Radiation Oncology, Inha University Hospital, Incheon, Korea
| | - Sang-Won Kim
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, Korea
- Department of Radiation Oncology, Konyang University College of Medicine, Daejeon, Korea
| | - Jeanny Kwon
- Department of Radiation Oncology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ki Jung Ahn
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Busan, Korea
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Postmastectomy radiation therapy for triple negative, node-negative breast cancer. Radiother Oncol 2018; 132:48-54. [PMID: 30825969 DOI: 10.1016/j.radonc.2018.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/09/2018] [Accepted: 11/18/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE The use of post-mastectomy radiation therapy (PMRT) for patients with node-negative, triple negative breast cancer (TNBC) is controversial. This study of a large, contemporary US database described national practice patterns and addressed the impact of PMRT on survival for patients with node-negative TNBC. METHODS The National Cancer Data Base was queried (2004-2014) for women with non-metastatic TNBC with pT1-4N0M0 disease undergoing mastectomy. Use of PMRT was assessed. Multivariable logistic regression ascertained factors associated with PMRT use. The Kaplan-Meier analysis evaluated overall survival (OS) between patients managed with either PMRT or observation following mastectomy when stratifying by pT stage. Cox proportional hazards modeling determined variables associated with OS. RESULTS A total of 14,464 patients met the selection criteria; of these, 1,569 (10.8%) received PMRT, whereas 12,895 (89.2%) did not receive PMRT. Use of PMRT varied significantly with pT stage, with only 5.7% of T1 patients undergoing PMRT, while 51.6% of patients with T3 disease underwent PMRT. Use of PMRT was associated with superior OS for patients with pT3 disease but not for patients with other T stages. Greater age was associated with decreased likelihood of PMRT use, while increased T stage and positive surgical margins were associated with use of PMRT. On multivariate analysis, increased age, T stage, and positive surgical margins were associated with worse OS. CONCLUSIONS In the largest study to date evaluating the use of PMRT in patients with node-negative TNBC, the use of PMRT was low in patients with T1 and T2 disease. Additionally, while an OS benefit was observed with the use of PMRT in patients with T3 disease, there was no benefit with the use of PMRT in other T stage groups. Further prospective studies are recommended to further elucidate the benefit on PMRT in patients with node-negative TNBC.
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He MY, Rancoule C, Rehailia-Blanchard A, Espenel S, Trone JC, Bernichon E, Guillaume E, Vallard A, Magné N. Radiotherapy in triple-negative breast cancer: Current situation and upcoming strategies. Crit Rev Oncol Hematol 2018; 131:96-101. [DOI: 10.1016/j.critrevonc.2018.09.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 07/30/2018] [Accepted: 09/05/2018] [Indexed: 01/04/2023] Open
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Barrientos R, Samtani S, Frelinghuysen M, Sotomayor C, Gormaz JG, Burotto M. Clinical decision making in postmastectomy radiotherapy in node negative breast cancer. Ecancermedicalscience 2018; 12:874. [PMID: 30483354 PMCID: PMC6214678 DOI: 10.3332/ecancer.2018.874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Indexed: 11/29/2022] Open
Abstract
For decades, postmastectomy radiotherapy (PMRT) has been recommended for node positive [N(+)] breast cancer patients; nevertheless, the beneficial effect of PMRT for treatment of node negative [N(−)] disease remains under discussion. Nowadays, the biology of breast cancer and the risk factors (RFs) for locoregional failure (LRF) must be included in the decision on whether or not to carry out PMRT. For these reasons, the present review aims to evaluate the rationale use of PMRT in N(−) patients and discuss which subgroups may further benefit from the treatment in present times where the decision must be personalised, according to the RFs of locoregional recurrence (LRR). To perform the analysis, we ponder that LRR of over 10% should be considered unacceptable due to the fact that LRRs generate great morbidity in patients. For this purpose, we consider that routine RT in these patients is not recommended, although there are subgroups of patients with high LRR, in which PMRT could be beneficial.
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Affiliation(s)
- Rodrigo Barrientos
- Department of Radiation Oncology, Instituto de Radiomedicina IRAM, Santiago, Chile
| | - Suraj Samtani
- Department of Medical Oncology, Clinica Alemana Santiago, Vitacura, Chile
| | | | - Camilo Sotomayor
- Radiation Oncology Unit, Hospital Clinico Regional de Concepción, Concepción, Chile
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Cui Y, Li B, Pollom EL, Horst KC, Li R. Integrating Radiosensitivity and Immune Gene Signatures for Predicting Benefit of Radiotherapy in Breast Cancer. Clin Cancer Res 2018; 24:4754-4762. [PMID: 29921729 DOI: 10.1158/1078-0432.ccr-18-0825] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/16/2018] [Accepted: 06/15/2018] [Indexed: 12/31/2022]
Abstract
Purpose: Breast cancer is a heterogeneous disease and not all patients respond equally to adjuvant radiotherapy. Predictive biomarkers are needed to select patients who will benefit from the treatment and spare others the toxicity and burden of radiation.Experimental Design: We first trained and tested an intrinsic radiosensitivity gene signature to predict local recurrence after radiotherapy in three cohorts of 948 patients. Next, we developed an antigen processing and presentation-based immune signature by maximizing the treatment interaction effect in 129 patients. To test their predictive value, we matched patients treated with or without radiotherapy in an independent validation cohort for clinicopathologic factors including age, ER status, HER2 status, stage, hormone-therapy, chemotherapy, and surgery. Disease-specific survival (DSS) was the primary endpoint.Results: Our validation cohort consisted of 1,439 patients. After matching and stratification by the radiosensitivity signature, patients who received radiotherapy had better DSS than patients who did not in the radiation-sensitive group [hazard ratio (HR), 0.68; P = 0.059; n = 322], whereas a reverse trend was observed in the radiation-resistant group (HR, 1.53; P = 0.059; n = 202). Similarly, patients treated with radiotherapy had significantly better DSS in the immune-effective group (HR, 0.46; P = 0.0076; n = 180), with no difference in DSS in the immune-defective group (HR, 1.27; P = 0.16; n = 348). Both signatures were predictive of radiotherapy benefit (P interaction = 0.007 and 0.005). Integration of radiosensitivity and immune signatures further stratified patients into three groups with differential outcomes for those treated with or without radiotherapy (P interaction = 0.003).Conclusions: The proposed signatures have the potential to select patients who are most likely to benefit from radiotherapy. Clin Cancer Res; 24(19); 4754-62. ©2018 AACR.
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Affiliation(s)
- Yi Cui
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Bailiang Li
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Kathleen C Horst
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Ruijiang Li
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
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Kaya C, Uçak R, Bozkurt E, Ömeroğlu S, Kartal K, Yazıcı P, İdiz UO, Mihmanlı M. The Impact of Micropapillary Component Ratio on the Prognosis of Patients With Invasive Micropapillary Breast Carcinoma. J INVEST SURG 2018; 33:31-39. [PMID: 29843540 DOI: 10.1080/08941939.2018.1474302] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background and Objectives: Invasive micropapillary carcinoma (IMPC) of the breast is a rare and aggressive variant of invasive ductal carcinoma characterized by high-grade lymphovascular invasion and high rates of nodal metastasis. The prognostic significance of the micropapillary component (MC) ratio that constitutes this aggressive variation is controversial. In this study, we aimed to investigate the effect of the MC ratio on the prognosis of these patients. Methods: The data of 47 patients with IMPC were retrospectively reviewed. Patients were divided into two groups: MC ratio of 10-75% (Group 1) and greater than 75% (Group 2). The demographic characteristics of the patients, histopathologic features of the tumors, and survival rates were compared. Results: We detected no significant difference in demographic characteristics between groups 1 and 2 (p = 0.21). No significant difference was detected in terms of tumor diameter, lymph node metastasis, lymphovascular invasion, histologic grade, multicentricity, local recurrence, distant metastasis, and overall survival. Conclusion: In the micropapillary subgroup of invasive ductal carcinoma, although positive receptor characteristics are directly proportional to the increase in MC ratio, recurrence and survival rates are not affected by micropapillary component level.
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Affiliation(s)
- Cemal Kaya
- Department of General Surgery, Istanbul Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, İstanbul, Turkey
| | - Ramazan Uçak
- Department of Pathology, Istanbul Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, İstanbul, Turkey
| | - Emre Bozkurt
- Department of General Surgery, Istanbul Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, İstanbul, Turkey
| | - Sinan Ömeroğlu
- Department of General Surgery, Hınıs Şehit Yavuz Yürekseven State Hospital, Erzurum, Turkey
| | - Kinyas Kartal
- Department of General Surgery, Istanbul Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, İstanbul, Turkey
| | - Pınar Yazıcı
- Department of General Surgery, Istanbul Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, İstanbul, Turkey
| | - Ufuk Oğuz İdiz
- Department of General Surgery, Istanbul Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, İstanbul, Turkey
| | - Mehmet Mihmanlı
- Department of General Surgery, Istanbul Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, İstanbul, Turkey
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26
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Muhsen S, Moo TA, Patil S, Stempel M, Powell S, Morrow M, El-Tamer M. Most Breast Cancer Patients with T1-2 Tumors and One to Three Positive Lymph Nodes Do Not Need Postmastectomy Radiotherapy. Ann Surg Oncol 2018; 25:1912-1920. [PMID: 29564588 DOI: 10.1245/s10434-018-6422-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Shirin Muhsen
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Simon Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mahmoud El-Tamer
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Affiliation(s)
- J Frank Wilson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Adam D Currey
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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Is post-mastectomy radiation therapy contributive in pN0-1mi breast cancer patients? Results of a French multi-centric cohort. Eur J Cancer 2017; 87:47-57. [PMID: 29107861 DOI: 10.1016/j.ejca.2017.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/29/2017] [Accepted: 10/03/2017] [Indexed: 11/21/2022]
Abstract
AIM To assess the value of post-mastectomy radiation therapy (PMRT) to breast cancer (BC) patients with no or minimal lymph node (LN) involvement. MATERIALS AND METHODS We retrospectively analysed a French multi-centric cohort of 4283 patients treated by mastectomy and axillary dissection, with or without PMRT, between 1980 and 2013. Practices were analysed for three treatment periods (1980-1999, 2000-2005 and 2006-2013). The impact of PMRT on loco-regional recurrence (LRR), disease-free survival (DFS), BC-specific survival and overall survival was assessed in pN0-1mi patients using multivariate analyses (logistic regression and Cox model). It was subsequently assessed based on the number of clinicopathological recurrence-risk factors, generating a prognostic index (French-PMRT index), to isolate a pN0-1mi patients subgroup that might derive a benefit from PMRT. We tested the accuracy of the Cambridge-PMRT (c-PMRT) index to discriminate between patients with significantly different outcomes and the value of PMRT in each c-PMRT prognostic group. RESULTS More than half of the pN0-1mi patients of our cohort underwent PMRT, which almost significantly improved LRR-free survival and DFS. Matching pN0-1mi patients based on the number of clinicopathologic recurrence-risk factors identified a higher risk subpopulation (≥3 recurrence-risk factors), but PMRT did not improve patient outcomes. Although the c-PMRT index had the potential to predict patient outcomes, its use did not help in making the decision of whether or not to use PMRT. CONCLUSION We failed to isolate a subgroup of early BC patients without LN involvement suitable for PMRT, despite studying a large cohort.
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29
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Horton JK. Postmastectomy Conundrum. Int J Radiat Oncol Biol Phys 2017; 98:976. [PMID: 28721909 DOI: 10.1016/j.ijrobp.2017.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Janet K Horton
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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30
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Mamtani A, King TA. Targeted Therapy and Local Control: The Dynamic Duo. Ann Surg Oncol 2017; 24:3110-3112. [PMID: 28748442 DOI: 10.1245/s10434-017-6022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Anita Mamtani
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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31
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Glorioso JM, Gonzalez Juarrero AB, Rodysill BR, Harmsen WS, Habermann EB, Carter JM, Mutter RW, Degnim AC, Jakub JW. Margin Proximity Correlates with Local Recurrence After Mastectomy for Patients Not Receiving Adjuvant Radiotherapy. Ann Surg Oncol 2017; 24:3148-3156. [DOI: 10.1245/s10434-017-5968-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Indexed: 11/18/2022]
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32
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Frandsen JE, Cannon G, Kokeny KE, Gaffney DK, Matsen C, Wright M, Poppe MM. Is radiation indicated for young women with early stage, node-negative breast cancer after mastectomy? A multi-institution, retrospective review. Breast J 2017; 24:7-11. [DOI: 10.1111/tbj.12827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/26/2016] [Accepted: 05/24/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Jonathan E. Frandsen
- Department of Radiation Oncology; Huntsman Cancer Hospital; University of Utah School of Medicine; Salt Lake City UT USA
| | - George Cannon
- Department of Radiation Oncology; Intermountain Medical Center; Murray UT USA
| | - Kristine E. Kokeny
- Department of Radiation Oncology; Huntsman Cancer Hospital; University of Utah School of Medicine; Salt Lake City UT USA
| | - David K. Gaffney
- Department of Radiation Oncology; Huntsman Cancer Hospital; University of Utah School of Medicine; Salt Lake City UT USA
| | - Cindy Matsen
- Department of General Surgery; Huntsman Cancer Hospital; University of Utah School of Medicine; Salt Lake City UT USA
| | - Melissa Wright
- Oncology Clinical Program; Intermountain Healthcare; Salt Lake City UT USA
| | - Matthew M. Poppe
- Department of Radiation Oncology; Huntsman Cancer Hospital; University of Utah School of Medicine; Salt Lake City UT USA
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33
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Li JL, Lin XY, Zhuang LJ, He JY, Peng QQ, Dong YP, Wu JX. Establishment of a risk scoring system for predicting locoregional recurrence in T1 to T2 node-negative breast cancer patients treated with mastectomy: Implications for postoperative radiotherapy. Medicine (Baltimore) 2017; 96:e7343. [PMID: 28658151 PMCID: PMC5500073 DOI: 10.1097/md.0000000000007343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
To establish a risk scoring system for predicting locoregional recurrence (LRR) and explore the potential value of radiotherapy in T1 to T2 node-negative breast cancer patients treated with mastectomy. From January 2001 to February 2008, a total of 353 node-negative T1 to T2 breast cancer cases treated with mastectomy without adjuvant radiotherapy were retrospectively analyzed. Preliminary screening of the prognostic factors was accomplished by Kaplan-Meier univariate analysis, and survival curves between different groups were compared by log-rank test. Risk factors were determined using Cox proportional hazards model. A categorical risk scoring system was generated according to the Cox model, weighing the relative importance of each risk variable. Median follow-up was 115.7 months (range, 1.2-238.4 months). The overall 5-year locoregional recurrence-free survival (LRFS) was 89.8% (95% confidence interval [CI] = 86.7%-92.9%). Chest wall (53.8%) was found to be the most common site of LRR, followed by supraclavicular nodes (48.7%). Age ≤40 years, primary tumor size ≥4.5 cm and number of nodes resected ≤10 were found to be independent factors for poor prognosis of LRR. Two risk stratifications based on the scoring system were subsequently obtained. The 5-year LRFS was 91.6% (95% CI = 88.5%-94.7%) with low risk (score <2) and 75.7% (95% CI = 61.8%-89.6%) with high risk (score ≥2), respectively (χ = 7.544, P = .006). In addition, significant differences in overall survival (P = .045) and disease-free survival (P = .019) were presented between them. Patients with T1-2N0M0 breast cancer achieved favorable prognosis in general. Those with risk factors, including age ≤40 years, primary tumor size ≥4.5 cm and number of nodes resected ≤10, were at higher risk of LRR. The established scoring system could help to distinguish the subgroups that might potentially benefit from postoperative radiotherapy.
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Affiliation(s)
- Jin-luan Li
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Xiao-yi Lin
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Li-juan Zhuang
- Department of Gynecology and Obstetrics, Quanzhou Maternity and Child Health Hospital, QuanZhou, China
| | - Jun-yan He
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Qing-qin Peng
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Ya-ping Dong
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
| | - Jun-xin Wu
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou
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Mamtani A, Patil S, Stempel MM, Morrow M. Are there patients with T1 to T2, lymph node-negative breast cancer who are "high-risk" for locoregional disease recurrence? Cancer 2017; 123:2626-2633. [PMID: 28334423 DOI: 10.1002/cncr.30658] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/31/2017] [Accepted: 02/13/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Indications for postmastectomy radiotherapy (PMRT) in patients with T1 to T2, lymph node-negative (N0) breast cancer with "high-risk" features are controversial. The European Organization for Research and Treatment of Cancer (EORTC) 22922 and National Cancer Institute of Canada Clinical Trials Group MA20 trials reporting improved 10-year disease-free survival with lymph node irradiation included patients with high-risk N0 disease, but, to the authors' knowledge, benefits in patients receiving modern systemic therapy are uncertain. METHODS The authors retrospectively identified patients with T1 to T2N0 disease who were treated with mastectomy from January 2006 through December 2011. High-risk features included age <40 years, multifocality/multicentricity, lymphovascular invasion, medial/central tumor location, and high nuclear grade. RESULTS Among 672 eligible patients, only 15 received PMRT and were excluded. Of the remaining 657 patients, 187 (28%) had 1 high-risk feature and 449 patients (68%) had ≥ 2 high-risk features. A total of 36 patients with unknown tumor grade were excluded from risk analysis. Approximately 98% of patients underwent sentinel lymph node biopsy alone and 86% received adjuvant systemic therapy. At a median of 5.6 years of follow-up, the locoregional disease recurrence (LRR) rate was 4.7% (31 patients). Increasing tumor size was found to be associated with LRR (hazard ratio, 1.70; P = .006), whereas other high-risk features were not (all P > .05). Receipt of systemic therapy decreased the LRR rate (hazard ratio, 0.40; P = .03). Although crude LRR rates increased from 3.8% to 9.4% with 1 versus ≥ 4 high-risk features, the number of risk factors was not found to be significantly associated with LRR (P = .54). CONCLUSIONS In the current study, a low crude LRR rate (4.7%) was observed in a large unselected cohort of patients with T1 to T2N0 breast cancer with high-risk features who were treated with mastectomy and systemic therapy without PMRT. Although increasing tumor size and the omission of systemic therapy were found to be predictive, other features did not confer a higher LRR risk either independently or together, and do not by themselves mandate the use of PMRT in this patient population. Cancer 2017;123:2626-33. © 2017 American Cancer Society.
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Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michelle M Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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35
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Possible benefits from post-mastectomy radiotherapy in node-negative breast cancer patients: a multicenter analysis in Korea (KROG 14-22). Oncotarget 2017; 8:59800-59809. [PMID: 28938683 PMCID: PMC5601779 DOI: 10.18632/oncotarget.16241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 02/20/2017] [Indexed: 02/06/2023] Open
Abstract
PURPOSE This study was performed to identify a subset of patients who may benefit from post-mastectomy radiotherapy (PMRT) among node-negative breast cancer patients. MATERIALS AND METHODS We retrospectively reviewed 1,828 patients with pT1-2N0 breast cancer, treated with mastectomy without PMRT from 2005 to 2010 at 10 institutions. Univariate and multivariate analyses for locoregional recurrence (LRR) and any first recurrence (AFR) were performed according to clinicopathologic factors and biologic subtypes. RESULTS During a median follow-up period of 5.9 years (range: 0.7-10.4 years), 98 patients developed AFR (39 isolated LRR, 13 LRR with synchronous distant metastasis, and 46 isolated distant metastasis), and 52 patients developed LRR. The 7-year LRR and AFR rates were 3.8% and 6.7%, respectively. Multivariate analysis revealed that age of ≤ 40 years (p<0.001) and T2 stage (p=0.013) were independent risk factors for LRR. The 7-year LRR rates were 2.5% with no risk factors, 4.5% with one risk factor, and 12.4% with two risk factors. Multivariate analysis for AFR revealed that age of ≤ 40 years (p<0.001), T2 stage (p<0.001), and triple-negative biological subtype (p=0.045) were independent risk factors for AFR. The 7-year AFR rates were 3.9% with no risk factors, 8.4% with one risk factor, and 15.7% with two to three risk factors. CONCLUSIONS Mastectomy without PMRT is a sufficient local treatment for pT1-2N0M0 breast cancer. Nevertheless, PMRT might be considered for patients with two or three risk factors, among those of young age, with T2 tumors, and with the triple-negative biological subtype based on LRR and AFR.
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36
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Jwa E, Shin KH, Lim HW, Jung SY, Lee S, Kang HS, Lee E, Park YH. Identification of Risk Factors for Locoregional Recurrence in Breast Cancer Patients with Nodal Stage N0 and N1: Who Could Benefit from Post-Mastectomy Radiotherapy? PLoS One 2015; 10:e0145463. [PMID: 26691445 PMCID: PMC4686923 DOI: 10.1371/journal.pone.0145463] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/03/2015] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The locoregional recurrence (LRR) rate was reported as high as approximately 20% in stage I-II breast cancer following mastectomy. To investigate the risk factors for LRR in pT1-2N0-1 breast cancer patients treated with mastectomy but not radiation, and to define a subgroup of patients at high risk of LRR who may benefit from postmastectomy radiotherapy (PMRT). METHODS AND MATERIALS In total, 390 patients with pT1-2N0M0 (n = 307) and pT1-2N1M0 (n = 83) breast cancer who underwent total mastectomy without adjuvant radiotherapy from 2002 to 2011 were enrolled in the study. RESULTS After a median follow-up period of 5.6 years (range, 0.6-11.3 years), 21 patients had 18 systemic relapses and 12 LRRs including six in the chest wall and eight in the regional nodal area. The 5-year LRR-free survival (LRRFS) rates were 97.0% in pN0, 98.8% in pN1, and 97.4% in all patients. Multivariate analysis revealed that age < 50 years (Hazard Ratio, 11.4; p = 0.01) and no adjuvant chemotherapy (Hazard Ratio, 10.2; p = 0.04) were independent risk factors for LRR in pN0 patients. Using these factors, the 5-year LRRFS rates were 100% without any risk factors, 96.4% with one risk factor, and 86.7% with two risk factors. In pN1 patients, multivariate analysis revealed that having a hormone receptor negative tumor (Hazard Ratio, 18.3; p = 0.03) was the only independent risk factor for LRR. The 5-year LRRFS rates were 100.0% for luminal type, and 92.3% for non-luminal type cancer. CONCLUSION Patients with pT1-2N0-1 breast cancer who underwent total mastectomy without PMRT could be stratified by nodal stage and risk factors for LRR. PMRT may have of value for node negative patients aged less than 50 years and who are not treated with adjuvant chemotherapy, and for non-luminal type patients with one to three positive nodes.
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Affiliation(s)
- Eunjin Jwa
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.,Department of Radiation Oncology, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Kyung Hwan Shin
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.,Departments of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeon Woo Lim
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - So-Youn Jung
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Seeyoun Lee
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Han-Sung Kang
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - EunSook Lee
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Young Hee Park
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.,Department of Radiation Oncology, Soonchunhyang University College of Medicine, Seoul, Korea
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37
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Whose Disease Will Recur After Mastectomy for Early Stage, Node-Negative Breast Cancer? A Systematic Review. Clin Breast Cancer 2015. [PMID: 26198331 DOI: 10.1016/j.clbc.2015.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Effective local control is associated with improved overall survival, particularly for women with early-stage cancers. No other local therapy is typically offered to women with T1-2 N0 breast cancer after mastectomy, although in select women the 5-year local recurrence rate can be as high as 20%. Therefore, accurately predicting the women who are at highest risk for recurrence after mastectomy will identify those who might benefit from more aggressive adjuvant treatment. A systematic search was conducted identifying risk factors associated with locoregional recurrence, including age, menopausal status, receptor status, lymphovascular invasion (LVI), margin status, use of systemic therapy, size, grade, and genomic classifer score. Although associations varied among studies, the risk factors most consistently identified were age ≤ 40 years, LVI, positive/close margin, and larger tumor size. In women with multiple high risk factors, risk of local recurrence was as high as 20% at 10 years. Additional multicenter studies are needed to investigate risk factors for locoregional recurrence after mastectomy without radiotherapy in T1-2N0 breast cancer. Consideration of additional adjuvant local therapy might be warranted in a subset of women at high risk of local recurrence.
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Abstract
OBJECTIVES Postmastectomy radiotherapy (PMRT) is proven to decrease locoregional recurrence (LRR) in locally advanced breast cancer. However, there is little data regarding PMRT in early stage disease. This study examines risk factors for LRR in patients who underwent mastectomy for T1 N0 breast cancer, with the aim of identifying a subgroup who may potentially benefit from PMRT. METHODS From 1994 to 2004, there were 1259 pathologic stage T1 N0 breast cancers treated with mastectomy and no radiation within the Kaiser Permanente Southern California medical system. Kaplan-Meier survival curves for LRR were compared using the log-rank test, and multivariate analysis was done using Cox proportional hazard ratios to identify risk factors for LRR. RESULTS Median follow-up was 8.15 years. The 10-year Kaplan-Meier LRR rate was 3.2% (95% confidence interval [CI], 2%-4.3%). The median time to LRR was 2.5 years after mastectomy, and the most common site was chest wall (68%). Grade 3 (hazard ratio 3.97; 95% CI, 1.94-8.14; P = 0.0002) and margins ≤ 3 mm (hazard ratio 2.97; 95% CI, 1.21-7.29; P = 0.02) were significantly associated with LRR on multivariate analysis. The 10-year Kaplan-Meier rate of LRR for the 1230 patients with neither or one factor was 2.7% (95% CI, 1.6%-3.8%), compared with a LRR rate of 25% (95% CI, 2.2%-42.7%) among the 29 patients with both high grade and margins ≤ 3 mm (P < 0.0001). CONCLUSIONS After mastectomy for pT1 N0 breast cancer, there is a small subgroup of patients with grade 3 disease and a close or positive margin (≤ 3 mm) who have an increased risk of LRR. These patients may benefit from the administration of PMRT.
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Wenz F, Sperk E, Budach W, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Piroth MD, Sautter-Bihl ML, Sedlmayer F, Souchon R, Fussl C, Sauer R. DEGRO practical guidelines for radiotherapy of breast cancer IV: radiotherapy following mastectomy for invasive breast cancer. Strahlenther Onkol 2014; 190:705-14. [PMID: 24888511 DOI: 10.1007/s00066-014-0687-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Since the last recommendations from the Breast Cancer Expert Panel of the German Society for Radiation Oncology (DEGRO) in 2008, evidence for the effectiveness of postmastectomy radiotherapy (PMRT) has grown. This growth is based on updates of the national S3 and international guidelines, as well as on new data and meta-analyses. New aspects were considered when updating the DEGRO recommendations. METHODS The authors performed a comprehensive survey of the literature. Data from recently published (meta-)analyses, randomized clinical trials and international cancer societies' guidelines yielding new aspects compared to 2008 were reviewed and discussed. New aspects were included in the current guidelines. Specific issues relating to particular PMRT constellations, such as the presence of risk factors (lymphovascular invasion, blood vessel invasion, positive lymph node ratio >20 %, resection margins <3 mm, G3 grading, young age/premenopausal status, extracapsular invasion, negative hormone receptor status, invasive lobular cancer, size >2 cm or a combination of ≥ 2 risk factors) and 1-3 positive lymph nodes are emphasized. RESULTS The evidence for improved overall survival and local control following PMRT for T4 tumors, positive resection margins, >3 positive lymph nodes and in T3 N0 patients with risk factors such as lymphovascular invasion, G3 grading, close margins, and young age has increased. Recently identified risk factors such as invasive lobular subtype and negative hormone receptor status were included. For patients with 1-3 positive lymph nodes, the recommendation for PMRT has reached the 1a level of evidence. CONCLUSION PMRT is mandatory in patients with T4 tumors and/or positive lymph nodes and/or positive resection margins. PMRT should be strongly considered in patients with T3 N0 tumors and risk factors, particularly when two or more risk factors are present.
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Affiliation(s)
- Frederik Wenz
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany,
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Walsh SM, Lowery AJ, Prichard RS, McDermott EW, Evoy D, Geraghty J. Postmastectomy radiotherapy: indications and implications. Surgeon 2014; 12:310-5. [PMID: 25037652 DOI: 10.1016/j.surge.2014.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 04/14/2014] [Accepted: 04/16/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although breast conservation surgery, when combined with radiotherapy, has been shown to provide excellent locoregional control for breast cancer, approximately one third of women with breast cancer require mastectomy. Many of these women are offered immediate reconstruction. Postmastectomy radiotherapy (PMRT) is indicated in some cases, but is associated with side-effects, including its impact on the reconstructed breast. OBJECTIVE To review the pertinent issues surrounding PMRT, including patient selection for radiotherapy and the effect of radiotherapy on reconstructive decisions. METHODS A literature review was performed using the Medline database. CONCLUSIONS PMRT is indicated in patients who are deemed to have a high risk of loco-regional recurrence. Although PMRT is strongly recommended for patients with four or more positive lymphnodes, other indications for PMRT remain controversial. Immediate reconstruction post mastectomy has been shown to have favorable outcomes. However, PMRT may increase the need for revision surgery post immediate reconstruction. There are few randomized trials looking at these key issues, and the evidence is largely derived from observational retrospective studies. Patients should be carefully counseled before a decision is made to proceed with immediate reconstruction, where there is a high chance that PMRT may be indicated.
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Affiliation(s)
- S M Walsh
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - A J Lowery
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - R S Prichard
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - E W McDermott
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D Evoy
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - J Geraghty
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
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Liu X, Guan Y, Zhang W, Liu S, Liu J, Wang L, Niu Y. Predictors of recurrence in breast cancer subtypes with negative lymph node in a Chinese population. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2014; 7:3202-3212. [PMID: 25031741 PMCID: PMC4097226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 05/26/2014] [Indexed: 06/03/2023]
Abstract
To establish a series of objective parameters to predict the risk of relapse from axillary lymph node-negative (ANN) breast cancer, and evaluate the patterns of recurrence according to molecular subtypes, we collected information on 2126 consecutive breast cancer patients operated between 2002 and 2006. In this case-control study, 212 patients experiencing recurrence or breast cancer related death were defined as 'poor group'. Another 212 patients were selected from the remaining cases with stratified sampling method to comprise the 'good group'. Significant differences were found in vascular invasion, grade and molecular subtype between the two groups. Expression of ER and PR in the 'poor group' was lower (P < 0.05). However, positive rates of Ki67, p53 and VEGF in the 'poor group' were higher (P < 0.05). Multivariate analysis revealed that molecular subtype, expression of VEGF, tumor grade, and vascular invasion were closely correlated with bad outcome. Analysis of the 'poor group' demonstrated that 'HER2 positive' and 'triple negative' subtypes more commonly suffered from distant metastases and death. No metastasis was found in patients with pure invasive papillary carcinoma, invasive cribriform carcinoma or adenoid cystic carcinoma, whereas the diagnoses of invasive micropapillary carcinoma, invasive apocrine carcinoma, invasive papillary carcinoma mixed with invasive ductal carcinoma, or metaplastic carcinoma were correlated with distant metastasis and death. In conclusion, molecular subtype and expression of VEGF are useful markers for predicting prognosis of ANN breast cancer patients. 'Luminal A-like' subtype has better outcome than others. Moreover, molecular subtypes have different recurrence patterns.
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Affiliation(s)
- Xia Liu
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of EducationWest Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin 300060, China
- Department of Oncology, General Hospital of Tianjin Medical University154 Anshan Road, Heping District, Tianjin 300052, China
| | - Yong Guan
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of EducationWest Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin 300060, China
| | - Wei Zhang
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of EducationWest Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin 300060, China
| | - Shan Liu
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of EducationWest Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin 300060, China
| | - Junjun Liu
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of EducationWest Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin 300060, China
| | - Li Wang
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of EducationWest Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin 300060, China
| | - Yun Niu
- Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of EducationWest Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin 300060, China
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Gomez C, Shah C, McCloskey S, Foster N, Vicini F. The Role of Radiation Therapy after Nipple-Sparing Mastectomy. Ann Surg Oncol 2014; 21:2237-44. [DOI: 10.1245/s10434-013-3446-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Indexed: 11/18/2022]
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Cohen M, Bannier M, Lambaudie E, Chéreau-Ewald E, Buttarelli M, Jauffret C, Houvenaeghel G. Conservation de la plaque aréolo-mamelonnaire en cas de mastectomie. ACTA ACUST UNITED AC 2014; 42:246-51. [DOI: 10.1016/j.gyobfe.2014.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
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Mukesh MB, Duke S, Parashar D, Wishart G, Coles CE, Wilson C. The Cambridge post-mastectomy radiotherapy (C-PMRT) index: A practical tool for patient selection. Radiother Oncol 2014; 110:461-6. [DOI: 10.1016/j.radonc.2013.09.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 08/29/2013] [Accepted: 09/11/2013] [Indexed: 10/25/2022]
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Is Biological Subtype Prognostic of Locoregional Recurrence Risk in Women With pT1-2N0 Breast Cancer Treated With Mastectomy? Int J Radiat Oncol Biol Phys 2014; 88:57-64. [DOI: 10.1016/j.ijrobp.2013.09.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/29/2013] [Accepted: 09/13/2013] [Indexed: 11/21/2022]
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Abstract
Many women undergo mastectomy as treatment of their breast cancer either because of personal preference or because of tumor-related factors making mastectomy the preferred surgical option. The use of postmastectomy radiation therapy has been shown to decrease the risk of local recurrence and in some cases improve overall survival. Decisions regarding the need for postmastectomy radiation therapy can be complex and rely on careful review of many factors. Lymph node status, tumor size, tumor grade, receptor status, presence or absence of lymphovascular space invasion, Her-2/neu status, margin width, and patient age all need to be considered when making recommendations for or against postmastectomy radiation therapy. In this article, we provide a review of the relevant literature pertaining to postmastectomy radiation therapy in order to help guide this decision-making process.
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Souchon R, Sautter-Bihl ML, Sedlmayer F, Wenz F, Budach W, Sauer R. Radiation oncologists' view on the zurich consensus. Breast Care (Basel) 2013; 8:448-52. [PMID: 24550754 PMCID: PMC3919487 DOI: 10.1159/000357417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Rainer Souchon
- Klinik für Radioonkologie und Strahlenklinik, Klinikum Karlsruhe, Germany
| | | | - Felix Sedlmayer
- Universitätsklinik für Radiotherapie und Radio-Onkologie, Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, LKH, Salzburg, Austria
| | - Frederik Wenz
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Germany
| | - Wilfried Budach
- Klinik für Strahlentherapie und Radiologische Onkologie, Universitätsklinikum Düsseldorf, Germany
| | - Rolf Sauer
- Strahlenklinik, Universitätsklinikum Erlangen, Germany
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Kraeima J, Siesling S, Vliegen IMH, Klaase JM, IJzerman MJ. Individual risk profiling for breast cancer recurrence: towards tailored follow-up schemes. Br J Cancer 2013; 109:866-71. [PMID: 23860534 PMCID: PMC3749573 DOI: 10.1038/bjc.2013.401] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 06/23/2013] [Accepted: 06/26/2013] [Indexed: 12/30/2022] Open
Abstract
Background: Breast cancer follow-up is not tailored to the risk of locoregional recurrences (LRRs) in individual patients or as a function of time. The objective of this study was to identify prognostic factors and to estimate individual and time-dependent LRR risk rates. Methods: Prognostic factors for LRR were identified by a scoping literature review, expert consultation, and stepwise multivariate regression analysis based on 5 years of data from women diagnosed with breast cancer in the Netherlands in 2005 or 2006 (n=17 762). Inter-patient variability was elucidated by examples of 5-year risk profiles of average-, medium-, and high-risk patients, whereby 6-month interval risks were derived from regression estimates. Results: Eight prognostic factors were identified: age, tumour size, multifocality, gradation, adjuvant chemo-, adjuvant radiation-, hormonal therapy, and triple-negative receptor status. Risk profiles of the low-, average-, and high-risk example patients showed non-uniform distribution of recurrence risks (2.9, 7.6, and 9.2%, respectively, over a 5-year period). Conclusion: Individual risk profiles differ substantially in subgroups of patients defined by prognostic factors for recurrence and over time as defined in 6-month time intervals. To tailor follow-up schedules and to optimise allocation of scarce resources, risk factors, frequency, and duration of follow-up should be taken into account.
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Affiliation(s)
- J Kraeima
- Department of Health Technology and Service Research, MIRA institute for Biomedical Technology and Technical Medicine, University of Twente, PO Box 217, Enschede 7500 AE, The Netherlands
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