Association of 21-gene recurrence score and locoregional recurrence in early breast cancer patients

BACKGROUND: The 21-gene recurrence score (RS) assay has been validated to predict the risk of disease-free survival in estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer patients. However, its relation with locoregional recurrence (LRR) risk is unclear. OBJECTIVE: This study aimed to explore the ability of RS to predict LRR risk. METHODS: Consecutive ER-positive, HER2-negative, pT1, pN0-1, and M0 early breast cancer patients were analyzed retrospectively. According to RS, patients were divided into low- (RS < 18), intermediate- (RS 18–30), and high-risk (RS ⩾ 31) groups. The primary endpoint was LRR. Subgroup analysis was conducted according to different nodal statuses and surgery types. RESULTS: A total of 1558 patients were enrolled: 354 (22.7%), 788 (50.6%), and 416 (26.7%) patients in the low-, intermediate-, and high-risk groups, respectively. The median follow-up time was 53 months, and 2, 8, and 14 LRR events were observed in the low-, intermediate-, and high-risk groups, respectively (P= 0.004). Both univariate (P= 0.009) and multivariate (P= 0.010) analyses demonstrated that 21-gene RS was correlated with LRR. Compared to low-risk patients, high-risk patients were at greater risk of LRR (HR 5.75, 95% CI 1.30–25.31, P= 0.021). Among pN0 (P= 0.033), pN1 (P= 0.049) and postmastectomy patients (P= 0.012), 21-gene RS remained predictive of the risk of LRR. CONCLUSION: The 21-gene RS assay was significantly associated with the risk of LRR in ER-positive, HER2-negative early breast cancer patients. Among patients with different nodal statuses and patients receiving mastectomy, RS remained predictive of the risk of LRR.

Postmastectomy radiotherapy for all node positive patients: The case against

Postmastectomy radiotherapy (PMRT) is accepted as the standard of care for women with early breast cancer with 4 or more involved axillary nodes. However the role of PMRT in women with 1-3 involved nodes remains controversial and guidelines vary. We present the arguments against advocating postmastectomy radiotherapy for all women with node positive breast cancer.

Post Mastectomy Radiation for Stage II Breast Cancer Patients with T1/T2 Lesions

Objective

Post mastectomy radiation (PMR) is usually recommended for T3 or N2 breast cancer (BC). The role of PMR for stage II BC with T1/T2 lesions remains controversial. The aim of this study was to assess the role of PMR in this subgroup of patients.

Materials and Methods

A retrospective analysis of a prospectively collected database of all stage II BC patients treated with mastectomy at our institution between the years 2005-2008 was performed. Demographics, disease-free survival rates were compared between the patients receiving radiation vs. those who were not irradiated.

Results

Eighty-two patients underwent mastectomies for stage II disease with a T1/T2 lesion. Twenty-two of those (27%) received PMR. Loco regional recurrence (LRR) occurred only in the non -irradiated (NR) group. A Kaplan Meier analysis of time to LRR in the NR group was performed. Mean time to local failure was 78.9 months, 6% at 3 years and 13% at 5 years. The time to LRR was significantly lower in the estrogen receptor (ER) negative group compared to the ER positive group (64 vs. 82 months, p=0.029). LRR free rate at 5 years was 100% in low grade tumors vs. 53% in high grade tumors, (p=0.001). In a Cox regression multivariate analysis none of those factors maintained significance.

Conclusion

ER negative status, high grade and node negativity were associated with LRR. A prospective trial randomizing stage II BC patients with T1/T2 lesions, negative hormone receptors and high-grade tumors to PMR following mastectomy arm vs. no radiation arm is recommended.

Postmastectomy radiotherapy reduces locoregional and disease recurrence in patients with stage II-III triple-negative breast cancer treated with neoadjuvant chemotherapy and mastectomy

Background

This study investigated the effect of postmastectomy radiotherapy (PMRT) in patients with stage II–III triple-negative breast cancer (TNBC) after neoadjuvant chemotherapy (NAC) and modified radical mastectomy (MRM).

Patients and methods

A total of 104 women with stage II–III TNBC who received NAC and MRM at our institution between January 2000 and July 2007 were identified. Patients were divided into 2 groups (PMRT and non-PMRT) for statistical analysis.

Results

The median follow-up time was 64 months (range 12–123 months). The 5 year cumulative locoregional recurrence (LRR) and disease recurrence (DR) rates were 26.5% and 49.6%, respectively. Despite their more adverse prognostic features, patients with PMRT had lower 5 year cumulative LRR and DR rates than those without PMRT (LRR: 18.3% vs 52.2%, respectively, p=0.0005; DR: 45% vs 69.1%, p=0.0334, respectively). On multivariate analysis of the entire study cohort, forgoing PMRT was significantly associated with developing LRR and DR. Subset analysis revealed that PMRT significantly reduced the 5 year LRR rate in patients with pre-chemotherapy clinical stages IIA (8.3% vs 46.2%, p=0.019) and IIIA (16% vs 66.7%, p=0.003). PMRT also significantly reduced the 5 year DR rate in patients with pre-chemotherapy clinical stage IIA (24.5% vs 69.3%, p=0.0151) and ≥IIIB (70.8% vs 100%, p=0.0481).

Conclusion

In our cohort of patients with TNBC treated with NAC and MRM, PMRT significantly improved locoregional control and disease-free survival in the entire cohort as well as in patients with stage IIA disease. Our results may help in tailoring adjuvant treatment decisions for these particular patient populations.

Postmastectomy radiation therapy for breast cancer patients with one to three positive lymph nodes: a propensity score matching analysis

AIM

Conducting postmastectomy radiation therapy (PMRT) for breast cancer patients with one to three positive lymph nodes is still controversial.

METHODS

Propensity score matching analysis was applied to balance the clinical baseline characteristics of patients. Cox proportional hazard analysis was used to analyze the survival prognosis factors and perform subgroup analysis.

RESULTS

There was no statistical difference in overall survival and cancer-specific survival rates (all, p > 0.05) between the PMRT and non-PMRT groups. However, for subgroup patients with tumor size ≥5 cm and the number of positive lymph nodes = 3, PMRT showed a significant survival benefit.

CONCLUSION

PMRT can improve overall survival and cancer-specific survival only in breast cancer patients whose tumor size is larger than 5 cm and with three positive lymph nodes.

Trends in use and outcome of postoperative radiotherapy following mastectomy: A population-based study

PURPOSE

The objective of the present population-based study was to evaluate the role and effectiveness of postmastectomy radiation therapy (PMRT) in clinical practice.

METHODS

The study included 16,675 patients diagnosed with invasive breast cancer from 1988 to 2012 and resident within the catchment area of the Munich Cancer Registry. Use of PMRT, local recurrence-free survival (LRFS), cumulative incidence of time to local recurrence, relative survival and conditional overall survival (cOS), were analysed for different time periods (1988-1997 and 1998-2012).

RESULTS

Variables favouring the use of PMRT on multivariate logistic regression analysis included young age, large tumour size, positive resection margin and positive nodal status. Over time, a significant increase of PMRT was registered for patients with ⩾4 positive lymph nodes. Moreover, the present findings track a less frequent use of PMRT in elderly patients. After adjusting for age, tumour characteristics and therapies, the Cox regression analysis for LRFS identified PMRT as an independent predictor for improved local control (HR: 2.145; 95% CI: 1.787-2.574, p<0.0001). Patients with 1-3 involved lymph nodes had a 10-year cumulative incidence of local recurrence of 13.7% following mastectomy, compared to 6.5% following PMRT (p=0.0001). Comparable findings were obtained for patients presenting with ⩾4 positive lymph nodes. All effects were smaller or extinct in elderly patients aged ⩾70years. On multivariate analysis for cOS, no significant advantage for PMRT could be detected (HR: 1.084; 95% CI: 0.986-1.191, p=0.095).

CONCLUSION

The present study was useful in providing an overview on trends in the adoption of PMRT over a 25-year period. An increase in the use of PMRT from 1988 to 2012 was observed, especially in high-risk patients with ⩾4 positive lymph nodes. Patients selected for PMRT had an improved local control and an equivalent relative survival compared to patients who had no indication for PMRT.

DEGRO practical guidelines for radiotherapy of breast cancer IV: radiotherapy following mastectomy for invasive breast cancer

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.

Post-mastectomy radiotherapy for breast cancer patients with t1-t2 and 1-3 positive lymph nodes: a meta-analysis

BACKGROUND

The role of post-mastectomy radiotherapy (PMRT) in patients with T1-2 and 1-3 positive lymph nodes remains controversial. The aim of this study is to investigate the possible benefits of PMRT for this subgroup.

METHODS

Three electronic databases were systematically quarried (Cochrane Library, MEDLINE, and EMBASE) for published studies evaluating the effects of PMRT on breast cancer patients with T1-T2 tumors with 1-3 positive lymph nodes. Of the 334 studies identified, information was available for 3432 patients from 10 clinical studies. Pooled relative risk estimates (RR) and overall survival (OS) were calculated using the inverse variance weighted approach, publication bias and chi-square test were also calculated.

RESULTS

From the 10 studies, the pooled RR (RRs) for locoregional recurrence (LRR) with PMRT was 0.348 (95% CI = 0.254 to 0.477), suggesting a significant benefit for PMRT to decrease the risk of LRR in patients with T1-T2 tumors and 1-3 positive nodes (p<0.05). Reporting bias ( Begg's p = 0.152; Egger's p = 0.107) or significant heterogeneity (Cochran's p = 0.380; I(2) = 6.7%) were not detected. For further subset analysis, the RR for T1, N1-3+ tumors was 0.330 (95% CI = 0.171 to 0.639); for T2, N1-3+ tumors the RR was 0.226 (95% CI = 0.121 to 0.424). The pooled RR for overall survival (OS) was not significantly different between PMRT and no-PMRT group (1.051, 95% CI =1.001 to 1.104).

CONCLUSIONS

Our pooled analysis revealed that PMRT significantly reduces the risk of LRR in patients with TI-T2 tumors with 1-3 positive nodes, and the magnitude of the LRR risk reduction is slightly greater for larger tumors. Our results suggest that PMRT should be considered for patients with T1/T2 tumors with 1-3 positive nodes to decrease the relatively high risk of LRR.

Which patients might benefit from postmastectomy radiotherapy in breast cancer patients with t1-2 tumor and 1-3 axillary lymph nodes metastasis?

Purpose

This study compared the clinical outcomes of T1-2N1 breast cancer patients with and without postmastectomy radiotherapy (PMRT). Risk factors for loco-regional recurrence (LRR) were identified in order to define a subgroup of patients who might benefit from PMRT.

Materials and Methods

Of 110 T1-2N1 breast cancer patients who underwent mastectomy from January 1994 through December 2009, 32 patients underwent PMRT and 78 patients did not. Treatment outcomes and risk factors for LRR were analyzed.

Results

The 5- and 10-year LRR rates were both 6.2% in the PMRT group, and 10.4% and 14.6% in the no-PMRT group (p=0.336). In addition, no significant differences in distant metastasis-free survival (DMFS) or overall survival (OS) were observed between patients receiving and not receiving PMRT. In multivariate analysis, factors associated with higher LRR rates included grade 3 disease, extracapsular extension (ECE), and triple negative subtype. Patients who had one or more risk factors for LRR were defined as a high-risk patient group. In the high-risk group, both 5- and 10-year LRR rates for patients who underwent PMRT was 18.2%, and LRR rates of 21.4% at five years and 36.6% at 10 years were observed for patients who did not undergo PMRT (p=0.069).

Conclusion

PMRT in T1-2N1 breast cancer patients should be considered according to several prognostic factors in addition to T and N stage. Findings of our study indicated that PMRT did not improve LRR, DMFS, or OS in T1-2N1 breast cancer patients. However, in a subgroup of patients with grade 3 disease, ECE, or triple negative subtype, PMRT might be beneficial.

Radiotherapy issues in elderly breast cancer patients

Breast cancer in the elderly is a rising health care challenge. Under-treatment is common. While the proportion of older patients receiving adjuvant radiotherapy (RT) is rising, the proportion undergoing breast-conserving surgery without irradiation has also risen. The evidence base for loco-regional treatment is limited, reflecting the historical exclusion of older patients from randomised trials. The 2011 Oxford overview shows that the risk of first recurrence is halved in all age groups by adjuvant RT after breast-conserving surgery, although the absolute benefit in older 'low-risk' patients is small. There is level 1 evidence that a breast boost after breast-conserving surgery and whole-breast irradiation reduces local recurrence in older as in younger women, although in the former the absolute reduction is modest. Partial breast irradiation (external beam or intraoperative or postoperative brachytherapy) is potentially an attractive option for older patients, but the evidence base is insufficient to recommend it routinely. Similarly, shortened (hypofractionated) dose fraction schedules may be more convenient for older patients and are supported by level 1 evidence. There remains uncertainty about whether there is a subgroup of older low-risk patients in whom postoperative RT can be omitted after breast-conserving surgery. Biomarkers of 'low risk' are needed to refine the selection of patients for the omission of adjuvant RT. The role of postmastectomy irradiation is well established for 'high-risk' patients but uncertain in the intermediate-risk category of patients with 1-3 involved axillary nodes or node-negative patients with other risk factors where its role is investigational.

Validating a prognostic scoring system for postmastectomy locoregional recurrence in breast cancer

PURPOSE

This study is designed to validate a previously developed locoregional recurrence risk (LRR) scoring system and further define which groups of patients with breast cancer would benefit from postmastectomy radiation therapy (PMRT).

METHODS AND MATERIALS

An LRR risk scoring system was developed previously at our institution using breast cancer patients initially treated with modified radical mastectomy between 1990 and 2001. The LRR score comprised 4 factors: patient age, lymphovascular invasion, estrogen receptor negativity, and number of involved lymph nodes. We sought to validate the original study by examining a new dataset of 1545 patients treated between 2002 and 2007.

RESULTS

The 1545 patients were scored according to the previously developed criteria: 920 (59.6%) were low risk (score 0-1), 493 (31.9%) intermediate risk (score 2-3), and 132 (8.5%) were high risk (score ≥4). The 5-year locoregional control rates with and without PMRT in low-risk, intermediate-risk, and high-risk groups were 98% versus 97% (P=.41), 97% versus 91% (P=.0005), and 89% versus 50% (P=.0002) respectively.

CONCLUSIONS

This analysis of an additional 1545 patients treated between 2002 and 2007 validates our previously reported LRR scoring system and suggests appropriate patients for whom PMRT will be beneficial. Independent validation of this scoring system by other institutions is recommended.

Impact of postmastectomy radiation on locoregional recurrence in breast cancer patients with 1-3 positive lymph nodes treated with modern systemic therapy

PURPOSE

Postmastectomy radiation therapy (PMRT) remains controversial for patients with 1-3 positive lymph nodes (LN+).

METHODS AND MATERIALS

We conducted a retrospective review of all 369 breast cancer patients with 1-3 LN+ who underwent mastectomy without neoadjuvant systemic therapy between 2000 and 2007 at Cleveland Clinic.

RESULTS

We identified 271 patients with 1-3 LN+ who did not receive PMRT and 98 who did receive PMRT. The median follow-up time was 5.2 years, and the median number of LN dissected was 11. Of those not treated with PMRT, 79% received adjuvant chemotherapy (of whom 70% received a taxane), 79% received hormonal therapy, and 5% had no systemic therapy. Of the Her2/neu amplified tumors, 42% received trastuzumab. The 5-year rate of locoregional recurrence (LRR) was 8.9% without PMRT vs 0% with PMRT (P=.004). For patients who did not receive PMRT, univariate analysis showed 6 risk factors significantly (P<.05) correlated with LRR: estrogen receptor/progesterone receptor negative (hazard ratio [HR] 2.6), lymphovascular invasion (HR 2.4), 2-3 LN+ (HR 2.6), nodal ratio >25% (HR 2.7), extracapsular extension (ECE) (HR 3.7), and Bloom-Richardson grade III (HR 3.1). The 5-year LRR rate was 3.4% (95% confidence interval [CI], 0.1%-6.8%] for patients with 0-1 risk factor vs 14.6% [95% CI, 8.4%-20.9%] for patients with ≥2 risk factors (P=.0006), respectively. On multivariate analysis, ECE (HR 4.3, P=.0006) and grade III (HR 3.6, P=.004) remained significant risk factors for LRR. The 5-year LRR was 4.1% in patients with neither grade III nor ECE, 8.1% with either grade III or ECE, and 50.4% in patients with both grade III and ECE (P<.0001); the corresponding 5-year distant metastasis-free survival rates were 91.8%, 85.4%, and 59.1% (P=.0004), respectively.

CONCLUSIONS

PMRT offers excellent control for patients with 1-3 LN+, with no locoregional failures to date. Patients with 1-3 LN+ who have grade III disease and/or ECE should be strongly considered for PMRT.

Locoregional recurrence risk factors in breast cancer patients with positive axillary lymph nodes and the impact of postmastectomy radiotherapy

BACKGROUND

Locoregional recurrence (LRR) after mastectomy reduces the patient's quality of life and survival. There is a consensus that postmastectomy radiotherapy (PMRT) helps establish locoregional control and reduces LRR in patients with ≥4 metastatic nodes. However, in patients with 1-3 metastatic nodes, the incidence of LRR and the role of PMRT have been the subject of substantial controversy. This study assessed the risk factors for LRR and the efficacy of PMRT in Japanese breast cancer patients with metastatic nodes.

METHODS

This study analyzed 789 cases of invasive breast carcinoma with metastatic nodes from 1998 to 2008. We divided the study population into 4 groups: 1-3 positive nodes with/without chemotherapy and ≥4 positive nodes with/without chemotherapy. Risk factors for LRR were identified and the relationship between LRR and PMRT was analyzed.

RESULTS

During the median follow-up of 59.6 months, 61 (7.7%) patients experienced LRR. In patients who received chemotherapy, independent LRR risk factors were high nuclear grade, severe lymphatic invasion, vascular invasion, and progesterone receptor-negative status in patients with 1-3 positive nodes, and severe lymphatic invasion and estrogen receptor-negative status in patients with ≥4 nodes. Although patients treated with PMRT had good outcomes, there was no significant difference, and PMRT did not significantly improve the outcome of the patients with all risk factors.

CONCLUSIONS

With systemic therapy and adequate dissection, PMRT by itself was of limited value in establishing locoregional control. The indication for PMRT in patients with 1-3 positive nodes remains controversial.

Management of early invasive breast cancer in very young women (<35 years)

BACKGROUND

To give an overview about current treatment recommendations and special problems concerning the management of women <35 years with early breast cancer.

METHODS

We performed a selective systematic literature review. We discussed with reference to key studies and meta-analyses, current standards of care, and controversies regarding patient management.

RESULTS

Breast cancer in patients younger than 35 years is rare but associated with an unsatisfactory prognosis. Local treatment should not differ from general guidelines, but awareness of the high risk of local recurrence must be maintained. Adjuvant polychemotherapy is almost always indicated, standard endocrine therapy is tamoxifen. Before the start of systemic therapy, the patient must be offered different types of fertility preservation. Pregnancy related breast cancer is not associated with a worse prognosis, but with delayed diagnosis. Therefore, every suspicious lesion in the breast or axilla must be imaged and biopsied. The optimal time to delay pregnancy following the diagnosis is unknown. Hormonal contraceptives are contraindicated after breast cancer. Every woman <35 years diagnosed with breast cancer should be offered genetic counseling.

CONCLUSION

The management of breast cancer in very young women requires a multidisciplinary team to find the optimal treatment and to solve their specific problems.

Comparison of treatment outcome between breast-conservation surgery with radiation and total mastectomy without radiation in patients with one to three positive axillary lymph nodes

PURPOSE

To test the difference in treatment outcome between breast-conservation surgery with radiation and total mastectomy without radiation, to evaluate the benefits of adjuvant radiotherapy in patients with one to three positive axillary lymph nodes.

METHODS AND MATERIALS

Using the Severance Hospital Breast Cancer Registry, we divided the study population of T1, T2 and one to three axillary node-positive patients into two groups: breast-conservation surgery with radiation (BCS/RT) and total mastectomy without radiation (TM/no-RT). Data related to locoregional recurrence, distant recurrence, and death were collected, and survival rates were calculated.

RESULTS

The study population consisted of 125 patients treated with BCS/RT and 365 patients treated with TM/no-RT. With a median follow-up of 68.4 months, the 10-year locoregional recurrence-free survival rate with BCS/RT and TM/no-RT was 90.5% and 79.2%, respectively (p = 0.056). The 10-year distant recurrence-free survival rate was 78.8% for patients treated with BCS/RT vs. 68.0% for those treated with TM/no-RT (p = 0.012). The 10-years overall survival rate for patients treated with BCT/RT and TM/no-RT was 87.5% and 73.9%, respectively (p = 0.035). After multivariate analysis, patients treated with BCT/RT had better distant recurrence-free survival (hazard ratio [HR], 0.527; 95% confidence interval [CI], 0.297-0.934; p = 0.028), with improving locoregional recurrence-free survival (HR, 0.491; 95% CI, 0.231-1.041; p = 0.064) and overall survival trend (HR, 0.544; 95% CI, 0.277-1.067; p = 0.076).

CONCLUSIONS

This study provides additional evidence that adjuvant radiation substantially reduces local recurrence, distant recurrence, and mortality for patients with one to three involved nodes.

Prognostic significance of number of positive nodes: a long-term study of one to two nodes versus three nodes in breast cancer patients

PURPOSE

Previous reports of breast cancer have generally analyzed patients with one to three positive lymph nodes as a single group, often leading to controversy regarding the practical clinical applicability. The present study separately analyzed the survival outcomes of Stage T1-T2 breast cancer patients according to whether one, two, or three axillary nodes were pathologically positive.

METHODS AND MATERIALS

The records of 5,996 patients were available for analysis from the population-based Saskatchewan provincial registry between 1981 and 1995. Because the reliability of the nodal assessment depends on the number of lymph nodes sampled, only those 755 patients with Stage T1-T2 disease and eight or more nodes examined were analyzed further for overall survival and cause-specific survival (CSS).

RESULTS

Patients with one and two positive nodes had nearly indistinguishable survival plots, but those with three positive nodes had a distinct trend toward worse survival. The overall survival rate of patients with one, two, and three nodes at 5, 10, and 15 years was 82.7%, 77.0%, and 79.0%, 64.8%, 60.9%, and 52.8%, and 48.8%, 48.0%, and 40.9%, respectively (p = .11). The corresponding CSS rates at 5, 10, and 15 years were 89.4%, 82.0%, and 81.3%, 78.87%, 72.9%, and 62.1%, and 72.7%. 69.0%, and 55.6% (p = .0004). The use of regional radiotherapy did not confer any apparent survival benefit in terms of either overall survival or CSS.

CONCLUSION

Patients with one or two positive nodes had a similar CSS. However, those with three positive nodes fared worse, with a significantly reduced CSS compared with those with one or two involved nodes. Thus, the survival data among patients with one to three nodes positive reveals clearly relevant differences when analyzed separately.

Radiotherapy of the regional lymph nodes: shooting at the sheriff?

The role of immune surveillance in controlling the spread of breast cancer to the regional nodes is poorly understood. In theory regional nodal irradiation (RNI) might compromise this host function. However the clinical evidence suggests that the risk of regional recurrence is lower in patients with early breast cancer whose axilla has been irradiated compared to no axillary treatment. The role of RNI after breast conserving surgery has not been well studied. A policy of level III clearance and only irradiating the axilla for residual disease and a selective policy of axillary irradiation in node positive patients after sentinel node biopsy or lower axillary node sample is recommended. Irradiation of the medial supraclavicular fossa after axillary dissection is suggested where there are four or more nodes involved on axillary dissection. There is little data to inform selection of patients for RNI after neoadjuvant systemic therapy. The role of postmastectomy radiotherapy (PMRT) was largely established on the basis of comprehensive RNI. It is unclear whether irradiating less than the chest wall and peripheral lymphatics confers the same level of benefit. The role of PMRT in women with 1-3 involved nodes remains controversial and investigational. Biological factors such as oestrogen and progesterone receptor status and HER-2 protein expression may play a role in determining benefits from PMRT. The role of internal mammary nodal irradiation is unclear. The individualisation of RNI based on molecular and genetic factors should be a priority for research. The benefits of RNI need to be carefully balanced against the risks of cardiotoxicity, pneumonitis, lymphoedema, brachial plexopathy and secondary malignancy.

Adjuvant chest wall radiotherapy for breast cancer: black, white and shades of grey

BACKGROUND

Adjuvant chest wall irradiation after mastectomy remains a core and highly effective element in the loco-regional management of early breast cancer. While the evidence base for postmastectomy radiotherapy (PMRT) in patients with 4 or more involved axillary nodes is robust, its role in 'intermediate' risk patients with 1-3 involved nodes is unclear and practice varies. Traditionally patients have been selected for PMRT on the basis of clinic-pathological factors such tumour size, nodal status, tumour grade and presence of lymphovascular invasion. However these factors alone may not predict the response of individual patients to radiotherapy. There is recent evidence that biological factors such as oestrogen and progesterone receptor and HER-2 status may also influence survival as well as loco-regional control.

METHODS

A literature review was undertaken, searching Pubmed using the mesh heading of 'breast cancer' and 'adjuvant chest wall irradiation/radiotherapy'. Priority was given to reports of meta-analyses and randomised trials of postmastectomy radiotherapy.

OBSERVATIONS

The 2005 Oxford Overview of randomised trials of postoperative radiotherapy established a clear biological link between loco-regional control and survival. Paradoxically the largest survival benefits do not occur in patients at the highest risk of recurrence. Molecular markers to identify exactly which patients are likely to benefit from PMRT are being actively investigated. Surgeons are encouraged to enter patients with 1-3 involved nodes into a clinical trial of postmastectomy radiotherapy.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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