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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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Dogan I, Aydin E, Khanmammadov N, Paksoy N, Ferhatoğlu F, Ak N, Emiroglu S, Ibis K, Onder S, Tukenmez M, Cabioglu N, Kucucuk S, Muslumanoğlu M, Ozmen V, Saip P, Igci A, Aydiner A. Long-term outcomes and predictors of recurrence in node-negative early stage breast cancer patients. J Cancer Res Clin Oncol 2023; 149:14833-14841. [PMID: 37594533 DOI: 10.1007/s00432-023-05276-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/10/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND We evaluated the outcomes, and risk factors for recurrence in patients with early stage node-negative breast cancer in this study. METHOD Retrospective data analysis was done on patient treatment records from 1988 to 2018. The patient's demographic, clinical, pathological, and therapeutic characteristics were noted. To evaluate survival analysis and predictors of recurrence, we employed Kaplan-Meier analysis with the log-rank test. RESULTS A total of 357 patients in all were enrolled in the research. At the time of diagnosis, the median age was 50 (with a range of 18-81). A total of 85.5% of patients had undergone a lumpectomy, while 14.5% had a mastectomy. 78.7% of patients had sentinel lymph node biopsy, and 21.3% had axillary lymph node dissection. In addition, the patients received adjuvant radiotherapy (88.7%), adjuvant endocrine therapy (82.1%), and adjuvant chemotherapy (48.5%). Recurrence of the tumor occurred in 31 (8.7%) patients (local recurrence 45.2% and metastatic disease 54.8%). Ten- and twenty-year recurrence-free survival rates were 92% and 77%. 19 (5.3%) patients had also developed contralateral breast cancer. Ten-year survival rates were 91.6%, and 20-year survival rates were 76.6%, respectively. Aged over 65 years (p = 0.004), necrosis (p = 0.002), mitosis (p = 0.003), and nuclear pleomorphism (p = 0.049) were found as statistically significant factors for recurrence in univariate analysis. In the ROC analysis, the largest size of the tumor (over 1.45 cm, p = 0.07) remained outside the statistical significance limit in terms of recurrence. CONCLUSIONS Thirty-year outcomes in individuals with early stage, node-negative breast cancer were shown in this study. We found that the recurrence ratios between 10 and 20 years were more frequent than the first 10 years during the follow-up. Despite the small number of patients who experienced a recurrence, we demonstrated that, in univariate analysis, being older than 65 and having some pathological characteristics (nuclear pleomorphism, mitosis, and necrosis) were statistically significant factors for disease recurrence.
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Affiliation(s)
- Izzet Dogan
- Department of Medical Oncology, Istanbul University Institute of Oncology, Medical Oncology, Çapa, Fatih, 34093, Istanbul, Turkey.
| | - Esra Aydin
- Department of Medical Oncology, Istanbul University Institute of Oncology, Medical Oncology, Çapa, Fatih, 34093, Istanbul, Turkey
| | - Nijat Khanmammadov
- Department of Medical Oncology, Istanbul University Institute of Oncology, Medical Oncology, Çapa, Fatih, 34093, Istanbul, Turkey
| | - Nail Paksoy
- Department of Medical Oncology, Istanbul University Institute of Oncology, Medical Oncology, Çapa, Fatih, 34093, Istanbul, Turkey
| | - Ferhat Ferhatoğlu
- Department of Medical Oncology, Istanbul University Institute of Oncology, Medical Oncology, Çapa, Fatih, 34093, Istanbul, Turkey
| | - Naziye Ak
- Department of Medical Oncology, Istanbul University Institute of Oncology, Medical Oncology, Çapa, Fatih, 34093, Istanbul, Turkey
| | - Selman Emiroglu
- Department of Surgery, Istanbul University, Faculty of Medicine, Istanbul, Turkey
| | - Kamuran Ibis
- Istanbul University Institute of Oncology, Radiation Oncology, Istanbul, Turkey
| | - Semen Onder
- Department of Pathology, Istanbul University, Faculty of Medicine, Istanbul, Turkey
| | - Mustafa Tukenmez
- Department of Surgery, Istanbul University, Faculty of Medicine, Istanbul, Turkey
| | - Neslihan Cabioglu
- Department of Surgery, Istanbul University, Faculty of Medicine, Istanbul, Turkey
| | - Seden Kucucuk
- Istanbul University Institute of Oncology, Radiation Oncology, Istanbul, Turkey
| | - Mahmut Muslumanoğlu
- Department of Surgery, Istanbul University, Faculty of Medicine, Istanbul, Turkey
| | - Vahit Ozmen
- Department of Surgery, Istanbul University, Faculty of Medicine, Istanbul, Turkey
| | - Pinar Saip
- Department of Medical Oncology, Istanbul University Institute of Oncology, Medical Oncology, Çapa, Fatih, 34093, Istanbul, Turkey
| | - Abdullah Igci
- Department of Surgery, Istanbul University, Faculty of Medicine, Istanbul, Turkey
| | - Adnan Aydiner
- Department of Medical Oncology, Istanbul University Institute of Oncology, Medical Oncology, Çapa, Fatih, 34093, Istanbul, Turkey
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Dayan D, Ernst K, Aktas B, Baierl R, Briest S, Dengler M, Dieterle D, Endres A, Engelken K, Faridi A, Frenz H, Hantschmann P, Janni W, Kaiser C, Kokott T, Laufhütte S, Schober F, Ebner F. Resemblance of the Recurrence Patterns in Primary Systemic, Primary Surgery and Secondary Oncoplastic Surgery. Curr Oncol 2022; 29:8874-8885. [PMID: 36421351 PMCID: PMC9689416 DOI: 10.3390/curroncol29110698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/12/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Surgical interventions tend to have an effect on the generation of recurrences in tumor patients due to the anesthesia involved as well as tissue damage and subsequent inflammation. This can also be found in patients with breast cancer. METHODS In this multicenter study, we investigated data of 632 patients with breast cancer and the subsequent diagnosis of a recurrence. The patient data were acquired from 1 January 2006 to 31 December 2019 in eight different centers in Germany. The data sets were separated into those with primary surgery, primary systemic therapy with subsequent surgery, and reconstructive surgery. Three different starting points for observation were defined: the date of diagnosis, the date of first surgery, and the date of reconstructive surgery, if applicable. The observational period was divided into steps of six months and maxima of recurrences were compared. Furthermore, the variance was calculated using the difference of the distribution in percent. RESULTS The descriptive analysis showed no resemblance between the groups. The variance of the difference of the recurrence rates analysis using the surgical date as the starting point showed similarities in the age subgroup. CONCLUSION Our clinical analysis shows different metastatic behavior in different analysis and treatment regimes. These findings justify further investigations on a larger database. These results may possibly identify an improved follow-up setting depending on tumor stage, biology, treatment, and patient factors (i.e., age, …).
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Affiliation(s)
- Davut Dayan
- Frauenklinik, Universität Ulm, 89075 Ulm, Germany
| | | | - Bahriye Aktas
- Universitätsklinik Leipzig, Frauenklinik, 04103 Leipzig, Germany
| | - Raffaela Baierl
- Brustkrebszentrum Passau, Klinikum Passau, 94032 Passau, Germany
| | - Susanne Briest
- Universitätsklinik Leipzig, Frauenklinik, 04103 Leipzig, Germany
| | - Martin Dengler
- Brustkrebszentrum Passau, Klinikum Passau, 94032 Passau, Germany
| | - Daniela Dieterle
- Brustzentrum Kaufbeuren, Klinikum Kaufbeuren, 87600 Kaufbeuren, Germany
| | - Amelie Endres
- Medical Facility, Universität Tübingen, 72016 Tübingen, Germany
| | | | | | - Hannes Frenz
- Medical Facility, Universität Tübingen, 72016 Tübingen, Germany
| | | | | | | | | | | | - Florian Schober
- Plastische Chirurgie, Diakoneo Schwäbisch Hall, 74523 Schwäbisch Hall, Germany
| | - Florian Ebner
- Frauenarztpraxis Freising, Marienplatz, 585354 Freising, Germany
- Correspondence:
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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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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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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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Impact of clinical-pathological factors on locoregional recurrence in mastectomy patients with T1-2N1 breast cancer: who can omit adjuvant radiotherapy? Breast Cancer Res Treat 2021; 190:277-286. [PMID: 34490502 PMCID: PMC8558198 DOI: 10.1007/s10549-021-06378-2] [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: 04/21/2021] [Accepted: 08/26/2021] [Indexed: 11/25/2022]
Abstract
Purpose Postmastectomy radiation therapy (PMRT) in T1–T2 tumors with 1–3 positive axillary lymph nodes (ALNs) is controversial. This study was to identify prognostic factors of locoregional control (LRC) following mastectomy with or without PMRT for patients with T1-2N1 breast cancer and to discuss the selection of patients who might omit PMRT. Materials and methods Between January 2006 and December 2012, the data of 1474 postmastectomy patients staged pT1-2N1 were analyzed. PMRT was applied in 663 patients. LRC and disease-free survival (DFS) were calculated using the Kaplan–Meier method. Cox regression model was applied in the univariate and multivariate analyses to recognize the recurrence risk factors. Results With the median follow-up duration of 93 months (range, 5–168 months), 78 patients (5.3%) failed to secure LRC and 220 patients (14.9%) experienced any recurrence. The 7.7-year LRC and DFS was 94.9% and 85.4% respectively in the entire cohort. PMRT significantly improved 7.7-year LRC from 93.4% to 96.6% (p = 0.005), but not the DFS (p = 0.335). Multivariate analysis revealed that PMRT was an independent prognostic factor of LRC (p < 0.001), meanwhile, age ≤ 40 years (p = 0.012), histological grade 3 (p = 0.004), 2–3 positive nodes (p < 0.001) and tumor size of 3–5 cm (p = 0.045) were significantly associated with decreased LRC. The 7.7-year LRC for patients with 0, 1, and 2–4 risk factors was 97.7% / 98.9% (p = 0.233), 95.3% / 98.0% (p = 0.092), and 80.3% / 94.8% (p < 0.001) in the non-PMRT and PMRT group, respectively. Conclusions In patients with T1-2N1 breast cancer, clinical-pathological factors including young age, histological grade 3, 2–3 positive nodes, and tumor size of 3–5 cm were identified to be predictors of a poorer LRC following mastectomy. Patients with 0–1 risk factor might consider the omission of PMRT.
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Genomically Guided Breast Radiation Therapy: A Review of the Current Data and Future Directions. Adv Radiat Oncol 2021; 6:100731. [PMID: 34409215 PMCID: PMC8361058 DOI: 10.1016/j.adro.2021.100731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose To highlight the current evidence and the limitations in data to support a personalized approach in breast oncology radiation therapy management and define steps needed for clinical implementation. Methods and Materials A critical review of the current literature on the use of genomics in breast radiation therapy was undertaken by a group of breast radiation oncologists to discuss current data, future directions, and challenges. Results A summary of the existing data, ongoing clinical trials, and future directions is provided. The authors note many groups have developed radiation-specific genomic assays, which demonstrate promise in prediction of local control and benefit from radiation therapy; however, prospective validation of their utility is needed. Limitations continue to exist in our understanding of tumor biology and how it can be integrated into clinical practice. Conclusions Given the relative ubiquity of breast radiation therapy, the variety of dose and fractionation approaches, and the current data to support a personalized approach, it is our belief that the delivery of breast radiation therapy is uniquely poised for a genomically personalized radiation therapy approach. Prospective clinical trials implementing genomic signatures are needed at this time to advance the field.
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Luo C, Zhong X, Luo T, Zheng H. Postmastectomy radiation therapy and survival outcome in older patients with T1-2N1 breast cancer. Breast 2021; 59:308-313. [PMID: 34388696 PMCID: PMC8361178 DOI: 10.1016/j.breast.2021.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/21/2021] [Accepted: 08/02/2021] [Indexed: 02/05/2023] Open
Abstract
Background The prognostic impact of postmastectomy radiation therapy (PMRT) on contemporary older patients with T1-2N1 breast cancer is unclear. We aimed to investigate the effect of PMRT in this setting. Methods Leveraging the Surveillance, Epidemiology, and End Results (SEER) program data from 2004 to 2015, 7052 patients aged 70 years or older with T1-2N1 breast cancer were identified for this propensity-matched analysis. Fine and Gray competing risks regression was conducted to explore the correlation between PMRT and breast cancer-specific survival, in subgroups defined by tumor size and positive lymph nodes. Results The median follow-up was 60.1 months (interquartile range, 28.0 to 87.0). Among propensity-matched patients, multivariate analysis identified an association between PMRT and decreased breast cancer mortality (BCM; HR 0.637; 95 % CI 0.436–0.931; P = 0.020) in patient subset with three positive nodes and tumors 2–5 cm in size, and this benefit was limited to patients with three positive nodes and tumors 2–5 cm in size who did not receive chemotherapy. In patient subsets who received chemotherapy, no association between PMRT and BCM was found. Conclusion PMRT was not associated with BCM in older patients with T1-2N1 breast cancer who received chemotherapy. The benefit of PMRT was limited to those with three positive nodes and tumors 2–5 cm in size who did not receive chemotherapy. 46.0 % older patients with T1-2N1 breast cancer received postmastectomy radiation therapy (PMRT). 28.8 % older patients with T1-2N1 breast cancer received chemotherapy. PMRT was beneficial for those with three positive nodes and tumors 2–5 cm in size who did not receive chemotherapy. No correlation between PMRT and BCM was found in patients who received chemotherapy.
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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
| | - Ting Luo
- Department of Head, Neck and Mammary Gland Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Hong Zheng
- Laboratory of Molecular Diagnosis of Cancer & Breast Medical Oncology, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
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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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Li M, Yue J, Wan X, Hua B, Yang Q, Yang P, Zhang Z, Pei Q, Han W, Xu Y, Xia X. Risk-Adapted Postmastectomy Radiotherapy Decision Based on Prognostic Nomogram for pT1-2N1M0 Breast Cancer: A Multicenter Study. Front Oncol 2020; 10:588859. [PMID: 33363018 PMCID: PMC7761288 DOI: 10.3389/fonc.2020.588859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/05/2020] [Indexed: 12/01/2022] Open
Abstract
PURPOSE The aim of this study was to develop a widely accepted prognostic nomogram and establish a risk-adapted PMRT strategy based on locoregional recurrence for pT1-2N1M0 breast cancer. METHODS AND MATERIALS A total of 3,033 patients with pT1-2N1M0 breast cancer treated at 6 participating institutions between 2000 and 2016 were retrospectively reviewed. A nomogram was developed to predicted locoregional recurrence-free survival (LRFS). A propensity score-matched (PSM) analyses was performed in risk-adapted model. RESULTS With the median follow-up of 65.0 months, the 5-year overall survival (OS), disease free survival (DFS) and LRFS were 93.0, 84.8, and 93.6%, respectively. There was no significant difference between patients who received PMRT or not for the entire group. A nomogram was developed and validated to estimate the probability of 5-year LRFS based on five independent factors including age, primary tumor site, positive lymph nodes number, pathological T stage, and molecular subtype that were selected by a multivariate analysis of patients who did not receive PMRT in the primary cohort. According to the total nomogram risk scores, the entire patients were classified into low- (40.0%), moderate- (42.4%), and high-risk group (17.6%). The 5-year outcomes were significantly different among these three groups (P<0.001). In low-risk group, patients who received PMRT or not both achieved a favorable OS, DFS, and LRFS. In moderate-risk group, no differences in OS, DFS, and LRFS were observed between PMRT and no PMRT patients. In high-risk group, compared with no PMRT, PMRT resulted in significantly different OS (86.8 vs 83.9%, P = 0.050), DFS (77.2 vs 70.9%, P = 0.049), and LRFS (90.8 vs. 81.6%, P = 0.003). After PSM adjustment, there were no significant differences in OS, DFS, and LRFS in low-risk and moderate-risk groups. However, in the high-risk group, PMRT still resulted in significantly better OS, DFS and improved LRFS. CONCLUSIONS The proposed nomogram provides an individualized risk estimate of LRFS in patients with pT1-2N1M0 breast cancer. Risk-adapted PMRT for high-risk patients is a viable effective strategy.
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Affiliation(s)
- Ming Li
- Department of Radiation Oncology, Beijing Hospital/National Center of Gerontology, Beijing, China
| | - Jinbo Yue
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University/Shandong Academy of Medical Sciences, Jinan, China
| | - Xiangbo Wan
- Department of Radiation Oncology, The Sixth Affiliated Hospital - Sun Yat-sen University, Guangzhou, China
| | - Bin Hua
- Department of Breast Cancer Surgery, Beijing Hospital/National Center of Gerontology, Beijing, China
| | - Qiuan Yang
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Pei Yang
- Department of Radiation Oncology, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine - Central South University, Changsha, China
| | - Zijian Zhang
- Department of Radiation Oncology, Xiangya Hospital - Central South University, Changsha, China
| | - Qian Pei
- Department of General Surgery, Xiangya Hospital - Central South University, Changsha, China
| | - Weidong Han
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yaping Xu
- Geneplus-Beijing Institute, Beijing, China
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12
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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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13
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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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14
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Analysis of Breast Cancer Patients with T1-2 Tumors and 1-3 Positive Lymph Nodes Treated with or without Postmastectomy Radiation Therapy. Sci Rep 2020; 10:9887. [PMID: 32555240 PMCID: PMC7303138 DOI: 10.1038/s41598-020-66495-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 04/07/2020] [Indexed: 11/16/2022] Open
Abstract
The use of postmastectomy radiation therapy (PMRT) has been recommended for patients with 4 or more positive lymph nodes, however, its role in patients with 1-3 positive lymph nodes remains unclear. The purpose of this study is to evaluate oncological outcomes for breast cancer patients with T1-2 tumors and 1-3 positive lymph nodes after undergoing PMRT. We performed a single-institution retrospective investigation that evaluated the association between PMRT and outcomes in breast cancer patients with T1-2 tumors and 1-3 positive lymph nodes, who underwent mastectomy from 2004 to 2015. Multivariable Cox proportional hazards regression was used to evaluate the association of PMRT with disease-free survival and overall survival. A total of 379 patients met inclusion criteria, of which 204 (54%) received PMRT while 175 (46%) did not receive PMRT following mastectomy and were followed over a median of 5.2 years (25th–75th percentile: 2.8–8.4 years). Recurrence was similar in patients receiving PMRT compared to those that did not: locoregional (0 vs 3, P = 0.061), distant (9 vs 3, P = 0.135) and any recurrence (11 vs 7, P = 0.525). After adjustment for potential confounding variables, PMRT was not associated with a statistically significant difference in disease-free survival (HR: 0.93; 95% CI: 0.48, 1.79) or overall survival (HR: 0.91; 95% CI: 0.45, 1.85). PMRT was not associated with improved oncological outcomes in patients with T1-2 breast cancer and 1-3 positive lymph nodes at our institution.
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15
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Chen M, Huang Y, Leng Z, Yang G, Li F, Yang H, Hou L. Post-mastectomy Radiotherapy in T1-2 Breast Cancer Patients With One to Three Lymph Node Metastases: A Propensity Score Matching Analysis. Front Oncol 2020; 9:1551. [PMID: 32117784 PMCID: PMC7033474 DOI: 10.3389/fonc.2019.01551] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/23/2019] [Indexed: 12/26/2022] Open
Abstract
Background and Objectives: Whether post-mastectomy radiotherapy (PMRT) could improve prognosis for T1-2 breast cancer patients with one to three lymph node metastases remains controversial. The present study aimed to determine the significance of PMRT in patients with T1-2N1M0 breast cancer. Methods: Data of 45,646 patients from the Surveillance, Epidemiology, and End Results (SEER) database were analyzed; 12,585 matched patients were divided into a PMRT group and non-radiotherapy group (no-PMRT), respectively, using the propensity score matching method. Univariate and multivariate analyses were performed to determine the prognostic factors of breast cancer, and subgroup analysis was performed according to the number of lymph node metastases. Results: With the median follow-up of 62 months, 5-year cancer-specific survival was 91.48% in the PMRT group and 91.88% in the no-PMRT group (P = 0.405). PMRT did not improve the breast cancer-specific survival (BCSS) in patients with stage T1-2N1M0 (HR = 0.99, 95% CI = 0.92-1.06, P = 0.715). In subgroup analysis, radiotherapy improved the BCSS in patients with three nodes positive, with the 5-year BCSS at 88.5% in the radiation group and 86.6% in the no-radiation group (HR = 0.78, 95% CI = 0.65-0.90, P < 0.001). In patients with two nodes positive, 5-year BCSS was 90.3% in the PMRT group and 89.5% in the no-PMRT group, with no significant difference between the two groups (HR = 0.96, 95% CI = 0.85-1.09, P = 0.552). In patients with one node positive, 5-year BCSS was higher in the no-PMRT group (92.1%) than that in the PMRT group (90.8%); radiotherapy increased the cancer-related death compared with those who did not receive it (HR = 1.21, 95% CI = 1.08-1.36, P = 0.002). Conclusion: The benefit of PMRT in T1-2N1M0 patients was obviously different, and the recommendation of PMRT for this population should be individualized. PMRT should be considered for patients with three nodes positive, should be suggested cautiously in those with two nodes positive, and could be omitted in those with one node positive.
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Affiliation(s)
- Maoshan Chen
- Department of Breast Surgery, Suining Central Hospital, Suining, China
| | - Yunhui Huang
- Department of Breast Surgery, Suining Central Hospital, Suining, China
| | - Zhengwei Leng
- Department of Breast and Thyroid Surgery, Hepatobiliary and Pancreatic Institution, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Guanglun Yang
- Department of Endocrine and Breast Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fangfang Li
- Department of Operating Room, Suining Central Hospital, Suining, China
| | - Hongwei Yang
- Department of Breast Surgery, Suining Central Hospital, Suining, China
| | - Lingmi Hou
- Department of Breast and Thyroid Surgery, Hepatobiliary and Pancreatic Institution, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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16
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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: 13] [Impact Index Per Article: 3.3] [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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17
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Hua X, Long ZQ, Huang X, Deng JP, He ZY, Guo L, Zhang WW, Lin HX. The Value of Prognostic Nutritional Index (PNI) in Predicting Survival and Guiding Radiotherapy of Patients With T1-2N1 Breast Cancer. Front Oncol 2020; 9:1562. [PMID: 32083015 PMCID: PMC7002465 DOI: 10.3389/fonc.2019.01562] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/24/2019] [Indexed: 12/19/2022] Open
Abstract
Background: To investigate the significance of the prognostic nutrition index (PNI) as a predictor of survival and guide for treating T1-2N1 breast cancer. Methods: Patients with T1-2N1 breast cancer (N = 380) who underwent a mastectomy at our center were studied. PNI was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm3). The cutoff for the PNI was calculated using the time-dependent receiver operating characteristic (ROC) curve analysis by overall survival (OS) prediction. The associations between the PNI and the clinicopathologic characteristics were analyzed using Pearson's χ2 test. Survival curves were calculated using the Kaplan–Meier method. Univariate and multivariate analyses were performed using the Cox proportional hazards model. Results: Subgroup analyses of patients with low PNI value (≤52.0) and high PNI value (>52.0) showed that a high PNI was significantly associated with HER2 status, the neutrophil–lymphocyte ratio (NLR), the monocyte–lymphocyte ratio (MLR), and KI 67 status. The OS of patients with a high PNI was significantly better than that of patients with a low PNI. We then conducted subgroup analyses based on PNI and radiotherapy. Among patients who received radiotherapy, the OS of those with a high PNI was significantly better than that of patients with a low PNI. Among patients with a high PNI, the OS of those who received radiotherapy was better than that of the patients who did not receive radiotherapy. However, among the patients with a low PNI, the OS of those who received radiation was worse than that of patients who did not receive radiotherapy. The Kaplan–Meier survival analysis and the multivariate analysis of patients with T1-2N1 breast cancer who received radiotherapy showed PNI independently predicted OS. Conclusions: The preoperative PNI may be a reliable predictor of OS of patients with operable T1-2N1 breast cancer, with the capacity to provide a personalized prognosis and facilitate the development of clinical treatment strategies. However, radiotherapy did not achieve satisfactory outcomes in patients with PNI ≤52.0; thus, further studies on treatment optimization are needed.
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Affiliation(s)
- Xin Hua
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Radiotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhi-Qing Long
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Radiotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xin Huang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jia-Peng Deng
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Radiotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhen-Yu He
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Radiotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ling Guo
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Wen-Wen Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Radiotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Huan-Xin Lin
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Radiotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
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18
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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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20
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Zhang N, Zhang J, Zhang H, Liu Y, Zhao W, Wang L, Chen B, Moran MS, Haffty BG, Yang Q. Individualized Prediction of Survival Benefit from Postmastectomy Radiotherapy for Patients with Breast Cancer with One to Three Positive Axillary Lymph Nodes. Oncologist 2019; 24:e1286-e1293. [PMID: 31315963 DOI: 10.1634/theoncologist.2019-0124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/28/2019] [Indexed: 01/21/2023] Open
Abstract
PURPOSE There still exist some arguments regarding the use of postmastectomy radiotherapy (PMRT) for patients with breast cancer carrying one to three positive axillary lymph nodes considering the heterogeneity of this cohort. Here, we developed a prognostic nomogram to estimate the probability of long-term outcome in patients receiving or not receiving PMRT in order to assist in making individually locoregional treatment decisions for this particular cohort. METHODS Altogether, 20,336 women, aged 18 to 80 years, diagnosed with breast cancer, and carrying one to three positive nodes were identified in the Surveillance, Epidemiology, and End Results (SEER) database. We applied multivariant Cox hazard model to determine the impact of covariates on disease-specific survival (DSS) and overall survival (OS). Then, the nomogram was built accordingly. Internal and external validations were performed to examine the accuracy of nomograms. RESULTS Age of diagnosis, tumor grade, size, estrogen and progesterone receptor status, and number of positive nodes were independent factors of DSS and OS in the multivariate analysis. Incorporating these factors into the constructed nomogram showed high accuracy when predicting 5- and 10-year survival, with internally and externally bootstrap-corrected concordance indexes in the range of 0.6 to 0.8. CONCLUSION Besides the number of involved nodes, extra variables existed as predictors of survival outcomes in this cohort; therefore, the recommendation of PMRT or no PMRT requires comprehensive consideration. This clinically validated nomogram provided a useful tool that could aid decision making by estimating DSS and OS benefits from PMRT, useful in predicting 5- and 10-year DSS and OS for patients with one to three positive nodes after mastectomy. IMPLICATIONS FOR PRACTICE This study evaluated population-based data to identify prognostic factors associated with patients with breast cancer with one to three lymph nodes and help clinicians to weigh the benefit of postmastectomy radiotherapy (PMRT). Surveillance, Epidemiology, and End Results (SEER) data were used to develop a prognostic nomogram to predict the likelihood of long-term survival with and without PMRT in order to optimize the individual locoregional control strategy for this particular cohort. This clinically validated nomogram provides a useful tool to predict 5- and 10-year disease-specific survival and overall survival for patients with one to three positive nodes and can aid tailored clinical decision making by estimating predicted benefit from PMRT.
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Affiliation(s)
- Ning Zhang
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Jiashu Zhang
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Hanwen Zhang
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Ying Liu
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Wenjing Zhao
- Pathology Tissue Bank, Qilu Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Lijuan Wang
- Pathology Tissue Bank, Qilu Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Bing Chen
- Pathology Tissue Bank, Qilu Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Meena S Moran
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Bruce G Haffty
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson and New Jersey Medical School, New Brunswick, New Jersey, USA
| | - Qifeng Yang
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
- Pathology Tissue Bank, Qilu Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
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21
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Park SH, Lee J, Lee JE, Kang MK, Kim MY, Park HY, Jung JH, Chae YS, Lee SJ, Kim JC. Local and regional recurrence following mastectomy in breast cancer patients with 1-3 positive nodes: implications for postmastectomy radiotherapy volume. Radiat Oncol J 2018; 36:285-294. [PMID: 30630267 PMCID: PMC6361249 DOI: 10.3857/roj.2018.00458] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 11/28/2018] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To determine the necessity of postmastectomy radiotherapy (PMRT) and which regions would be at risk for recurrence, we evaluated local and regional recurrence in breast cancer patients with 1-3 positive nodes and a tumor size of <5 cm. MATERIALS AND METHODS We retrospectively analyzed data of 133 female breast cancer patients with 1-3 positive nodes, and a tumor size of <5 cm who were treated with mastectomy followed by adjuvant systemic therapy between 2007 and 2016. The median follow-up period was 57 months (range, 12 to 115 months). Most patients (82.7%) were treated with axillary lymph node dissection. Adjuvant chemotherapy, endocrine therapy, and trastuzumab therapy were administered to 124 patients (93.2%), 112 (84.2%), and 33 (24.8%), respectively. The most common chemotherapy regimen was anthracycline and cyclophosphamide followed by taxane (71.4%). RESULTS Three patients (2.3%), 8 (6.0%), and 12 (9.0%) experienced local, regional, and distant failures, respectively. The 5-year cumulative risk of local recurrence, regional recurrence, distant metastasis, and disease-free survival was 3.1%, 8.0%, 11.7%, and 83.4%, respectively. There were no statistically significant clinicopathologic factors associated with local recurrence. Lymphovascular invasion (univariate p = 0.015 and multivariate p = 0.054) was associated with an increased risk of regional recurrence. CONCLUSION Our study showed a very low local recurrence in patients with 1-3 positive nodes and tumor size of <5 cm who were treated with mastectomy and modern adjuvant systemic treatment. The PMRT volume need to be tailored for each patient's given risk for local and regional recurrence, and possible radiation-related toxicities.
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Affiliation(s)
- Shin-Hyung Park
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jeeyeon Lee
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jeong Eun Lee
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min Kyu Kang
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Mi Young Kim
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Ho Yong Park
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jin Hyang Jung
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yee Soo Chae
- Deaprtment of Hemato-Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Jung Lee
- Deaprtment of Hemato-Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jae-Chul Kim
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
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Abstract
Breast cancer treatment is multidisciplinary. Most women with early stage breast cancer are candidates for breast-conserving surgery with radiotherapy or mastectomy. The risk of local recurrence and the chance of survival does not differ with these approaches. Sentinel node biopsy is used for axillary staging, and individualized approaches are minimizing the need for axillary dissection in women with positive sentinel nodes. Adjuvant systemic therapy is used in most women based on proven survival benefit, and molecular profiling to individualize treatment based on risk is now a clinical reality for patients with hormone receptor-positive cancers.
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Affiliation(s)
- Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA
| | - Rachel Sanford
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA
| | - Chau Dang
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY 10065, USA.
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23
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Molecular determinants of post-mastectomy breast cancer recurrence. NPJ Breast Cancer 2018; 4:34. [PMID: 30345349 PMCID: PMC6185974 DOI: 10.1038/s41523-018-0089-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 07/09/2018] [Accepted: 09/21/2018] [Indexed: 02/06/2023] Open
Abstract
Breast cancer (BC) adjuvant therapy after mastectomy in the setting of 1-3 positive lymph nodes has been controversial. This retrospective Translational Breast Cancer Research Consortium study evaluated molecular aberrations in primary cancers associated with locoregional recurrence (LRR) or distant metastasis (DM) compared to non-recurrent controls. We identified 115 HER2 negative, therapy naïve, T 1-3 and N 0-1 BC patients treated with mastectomy but no post-mastectomy radiotherapy. This included 32 LRR, 34 DM, and 49 controls. RNAseq was performed on primary tumors in 110 patients; with no difference in RNA profiles between patients with LRR, DM, or controls. DNA analysis on 57 primary tumors (17 LRR, 15 DM, and 25 controls) identified significantly more NF1 mutations and mitogen-activated protein kinase (MAPK) pathway gene mutations in patients with LRR (24%, 47%) and DM (27%, 40%) compared to controls (0%, 0%; p < 0.0001 and p = 0.0070, respectively). Three patients had matched primary vs. LRR samples, one patient had a gain of a NF1 mutation in the LRR. There was no significant difference between the groups for PTEN loss or cleaved caspase 3 expression. The mean percentage Ki 67 labeling index was higher in patients with LRR (29.2%) and DM (26%) vs. controls (14%, p = 0.0045). In summary, mutations in the MAPK pathway, specifically NF1, were associated with both LRR and DM, suggesting that alterations in MAPK signaling are associated with a more aggressive tumor phenotype. Validation of these associations in tissues from randomized trials may support targeted therapy to reduce breast cancer recurrence.
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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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25
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Grossmith S, Nguyen A, Hu J, Plichta JK, Nakhlis F, Cutone L, Dominici L, Golshan M, Duggan M, Carter K, Rhei E, Barbie T, Calvillo K, Nimbkar S, Bellon J, Wong J, Punglia R, Barry W, King TA. Multidisciplinary Management of the Axilla in Patients with cT1-T2 N0 Breast Cancer Undergoing Primary Mastectomy: Results from a Prospective Single-Institution Series. Ann Surg Oncol 2018; 25:3527-3534. [PMID: 29868979 DOI: 10.1245/s10434-018-6525-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The after mapping of the axilla: radiotherapy or surgery (AMAROS) trial concluded that for patients with cT1-2 N0 breast cancer and one or two positive sentinel lymph nodes (SLNs), axillary radiotherapy (AxRT) provides equivalent locoregional control and a lower incidence of lymphedema compared with axillary lymph node dissection (ALND). The study prospectively assessed how often ALND could be replaced by AxRT in a consecutive cohort of patients undergoing mastectomy for cT1-2 N0 breast cancer. METHODS In November 2015, our multidisciplinary group agreed to omit routine intraoperative SLN evaluation for cT1-2 N0 patients undergoing upfront mastectomy and potentially eligible for postmastectomy radiation therapy (PMRT), including those 60 years of age or younger and those older than 60 years with high-risk features. Patients with one or two positive SLNs on final pathology were reviewed to determine whether PMRT including the full axilla was an appropriate alternative to ALND. RESULTS From November 2015 to December 2016, 154 patients met the study criteria, and 114 (74%) formed the final study cohort. Intraoperative SLN evaluation was omitted for 76 patients (67%). Of these patients, 20 (26%) had one or two positive SLNs, and 14 of these patients received PMRT + AxRT as an alternative to ALND. Three patients returned for ALND, and three patients were observed. On univariate analysis, tumor size, LVI, number of positive lymph nodes, and receipt of chemotherapy were associated with receipt of PMRT. CONCLUSIONS For the majority of patients with one or two positive SLNs, ALND was avoided in favor of PMRT + AxRT. With appropriate multidisciplinary strategies, intraoperative evaluation of the SLN and immediate ALND can be avoided for patients meeting the AMAROS criteria and eligible for PMRT.
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Affiliation(s)
- Samantha Grossmith
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Anvy Nguyen
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jiani Hu
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Faina Nakhlis
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Linda Cutone
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Laura Dominici
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mehra Golshan
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Margaret Duggan
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Katharine Carter
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Esther Rhei
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Thanh Barbie
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Katherina Calvillo
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Suniti Nimbkar
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jennifer Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Julia Wong
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rinaa Punglia
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - William Barry
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tari A King
- Breast Surgical Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA. .,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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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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27
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Ohri N, Sittig MP, Tsai CJ, Hwang ESS, Mittendorf EA, Shi W, Zhang Z, Ho AY. Trends and variations in postmastectomy radiation therapy for breast cancer in patients with 1 to 3 positive lymph nodes: A National Cancer Data Base analysis. Cancer 2017; 124:482-490. [PMID: 29112227 DOI: 10.1002/cncr.31080] [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: 06/20/2017] [Revised: 09/14/2017] [Accepted: 09/21/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND High-level evidence is lacking to guide treatment decisions about postmastectomy radiation therapy (PMRT) in patients who have breast cancer with 1 to 3 positive lymph nodes who receive contemporary systemic therapies, leading to potential variations in PMRT delivery. The objective of this study was to examine nationwide trends in PMRT use in this group. METHODS The National Cancer Data Base (NCDB) was used to identify 93,372 women who had T1-T2N1 breast cancer diagnosed between 2003 and 2012. Patients who received neoadjuvant chemotherapy or radiation therapy (RT) and those who had bilateral breast cancers were excluded. Time trends were evaluated using the Cochrane-Armitage test and correlated the receipt of PMRT with various patient demographic, facility, clinicopathologic, and treatment variables using multivariable logistic regression. A second analysis was performed for patients who were diagnosed during 2010 and included radiation oncologist density as an additional covariate. P values < .0001 were considered statistically significant. RESULTS Overall, 22.5% of the study population received PMRT, representing an increase from 19.1% in 2003 to 30.3% in 2012. Factors associated with greater PMRT use included younger age, lower Charlson-Deyo comorbidity scores, shorter distance to the treating facility, treatment at a comprehensive cancer program, facility location in the New England Census division, and higher density of radiation oncologists. Increased PMRT use was associated with later year of diagnosis, receipt of chemotherapy, receipt of hormone therapy, higher grade disease, larger tumor size, greater numbers of positive lymph nodes, positive margins, and absence of immediate breast reconstruction (all P < .0001). CONCLUSIONS The receipt of PMRT by patients with breast cancer who have 1 to 3 positive lymph nodes has increased over time, with wide variability in practice patterns in the United States. Cancer 2018;124:482-90. © 2017 American Cancer Society.
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Affiliation(s)
- Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Mark P Sittig
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Elizabeth Ann Mittendorf
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Weiji Shi
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alice Y Ho
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
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28
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See MSF, Farhadi J. Radiation Therapy and Immediate Breast Reconstruction: Novel Approaches and Evidence Base for Radiation Effects on the Reconstructed Breast. Clin Plast Surg 2017; 45:13-24. [PMID: 29080655 DOI: 10.1016/j.cps.2017.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients who undergo breast reconstruction experience higher complication rates if they have had a history of radiotherapy. However, implant-based reconstruction confers significantly higher complication and reconstruction failure rates compared with autologous reconstruction. This article analyses the factors that contribute to the complications of the different breast reconstruction modalities and the strategies described to mitigate these problems.
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Affiliation(s)
- Marlene Sue-Fen See
- Department of Plastic Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK.
| | - Jian Farhadi
- Department of Plastic Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK; Reconstructive and Aesthetic Surgery, University of Basel, Petersplatz 1, 4001 Basel, Switzerland; Centre for Plastic Surgery, Klinik Pyramide am See, Bellerivestrasse 34, 8034 Zürich, Switzerland
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29
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Mamtani A, Patil S, Stempel M, Morrow M. Axillary Micrometastases and Isolated Tumor Cells Are Not an Indication for Post-mastectomy Radiotherapy in Stage 1 and 2 Breast Cancer. Ann Surg Oncol 2017; 24:2182-2188. [PMID: 28429197 PMCID: PMC5568787 DOI: 10.1245/s10434-017-5866-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND Randomized trials demonstrate equivalent locoregional control with sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for T1-2 micrometastatic breast cancer, but include few mastectomy patients. Consensus is lacking on indications for post-mastectomy radiotherapy (PMRT) in this population. Herein, we evaluate locoregional recurrence (LRR) in an unselected, modern cohort of T1-2 breast cancer patients with micrometastases or isolated tumor cells (ITCs; N0i+/N1mi) having a mastectomy. METHODS We identified patients with T1-2N0i+/N1mi breast cancer treated with mastectomy from January 2006 to December 2011. Recurrent, bilateral, and neoadjuvant cases were excluded. The primary outcome of interest was LRR. RESULTS Overall, 352 patients [211 (60%) with ITCs and 141 (40%) with micrometastases] were identified. 162 (46%) patients had SLNB alone and one node was positive in 295 (84%) cases; 31 (9%) patients had PMRT and 95% had systemic therapy. At a median 6 years of follow-up, the overall crude LRR rate was 2.8% (n = 9), with no axillary recurrences, and the crude LRR rate was 3.9% among those who had SNB alone. Those with LRR had a median age of 55 years, median tumor size of 1.7 cm, and ductal histology; the majority were high-grade (89%) and estrogen receptor positive (78%), with one positive node (89%). There was no association between LRR and receipt of PMRT (p = 0.4), SLNB versus ALND (p = 0.2), or number of positive nodes (p = 0.7) using the log-rank test. CONCLUSIONS LRR was infrequent among T1-2N0i+/N1mi patients treated with mastectomy without PMRT, with no axillary failures, suggesting that PMRT or nodal radiotherapy are not routinely indicated in this population.
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Affiliation(s)
- Anita Mamtani
- 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
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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30
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Rosso KJ, Tadros AB, Weiss A, Warneke CL, DeSnyder S, Kuerer H, Ueno NT, Stecklein SR, Woodward WA, Lucci A. Improved Locoregional Control in a Contemporary Cohort of Nonmetastatic Inflammatory Breast Cancer Patients Undergoing Surgery. Ann Surg Oncol 2017; 24:2981-2988. [PMID: 28766220 DOI: 10.1245/s10434-017-5952-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Inflammatory breast cancer (IBC) is an aggressive form of breast cancer characterized by rapid progression and early metastatic dissemination. The purpose of this study was to assess contemporary rates of local regional recurrence (LRR) in the era of trimodality therapy for nonmetastatic IBC and identify risk factors leading to local failure. METHODS A total of 114 patients with nonmetastatic IBC receiving trimodality therapy (neoadjuvant chemotherapy, surgery, and radiation therapy) were identified from a prospectively collected database from 2007 to 2015 and outcomes analyzed. RESULTS Median age at diagnosis was 52 years, and the median follow-up was 3.6 years. Sixty-three (55%) patients presented with N2 IBC, and 52 patients (45%) presented with N3 IBC. Local regional recurrence was observed during follow-up for four patients; 25 died, and 85 were censored at last follow-up. Surgical margins were negative in 99% of patients (n = 113). The 2-year probability of LRR was 3.19% (95% confidence interval 1.03-9.90%). Five-year overall survival for this cohort was 69.14%. Improvement in disease-free survival was seen among patients with HER2+ subtype, clinical stage IIIB, complete or partial radiologic response to neoadjuvant therapy, pathologic complete response, and lower nodal burden on presentation. CONCLUSIONS Locoregional recurrences were rare at a median of 3.6 years follow-up in a contemporary cohort of IBC patients treated with trimodality therapy. Although longer follow-up is needed, aggressive surgical resection to negative margins in the frame of trimodality therapy with curative intent can lead to LRR rates that mirror non-IBC rates.
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Affiliation(s)
- Kelly J Rosso
- Department of Breast Surgical Oncology, University of Texas, MD Anderson Cancer Center, 1400 Pressler Drive, Unit 1434, FCT 7.5046, Houston, TX, 77030, USA
| | - Audree B Tadros
- Department of Breast Surgical Oncology, University of Texas, MD Anderson Cancer Center, 1400 Pressler Drive, Unit 1434, FCT 7.5046, Houston, TX, 77030, USA
| | - Anna Weiss
- Department of Breast Surgical Oncology, University of Texas, MD Anderson Cancer Center, 1400 Pressler Drive, Unit 1434, FCT 7.5046, Houston, TX, 77030, USA
| | - Carla L Warneke
- Department of Biostatics, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah DeSnyder
- Department of Breast Surgical Oncology, University of Texas, MD Anderson Cancer Center, 1400 Pressler Drive, Unit 1434, FCT 7.5046, Houston, TX, 77030, USA
| | - Henry Kuerer
- Department of Breast Surgical Oncology, University of Texas, MD Anderson Cancer Center, 1400 Pressler Drive, Unit 1434, FCT 7.5046, Houston, TX, 77030, USA
| | - Naoto T Ueno
- Department of Breast Medical Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Shane R Stecklein
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy A Woodward
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Breast Surgical Oncology, University of Texas, MD Anderson Cancer Center, 1400 Pressler Drive, Unit 1434, FCT 7.5046, Houston, TX, 77030, USA. .,Department of Surgical Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
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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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Miyashita M, Tada H, Suzuki A, Watanabe G, Hirakawa H, Amari M, Kakugawa Y, Kawai M, Furuta A, Sato K, Yoshida R, Ebata A, Sasano H, Jingu K, Ohuchi N, Ishida T. Minimal impact of postmastectomy radiation therapy on locoregional recurrence for breast cancer patients with 1 to 3 positive lymph nodes in the modern treatment era. Surg Oncol 2017; 26:163-170. [DOI: 10.1016/j.suronc.2017.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 01/31/2017] [Accepted: 03/12/2017] [Indexed: 01/01/2023]
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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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The effect of post-mastectomy radiation in women with one to three positive nodes enrolled on the control arm of BCIRG-005 at ten year follow-up. Radiother Oncol 2017; 123:10-14. [DOI: 10.1016/j.radonc.2017.03.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/25/2017] [Accepted: 03/01/2017] [Indexed: 11/22/2022]
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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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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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37
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Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, Hudis CA, Hwang ES, Kirshner JJ, Morrow M, Salerno KE, Sledge GW, Solin LJ, Spears PA, Whelan TJ, Somerfield MR, Edge SB. Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. Ann Surg Oncol 2017; 24:38-51. [PMID: 27646018 PMCID: PMC5179596 DOI: 10.1245/s10434-016-5558-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Indexed: 12/24/2022]
Abstract
PURPOSE A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT). METHODS A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data. RECOMMENDATIONS The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.
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Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Richard E Fine
- West Clinic Comprehensive Breast Center, Germantown, TN, USA
| | | | | | - Alice Y Ho
- Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | | | - Timothy J Whelan
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Mark R Somerfield
- American Society of Clinical Oncology, 2318 Mill Road, Suite 800, Alexandria, VA, 22314, USA.
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Kuerer HM, Cordeiro PG, Mutter RW. Optimizing Breast Cancer Adjuvant Radiation and Integration of Breast and Reconstructive Surgery. Am Soc Clin Oncol Educ Book 2017; 37:93-105. [PMID: 28561684 DOI: 10.1200/edbk_175342] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Postmastectomy radiotherapy (PMRT) reduces the risk of locoregional and distant recurrence and improves overall survival in women with lymph node-positive breast cancer. Because of stage migration and improvements in systemic therapy and other aspects of breast cancer care, the absolute benefit of PMRT and regional nodal irradiation may be small in some favorable subsets of patients with very low nodal burden, and newer consensus guidelines do not mandate PMRT in all node-positive cases. The use and need for PMRT may considerably complicate breast reconstruction after mastectomy and therefore mandates multidisciplinary input that takes into account patient choice given potential risk of acute and long-term toxicities, benefits, life expectancy, the biology of the tumor, plans for systemic therapy, and actual tumor burden. Management of axillary lymph node metastases is changing with selective use of axillary lymph node dissection for advanced disease, sentinel lymph node biopsy alone for clinically and pathologic node-negative cases receiving mastectomy, and targeted axillary dissection alone among patients with eradication of initial biopsy-proven nodal metastases with neoadjuvant systemic therapy use. In general, when the need for PMRT is anticipated, autologous reconstruction should be delayed. This comprehensive article reviews the current indications and implications regarding integration of breast cancer surgery and timing of reconstruction with optimum radiation delivery to achieve the best possible patient outcomes.
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Affiliation(s)
- Henry M Kuerer
- From the Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Peter G Cordeiro
- From the Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Robert W Mutter
- From the Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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Lai SF, Chen YH, Kuo WH, Lien HC, Wang MY, Lu YS, Lo C, Kuo SH, Cheng AL, Huang CS. Locoregional Recurrence Risk for Postmastectomy Breast Cancer Patients With T1–2 and One to Three Positive Lymph Nodes Receiving Modern Systemic Treatment Without Radiotherapy. Ann Surg Oncol 2016; 23:3860-3869. [DOI: 10.1245/s10434-016-5435-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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40
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Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, Hudis CA, Hwang ES, Kirshner JJ, Morrow M, Salerno KE, Sledge GW, Solin LJ, Spears PA, Whelan TJ, Somerfield MR, Edge SB. Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. J Clin Oncol 2016; 34:4431-4442. [PMID: 27646947 DOI: 10.1200/jco.2016.69.1188] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT). Methods A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data. Recommendations The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.
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Affiliation(s)
- Abram Recht
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth A Comen
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Richard E Fine
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Gini F Fleming
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Patricia H Hardenbergh
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Alice Y Ho
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Clifford A Hudis
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - E Shelley Hwang
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey J Kirshner
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Monica Morrow
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Kilian E Salerno
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - George W Sledge
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence J Solin
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Patricia A Spears
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Timothy J Whelan
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Mark R Somerfield
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Stephen B Edge
- Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; Elizabeth A. Comen, Alice Y. Ho, Clifford A. Hudis, Monica Morrow, Memorial Sloan Kettering Cancer Center; New York; Jeffrey J. Kirshner, Hematology Oncology Associates of Central New York, East Syracuse; Kilian E. Salerno and Stephen B. Edge, Roswell Park Cancer Institute, Buffalo, NY; Richard E. Fine, West Clinic Comprehensive Breast Center, Germantown, TN; Gini F. Fleming, University of Chicago Medical Center, Chicago, IL; Patricia H. Hardenbergh, Shaw Regional Cancer Center, Edwards, CO; E. Shelley Hwang, Duke University Medical Center, Durham; Patricia A. Spears, North Carolina State University, Raleigh, NC; George W. Sledge Jr, Stanford University Medical Center, Palo Alto, CA; Lawrence J. Solin, Albert Einstein Healthcare Network, Philadelphia, PA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; and Timothy J. Whelan, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
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Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, Hudis CA, Hwang ES, Kirshner JJ, Morrow M, Salerno KE, Sledge GW, Solin LJ, Spears PA, Whelan TJ, Somerfield MR, Edge SB. Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. Pract Radiat Oncol 2016; 6:e219-e234. [PMID: 27659727 DOI: 10.1016/j.prro.2016.08.009] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/12/2016] [Accepted: 08/17/2016] [Indexed: 10/21/2022]
Abstract
A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT). METHODS A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data. RECOMMENDATIONS The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.
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Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | - Alice Y Ho
- Memorial Sloan Kettering Cancer Center, New York
| | | | | | | | | | | | | | | | | | - Timothy J Whelan
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
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Wen G, Zhang JS, Zhang YJ, Zhu YJ, Huang XB, Guan XX. Predictive Value of Molecular Subtyping for Locoregional Recurrence in Early-Stage Breast Cancer with N1 without Postmastectomy Radiotherapy. J Breast Cancer 2016; 19:176-84. [PMID: 27382394 PMCID: PMC4929259 DOI: 10.4048/jbc.2016.19.2.176] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 05/15/2016] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was designed to investigate the relationship between molecular subtype and locoregional recurrence (LRR) in patients with early-stage breast cancer with 1–3 positive axillary lymph nodes (ALNs) and improve the individualized indications for postmastectomy radiotherapy (PMRT). Methods The records of 701 patients with pT1-2N1M0 breast cancer who did not undergo PMRT were retrospectively analyzed. Tumors were subclassified as follows: luminal A, luminal B, human epidermal growth factor receptor 2 (HER2)-enriched, and basal-like subtypes. Multivariate Cox analysis was used to determine the risk of LRR associated with the different subtypes and to adjust for clinicopathologic factors. Results Luminal A, luminal B, HER2-enriched, and basal-like subtypes accounted for 51.2%, 28.0%, 8.1%, and 12.7% of cases, respectively. The median follow-up duration was 67 months (range, 9–156 months). Univariate analysis revealed that, compared with the luminal A subtype, the HER2-enriched and basal-like subtypes were associated with significantly higher 5-year LRR rates (5.6% vs. 21.6% and vs.15.7% respectively; p=0.002 each), lower 5-year LRR-free survival (LRFS) rates (90.6% vs. 73.8% and 78.5%, respectively; p=0.001 each), and poorer 5-year breast cancer-specific survival (BCSS) rates (93.7% vs. 82.2% [p=0.002] and 84.9% [p=0.001], respectively). Multivariate analysis revealed that the HER2-enriched and basal-like subtypes, age ≤35 years, a medial tumor, and pT2 stage were poor prognostic factors for LRR and LRFS; furthermore, 2 to 3 positive ALNs represented an independent prognostic factor affecting LRR. The 10-year LRR rates of patients with 0, 1, 2, 3, and 4 risk factors were 1.0%, 6.9%, 14.3%, 30.4%, and 54.3%, respectively (p<0.001); the 10-year BCSS rates were 86.6%, 88.5%, 84.4%, 79.7%, and 38.8%, respectively (p<0.001). Conclusion Molecular subtyping allows for individualized evaluation of LRR risk in patients with pT1-2N1M0 breast cancer. PMRT should be recommended for patients with ≥3 LRR risk factors.
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Affiliation(s)
- Ge Wen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangdong, China.; Department of Radiation Oncology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jin-Shan Zhang
- Department of Radiation Oncology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yu-Jing Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangdong, China
| | - Yu-Jia Zhu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangdong, China
| | - Xiao-Bo Huang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangdong, China
| | - Xun-Xing Guan
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangdong, China
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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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Shen H, Zhao L, Wang L, Liu X, Liu X, Liu J, Niu F, Lv S, Niu Y. Postmastectomy radiotherapy benefit in Chinese breast cancer patients with T1-T2 tumor and 1-3 positive axillary lymph nodes by molecular subtypes: an analysis of 1369 cases. Tumour Biol 2015; 37:6465-75. [PMID: 26631044 DOI: 10.1007/s13277-015-4546-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 11/27/2015] [Indexed: 12/26/2022] Open
Abstract
The aim of this study was to examine the association between molecular subtype (MST) and prognosis and research the postmastectomy radiotherapy (PMRT) effect in T1-T2 tumors with 1-3 positive axillary lymph nodes (ALNs). This retrospective study studied breast cancer patients with T1-T2 tumors and 1-3 positive ALNs according to MST: Luminal A, Luminal B, human epidermal growth factor receptor-2 (Her-2) positive, and Triple negative. The impact of adjuvant PMRT in T1-T2 tumors with 1-3 positive ALNs was also assessed. This study included 1369 patients: 33.0 % Luminal A, 42.9 % Luminal B, 11.9 % Her-2 positive, and 12.2 % Triple negative. On univariate and multivariate analyses, MST was associated with locoregional relapse (LRR). Kaplan-Meier analysis showed that PMRT significantly decreased LRR risk (p = 0.017) and distant metastasis (DM) risk (p < 0.0001). In subgroup analysis, PMRT showed significant benefits of improvement in LRR in patients with younger age, positive lymphovascular invasion (LVI), and ratio of positive lymph nodes (LNs) >25 %. Moreover, the nomogram could more accurately predict LRR (c-index 0.75) in T1-2N1 breast cancer patients. MST associated with patient outcomes in breast cancer patients with T1-T2 tumors and 1-3 positive ALN. It makes sense to offer PMRT for patients aged<40 years old, LVI, 2 and 3 positive lymph nodes, and ratio of positive LNs >25 %.
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Affiliation(s)
- Honghong Shen
- 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 Education, West Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin, 300060, China
| | - Lin Zhao
- 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 Education, West 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 Education, West Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin, 300060, China
| | - Xiaozhen 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 Education, West Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin, 300060, China
| | - Xia Liu
- Department of Oncology, General Hospital of Tianjin Medical University, 154 Anshan Road, Heping District, Tianjin, 300052, 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 Education, West Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin, 300060, China
| | - Fengting 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 Education, West Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin, 300060, China
| | - Shuhua Lv
- Department of Pathology, Nankai University Affiliated Hospital, 190, Jie-Yuan Road, Hong Qiao District, Tianjin, 300121, 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 Education, West Huanhu Road, Ti Yuan Bei, Hexi District, Tianjin, 300060, China.
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Garvey EM, Senior DA, Pockaj BA, Wasif N, Dueck AC, McCullough AE, Ocal IT, Gray RJ. Rates of residual disease with close but negative margins in breast cancer surgery. Breast 2015; 24:413-7. [DOI: 10.1016/j.breast.2015.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 01/11/2015] [Accepted: 03/15/2015] [Indexed: 01/03/2023] Open
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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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Drinka E, Allen P, McBride A, Buchholz T, Sahin A. Metastatic Tumor Volume and Extranodal Tumor Extension: Clinical Significance in Patients With Stage II Breast Cancer. Arch Pathol Lab Med 2015; 139:1288-94. [PMID: 25768237 DOI: 10.5858/arpa.2014-0375-oa] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Lymph node status and the number of lymph node (LN) positive for cancer cells are the most important prognostic factors in breast cancer. Extranodal tumor extension (ENTE) has been used as a histopathologic feature to classify patients into high risk versus low risk for local recurrence. However, in the current era of early detection and systemic therapy, the prognostic significance of ENTE is not as well defined in patients with 1 to 3 LNs positive for cancer. OBJECTIVE To determine whether the amount of tumor burden in an axillary dissection or the presence of ENTE provides any additional information regarding patient outcome in patents with 1 to 3 positive LN results. DESIGN Clinical and pathologic factors were identified for 456 patients with breast cancer at the University of Texas MD Anderson Cancer Center, Houston, who had pT1 tumors and 1 to 3 LNs positive for cancer and were treated by mastectomy, with or without postmastectomy radiotherapy, between 1978 and 2007. RESULTS Of the 456 patients, 257 (56.4%), 141 (31.6%), and 58 (12.7%) patients had 1, 2, or 3 positive LN results, respectively. Extranodal tumor extension was present in 99 patients (21.7%) and was absent in the remaining 357 cases (78.3%). Seventy-six patients (16.7%) received radiation therapy. Patients had both worse overall survival time and disease-free survival when ENTE was present, regardless of the amount, as long as the treatment era was not included in the multivariate analysis (pre-2000 versus post-2000). However, ENTE was no longer significant on multivariate analysis when the year of treatment was taken into account. CONCLUSIONS The number of positive LNs remains an important predictor of survival in patients with 1 to 3 positive LN results, but the prognostic significance of ENTE in this cohort of patients has diminished over time.
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Affiliation(s)
- Eva Drinka
- From the Departments of Pathology (Drs Drinka and Sahin), Radiation Oncology (Drs Allen and Buchholz), and the Office of Executive Vice President and Physician-in-Chief (Dr Buchholz), University of Texas MD Anderson Cancer Center, Houston; and the Department of Radiation Oncology, University of Arizona School of Medicine, Phoenix (Dr McBride)
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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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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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