Effect of Elective Internal Mammary Node Irradiation on Disease-Free Survival in Women With Node-Positive Breast Cancer

Kim, Yong Bae; Byun, Hwa Kyung; Kim, Dae Yong; Ahn, Sung‐Ja; Lee, Hyung-Sik; Park, Won; Kim, Su Ssan; Kim, Jin Hee; Lee, Kyu Chan; Lee, Ik Jae; Kim, Won Taek; Shin, Hyun Soo; Kim, Kyubo; Shin, Kyung Hwan; Nam, Chung Mo; Suh, Chang‐Ok

doi:10.1001/jamaoncol.2021.6036

Cited by 46 publications

(73 citation statements)

References 32 publications

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“…In KROG 08-06, a significant benefit from IMNI was found in patients with medial/central tumors for disease-free survival and breast cancer mortality. 23 This pattern was in agreement with our findings. Results from both NCIC-CTG MA.20 and KROG 08-06 suggested a more pronounced effect of nodal irradiation in patients with hormone receptor-negative disease.…”

Section: No Imnisupporting

confidence: 93%

Internal Mammary Node Irradiation in Patients With Node-Positive Early Breast Cancer: Fifteen-Year Results From the Danish Breast Cancer Group Internal Mammary Node Study

Thorsen

Overgaard

Matthiessen

et al. 2022

JCO

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PURPOSE The Danish Breast Cancer Group Internal Mammary Node study demonstrated improved 8-year overall survival (OS) with internal mammary node irradiation (IMNI) in patients with node-positive early breast cancer. Here, we present long-term results from the Danish Breast Cancer Group Internal Mammary Node study cohort. PATIENTS AND METHODS This nationwide, prospective cohort study allocated patients with node-positive early breast cancer to adjuvant radiotherapy with or without IMNI depending on cancer laterality. Patients with right-sided cancer received IMNI. Patients with left-sided cancer were treated without IMNI because of risk of radiation-induced heart disease. Other treatment was independent of laterality. The primary study end point was OS. Secondary end points were distant recurrence and breast cancer mortality. Analyses were by intention to treat. RESULTS During 2003-2007, 3,089 women were allocated to IMNI (right-sided, n = 1,491) or no IMNI (left-sided, n = 1,598). With a median follow-up of 14.8 years, 589 patients with and 701 patients without IMNI had died. The corresponding 15-year OS rates were 60.1% and 55.4%. The adjusted hazard ratio (HR) for death was 0.86 (95% CI, 0.77 to 0.96; P = .007) in favor of IMNI. The 15-year risk of developing distant recurrence was 35.6% (523 recurrences) and 38.6% (602 recurrences) with vs. without IMNI (adjusted HR 0.88 [95% CI, 0.79 to 0.99; P = .04]). The 15-year breast cancer mortality with IMNI was 31.7% (467 deaths) compared with 33.9% (537 deaths) without IMNI (adjusted HR 0.88 [95% CI, 0.78 to 1.00; P = .05]). The distribution of other deaths was similar across groups. CONCLUSION In patients with node-positive early breast cancer treated with IMNI or without IMNI depending on breast cancer laterality, IMNI reduced the risk of distant recurrence and death from breast cancer, thereby improving long-term survival.

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Section: No Imnisupporting

confidence: 93%

Internal Mammary Node Irradiation in Patients With Node-Positive Early Breast Cancer: Fifteen-Year Results From the Danish Breast Cancer Group Internal Mammary Node Study

Thorsen

Overgaard

Matthiessen

et al. 2022

JCO

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“…An additional study was identified by Google [ 13 ]. After the removal of duplicates and studies not meeting the inclusion criteria, seven publications reporting on five independent studies were included (see Figure 1 for the study selection schema) [ 10 , 11 , 12 , 13 , 14 , 15 , 24 ]. An additional study reported on updated toxicity, but these data were not relevant to the analysis [ 25 ].…”

Section: Resultsmentioning

confidence: 99%

“…Individual study characteristics and details on the radiation treatment in each arm are shown in Table 1 . In three studies, the control group was treated with radiation to the regional lymph nodes other than the IMN [ 13 , 14 , 24 ] and in two studies, the control group was treated with radiation to the breast or chest wall only [ 10 , 11 ]. About half of the included women had left sided tumor.…”

Section: Resultsmentioning

confidence: 99%

Efficacy and Safety of the Addition of Internal Mammary Irradiation to Standard Adjuvant Radiation in Early-Stage Breast Cancer: A Systematic Review and Meta-Analysis

et al. 2022

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Background: Existing data on adding internal mammary nodal irradiation (IMNI) to the regional nodal fields are inconsistent. Methods: Randomized trials investigating the addition of IMNI to standard adjuvant radiation were identified. Hazard ratios (HRs) and 95% confidence intervals (CI) were extracted for overall-survival (OS), breast cancer specific-survival (BCSS), and disease-free survival (DFS) as well as distant-metastasis free survival (DMFS). The odds ratios (ORs) for regional and loco-regional recurrence, non-breast cancer mortality, secondary non-breast cancer, contralateral breast cancer, and cardiovascular morbidity and mortality were also extracted. Results: Analysis included five trials comprising 10,994 patients, predominantly with higher risk, lymph node positive disease. Compared to the control group, IMNI was associated with significant improvement in OS (HR = 0.91, p = 0.004), BCSS (HR = 0.84, p < 0.001), DFS (HR = 0.89, p= 0.01), and DMFS (HR = 0.89, p = 0.02). IMNI was also associated with reduced odds for regional (OR = 0.58, p < 0.001) and loco-regional recurrence (OR = 0.85, p = 0.04). The odds for cardiotoxicity were not statistically significantly higher (OR = 1.23, p = 0.07). There were comparable odds for cardiovascular mortality (OR = 1.00, p = 1.00), non-breast cancer mortality (OR = 1.05, p = 0.74), secondary cancer (OR = 0.95, p = 0.51), and contra-lateral breast cancer (OR = 1.07, 95% 0.77–1.51, p = 0.68). Conclusions: Compared to the control group, the addition of IMNI in high-risk patients is associated with a statistically significant improvement in survival, albeit with a magnitude of questionable clinical meaningfulness.

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“…Study participants were stratified by N stage and surgery type. 8 Although the study found no significant effect on outcomes, regardless of whether the internal mammary nodes were radiated, an unplanned subset analysis showed inclusion of the internal mammary nodal chain resulted in a 10% improvement in disease-free survival in patients with centrally or medially located tumors (hazard ratio, 0.42; P5.03). # 2022 National Comprehensive Cancer Network, Inc. All rights reserved.…”

Section: Debates Over Rnimentioning

confidence: 85%

Locoregional Management of Early-Stage Breast Cancer

Moran¹,

Leitch²

2022

Journal of the National Comprehensive Cancer Network

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The latest version of NCCN Guidelines for Breast Cancer on locoregional management of early-stage breast cancer contains numerous updated recommendations, particularly focusing on management of the axilla, locoregional management after neoadjuvant therapy, and radiation delivery. Recommendations for axillary staging have been separated for patients who have undergone breast-conserving surgery and those who have had a mastectomy, creating 2 individual pathways. The section on locoregional treatment after neoadjuvant therapy has been reformatted; optimal management of this patient group continues to evolve. Lastly, specifics regarding the delivery and sequencing of radiotherapy have been updated.

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Effect of Elective Internal Mammary Node Irradiation on Disease-Free Survival in Women With Node-Positive Breast Cancer

Cited by 46 publications

References 32 publications

Internal Mammary Node Irradiation in Patients With Node-Positive Early Breast Cancer: Fifteen-Year Results From the Danish Breast Cancer Group Internal Mammary Node Study

Internal Mammary Node Irradiation in Patients With Node-Positive Early Breast Cancer: Fifteen-Year Results From the Danish Breast Cancer Group Internal Mammary Node Study

Efficacy and Safety of the Addition of Internal Mammary Irradiation to Standard Adjuvant Radiation in Early-Stage Breast Cancer: A Systematic Review and Meta-Analysis

Locoregional Management of Early-Stage Breast Cancer

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