Evaluation of irradiation of the peripheral lymphatics in conjunction with radical mastectomy for cancer of the breast

Abstract

From 1948 through 1964, 978 patients with cancer of the breast were treated by radical mastectomy alone or in conjunction with pre‐ or postoperative irradiation of the peripheral lymphatics. Since 1954 with increasing availability of skin‐sparing beams (60Co, 137Cs and electron beam), the dose to the supraclavicular and internal mammary chain nodes has been increased. This paper reviews over‐all survival rates, survival rates related to the location of the tumor within the breast and the incidence of recurrences in the regional lymphatics and the chest wall. The analysis shows a very low incidence of supraclavicular disease and a negligible incidence of parasternal recurrences. Since 1955 chest wall recurrences have also been few. It seems that one can draw the conclusion that irradiation of the peripheral lymphatics in conjunction with radical mastectomy is worthwhile except for small tumors located in the outer quadrants with the axillary nodes negative in the surgical specimen.

Tangential breast irradiation—rationale and methods for improving dosimetry

“…There is little prospectively gathered clinical data for the breast regarding the dose-response effect. Retrospective studies are consistent with a 10% reduction in radiation dose from 50 Gy to 45 Gy leading to a reduction in tumour control probability from 95% to 85% [2][3][4].…”

Radiation therapy for operable breast cancer

“…With the observations that 90% of locoregional recurrences involved the chest wall, and that radiation could reduce local recurrences, it was recommended that radiation when given should include the chest wall as well as regional lymphatics. 8,9 In these early years, radiation therapy for breast cancer was orthovoltage, or low-kilovoltage beams that had limited penetration and high absorbed dose in bone relative to soft tissue. The dose to the skin and resulting desquamation was the limiting factor for the dose that could be delivered to the tumor.…”

“…''-Gilbert H. Fletcher, MD, Radiation Oncologist, et al, in Cancer, 1968. 9 A promising avenue for improving outcomes in breast cancer in the 1950s was aimed at improving locoregional control by means of more radical surgery. More radical local operations of the chest wall alone, such as extended dermal dissection, had not eliminated local recurrences or improved survival.…”

Management of the Axilla After the Finding of a Positive Sentinel Lymph Node: A Proposal for an Evidence-Based Risk-Adapted Algorithm

“…51 The dose-response relationship for the eradication of subclinical disease has been demonstrated to be 60% to 70% with conventionally fractionated doses of 30 to 40 Gy, 85% at 45 Gy, and 95% with doses between 45 and 50 Gy. 49,52,53 As the tumor burden in the axillary lymph nodes increases beyond 10 8 clonogens, there is a sharp increase in the radiation dose beyond 50 Gy that is required to maintain 95% probability of tumor control. 51,54,55 As such, there is a concomitant dramatic increase in the risk of severe radiation related late complications.…”