Irradiation after Surgery for Breast Cancer Patients with Primary Tumours and One to Three Positive Axillary Lymph Nodes: Yes or No?

Abstract

Objective and Methods: We retrospectively analyzed clinicopathologic features and survival in breast cancer patients who had T1 or T2 primary tumours and 1–3 histologically involved axillary lymph nodes and who were treated with modified radical mastectomy without adjuvant radiotherapy (RT). We also explored prognosis to find the high- and low-risk groups. Results: From May 2001 to April 2005, 368 patients treated at Tianjin Tumor Hospital met the study criteria. The 5- and 8-year rates were 7.2% and 10.7% for locoregional recurrence (LRR), 85.1% and 77.7% for disease-free survival (DFS), and 92.8% and 89.3% for overall survival (OS). Multivariate Cox regression analysis showed that age, tumour size, estrogen receptor (ER) status, and lymphovascular invasion (LVI) were independent prognostic factors for LRR and DFS. Based on 4 patient-related factors that indicate poor prognosis (age < 40 years, tumour > 3 cm, ER negativity, and LVI), the high-risk group (patients with 3 or 4 factors, accounting for 12.5% of the cohort) had 5- and 8-year rates of 24.3% and 36.9% for LRR, 57.2% and 39.2% for DFS, and 74.8% and 43.8% for OS compared with 5.0% and 7.1% for LRR, 88.9% and 83.1% for DFS, 91.6% and 83.4% for OS in the low-risk group (patients with 0–2 factors, accounting for 87.5% of the cohort; p < 0.001). Conclusions: Our study identified several risk factors that correlated independently with a greater incidence of LRR and distant metastasis in patients with T1 and T2 breast cancer and 1–3 positive nodes. Patients with 0–2 risk factors may not be likely to benefit from post-mastectomy RT, but patients with 3–4 risk factors may need RT to optimize locoregional control and improve survival.

Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

“…Until more definitive evidence is available, using its best clinical opinion, the panel recommends that such a strategy or risk estimation include assessment of patient age as it affects the risk of LRF,7,10,21,22,38,39 estimated life expectancy in relation to age and comorbid conditions that might reduce life expectancy40–44 or increase the risk of complications,45–49 tumor size,6,7 axillary lymph node burden (number of positive nodes,9,16,19,22 nodal ratio,10,20,22,38 and size of nodal tumor deposits16,17,19), tumor grade,11,16,20,22,38,50 lymphovascular invasion,10,16,21,22,38,51 biomarker or receptor status,7,8,16,22,38,52–56 and planned systemic therapy (Data Supplement provides discussions of these and additional factors, such as margin status57,58 and extranodal extension16,19,20). Several groups have proposed prognostic models to estimate the risk of LRF after mastectomy by combining several of these factors 10,16,20,22,38. Although the panel cannot endorse any specific model, because the models have yet to be validated, physicians may find them useful in explaining the benefits of PMRT.…”

Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

“…Several groups have proposed prognostic models to estimate the risk of LRF after mastectomy by combining several of these factors. 10,16,20,22,38 Although the panel cannot endorse any specific model, because the models have yet to be validated, physicians may find them useful in explaining the benefits of PMRT. Further research is needed on these models and how to accurately estimate an individual's risk of LRF and hence the potential reduction in LRF and breast cancer mortality.…”

Risk Factors and a Predictive Nomogram for Non-Sentinel Lymph Node Metastases in Chinese Breast Cancer Patients with One or Two Sentinel Lymph Node Macrometastases and Mastectomy

“…In a meta-analysis, van Wely et al 32 also found that patients with abnormal alns on imaging had a higher risk of having multiple metastatic lymph nodes. Patients with multiple metastatic lymph nodes might need postmastectomy radiotherapy to lower the recurrence rate 33,34 .…”