Predicting Patients at Low Probability of Requiring Postmastectomy Radiation Therapy

Chagpar, Anees B.; Scoggins, Charles R.; Martin, Robert C.G.; Cook, E. Francis; McCurry, Terry; Mizuguchi, Nana; Paris, Kristie J.; Carlson, David J.; Laidley, Alison L.; El‐Eid, Souzan E.; McGlothin, Terre Q.; McMasters, Kelly M.

doi:10.1245/s10434-006-9107-8

Cited by 44 publications

(24 citation statements)

References 28 publications

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“…Also the number of examined nodes influences the detection rate of four or more positive nodes [16]. Nevertheless, the identified risk factors predicting four or more positive axillary nodes in the present study were rather similar as reported in the earlier studies [3,[13][14][15]. Preoperative axillary US and fine needle aspiration cytology have been addressed as a useful method of detecting lymph node metastases in order to avoid unnecessary SN biopsies.…”

Section: Discussion the Prevalence Of Four Or More Metastastic Axillasupporting

confidence: 85%

The prevalence of and risk factors for four or more metastatic axillary lymph nodes in breast cancer patients undergoing sentinel node biopsy

Leidenius

Vaalavirta

Heikkilä

et al. 2008

Journal of Surgical Oncology

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Section: Discussion the Prevalence Of Four Or More Metastastic Axillasupporting

confidence: 85%

The prevalence of and risk factors for four or more metastatic axillary lymph nodes in breast cancer patients undergoing sentinel node biopsy

Leidenius

Vaalavirta

Heikkilä

et al. 2008

Journal of Surgical Oncology

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“…6 Within limitations, the probability of having ≥4 axillary lymph nodes involved in patients with positive SLN biopsy can be predicted using known pathological features with nomograms. 7,8 However, to offer patients PMRT and/or SCFRT in strict accordance with the absolute indications, full axillary staging either on imaging and/or ALNC is an essential prerequisite. With the preoperative staging modalities used currently (eg axillary ultrasonography and FNA) showing a variable rate of diagnostic sensitivities, 9,10 ALNC for axillary staging continues to remain the gold standard.…”

Section: Discussionmentioning

confidence: 99%

Axillary lymph node clearance in patients with positive sentinel lymph node biopsy

Hussain

Kneeshaw

2014

annals

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INTRODUCTION The use of adjuvant radiotherapy is standard practice following breast conserving surgery and mastectomy in selected patients. Prospective clinical trials are currently being designed to assess the effect of omitting axillary lymph node clearance (ALNC) in selected patients. The aim of this study was to identify the percentage of patients understaged and not considered for postmastectomy radiotherapy (PMRT) and/or supraclavicular fossa radiotherapy (SCFRT) with positive sentinel lymph node (SLN) macrometastasis if the proposed prospective trial inclusion/exclusion protocols are followed. METHODS A total of 38 women who were found negative for axillary metastases preoperatively but positive at SLN biopsy and who had ALNC were analysed. PMRT or SCFRT was offered to patients if ≥4 positive lymph nodes (including sentinel nodes) were positive for macrometastasis and/or a tumour size of ≥5cm was detected. Fisher's exact test was used to determine the statistical significance of omitting ALNC. RESULTS The mean age of the 38 patients was 55 years. A fifth (21.1%) of patients had T1, 76.3% had T2 and 2.6% had T3 disease. The percentage of positive SLNs was 52.6% (1 node), 34.2% (2 nodes) and 13.1% (3 nodes). The number of positive nodes at clearance was 0-3. If the inclusion criteria for trials that consider omitting ALNC are followed (eg POSNOC trial), 23.7% of patients (p=0.0001) with ≥4 positive nodes (including SLNs) would not be offered SCFRT and PMRT. Similarly, if multicentric disease were to be excluded from the trial criteria, the proportion of undertreated patients would reduce by 15.7%. CONCLUSIONS Our study has shown a significant risk of missing patients for PMRT or SCFRT if no ALNC is offered in the presence of SLN macrometastasis. Tumour multicentricity is an important factor in predicting high axillary nodal involvement. Consequently, exclusion of T2 tumours with multicentric involvement in trials considering omitting ALNC may be more appropriate.

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“…32 Conversely, the ability to accurately stratify patients according to risk would help spare low-risk patients from the toxicity associated with additional radiation fields. It has been demonstrated that the addition of supraclavicular and axillary fields to standard tangents increases the 2% to 8% risk of lymphedema to approximately 9% to 24% in patients who undergo axillary dissection, 33,34 although the risk of arm edema may be considerably lower in patients who do not undergo cALND. 35 It also has been noted that such fields increase the incidence of pneumonitis and brachial plexopathy.…”

Section: (7)mentioning

confidence: 99%

Radiation field design and regional control in sentinel lymph node‐positive breast cancer patients with omission of axillary dissection

Setton

Cody

Tan

et al. 2011

Cancer

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BACKGROUND: Randomized data suggest that axillary clearance is not necessary in select, clinically lymph nodenegative women with positive sentinel lymph node (SLN) biopsies (SLNBs) who undergo breast-conserving surgery or receive whole-breast radiotherapy and systemic therapy. The additional value of axillary radiotherapy in these patients is unknown. METHODS: The authors identified 326 patients with positive SLNBs who underwent breast-conserving surgery without axillary lymph node dissection from 1997 to 2009. SLN tumor deposits measured 0.2 mm in 58% of patients, 0.3 to 2.0 mm in 35% of patients, and >2 mm in 7% Patients. Ninety-three percent of patients received adjuvant radiotherapy. Radiation fields were categorized as standard tangents, high tangents, comprehensive (tangents plus supraclavicular), or partial breast to reflect coverage of the axilla. Standard tangents included both prone and supine positions. Regional failure was defined as recurrence in the ipsilateral supraclavicular, axillary, or internal mammary lymph nodes. RESULTS: The median follow-up was 55 months (range, 1-158 months). The 4-year rates of regional control, local control, disease-free survival, and overall survival were 99%, 98%, 95%, and 91%, respectively. Three patients had regional recurrences. Two of those patients received adjuvant radiotherapy with standard supine tangents, and 1 patient did not receive radiotherapy. No regional recurrences occurred among 66 patients who received radiotherapy in the prone position. CONCLUSIONS: Regional control was high (99% at 4 years) in patients who had low-volume SLN disease who did not undergo axillary dissection, regardless of whether the axilla was irradiated. Whole-breast radiation alone, including in the prone position, is sufficient treatment after breast-conserving surgery for select patients with tumor-containing SLNs who omit axillary dissection.

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Predicting Patients at Low Probability of Requiring Postmastectomy Radiation Therapy

Abstract: Tumor size, number of positive SLN, and the proportion of positive SLN influence whether patients will have four or more LN+. A simple model can predict the probability of requiring PMRT.

Cited by 44 publications

References 28 publications

The prevalence of and risk factors for four or more metastatic axillary lymph nodes in breast cancer patients undergoing sentinel node biopsy

The prevalence of and risk factors for four or more metastatic axillary lymph nodes in breast cancer patients undergoing sentinel node biopsy

Axillary lymph node clearance in patients with positive sentinel lymph node biopsy

Radiation field design and regional control in sentinel lymph node‐positive breast cancer patients with omission of axillary dissection

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