Supraclavicular Nodal Failure in Patients with One to Three Positive Axillary Lymph Nodes Treated with Breast Conserving Surgery and Breast Irradiation, without Supraclavicular Node Radiation

Abstract

The purpose of this study was to evaluate the risk factors associated with supraclavicular nodal failure (SCF) in patients with one to three positive axillary nodes treated with breast conserving surgery and axillary dissection without supraclavicular node radiation (S/C RT) to aid in the selection of patients for S/C RT. Two hundred two breast conservation patients with one to three positive axillary nodes on axillary dissection treated with breast irradiation without S/C RT and 20 patients with S/C RT between August 1985 and May 2002 were identified and retrospectively evaluated. The Kaplan-Meier method was used to determine SCF-free and overall survival curves. Risk factors for SCF were examined. The median follow-up from surgery was 72 months (range: 4-195). Nine of 202 patients (4%) failed in the ipsilateral breast, 4 (2%) in the ipsilateral supraclavicular lymph nodes, 4 (2%) in the ipsilateral axillary and/or internal mammary nodes and 30 (15%) distantly. The 5- and 10-year SCF-free survival was 97.92%. The overall survival at 5, 10, and 15 years was 91.35%, 75.58%, and 67.18%, respectively. SCFs were associated with high grade or ER negative cancers, but not with number of positive nodes. Two of the four SCFs were associated with distant metastases, and two with local failures. One patient with a SCF was salvaged and is disease-free at 134 months. The overall low incidence of SCF in patients with one to three positive nodes treated with breast radiation alone after breast conserving surgery and adequate axillary dissection suggests that additional S/C RT is unnecessary in this cohort. When it occurs, supraclavicular nodal failure is often associated with distant metastases.

Postoperative periclavicular radiotherapy in breast cancer patients with 1–3 positive axillary lymph nodes

“…On the other hand, the selection of a special subgroup of patients with 1-3 pN+ in whom the effect of RT outbalances the possible late side effects is of great importance. After a follow-up of 8 years, the rate of periclavicular recurrences was low in both groups, which is in line with other published data [15,17,32,29,34]. We could not demonstrate any differences in outcome with or without PCLNI, despite the significant imbalance in relevant prognostic factors, i.e., number of positive lymph nodes, T-stage, and ECS in the PCLNI group, so that additional periclavicular RT may have counterbalanced these risk factors.…”

“…In patients with ≥ 4 involved axillary lymph nodes, PCLNI is part of the wellestablished guidelines, whereas for 1-3 pN+ there is still controversy about the adequate therapy as additional irradiation may lead to late toxicities, and the periclavicular failure rates between 0.5-3% are low [4,17,34,42]. Thus, several authors do not recommend prophylactic irradiation of the periclavicular fossa [17,29,30,34,48].…”

“…Thus, several authors do not recommend prophylactic irradiation of the periclavicular fossa [17,29,30,34,48]. But according to a recent phase III study with 1,832 patients and 85% with 1-3 pN+, there was a statistically significant decrease in the rate of locoregional failure (LRF) and an increase in DFS for patients with locoregional RT [46].…”

“…We could not demonstrate any differences in outcome with or without PCLNI, despite the significant imbalance in relevant prognostic factors, i.e., number of positive lymph nodes, T-stage, and ECS in the PCLNI group, so that additional periclavicular RT may have counterbalanced these risk factors. However, prophylactic irradiation of the periclavicular fossa should be considered in case of specific histopathological features, an inadequate dissected axilla, or a nodal ratio (ratio of number of dissected to involved nodes) > 25% [34,52]. Troung et al [7,40,41]examined 542 patients and found a nodal ratio (NR) > 25% to be an independent prognostic factor for OS, which may therefore represent a selection criteria for PCLNI.…”

Predictive Factors for Supraclavicular Lymph Node Recurrence in N1 Breast Cancer Patients

“…A few studies have reported a subgroup of N1 breast cancer patients who may be at particularly high risk of SCLR and might benefit from supraclavicular nodal RT (Chen et al, 2002;Grills et al, 2003;Reddy and Kiel, 2007;Truong et al, 2009;Yu et al, 2010). However, there is a lack of consensus between these studies.…”