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01-10-2013 | Breast Oncology

Selection Criteria for Postmastectomy Radiotherapy in T1–T2 Tumors with 1 to 3 Positive Lymph Nodes

Authors: Tracy Ann Moo, MD, Robert McMillan, MD, Michele Lee, BA, Michelle Stempel, MPH, Sujata Patil, PhD, Alice Ho, MD, Mahmoud El-Tamer, MD

Published in: Annals of Surgical Oncology | Issue 10/2013

Abstract

Background

Postmastectomy radiotherapy (PMRT) is well established in patients with ≥4 positive axillary lymph nodes (ALN); indications in 1 to 3 positive ALN remains controversial. We examined clinicopathologic criteria used for PMRT selection and compared locoregional recurrence (LRR), recurrence-free survival (RFS), and overall survival (OS) among patients with and without PMRT.

Methods

Between 1995 and 2006, a total of 1,331 patients with T1–T2 tumors and 1 to 3 positive ALN underwent mastectomy. We excluded T3/T4 tumors and neoadjuvant chemotherapy; we analyzed 1,087 patients (924 without PMRT, 163 with PMRT). Chi square testing compared clinicopathologic features between groups. The Kaplan–Meier method and Cox regression analysis examined the association between PMRT and LRR, RFS, and OS.

Results

PMRT patients were more likely to be ≤50 years old (p = 0.001) and to have larger tumors (p = 0.01), disease of a higher histologic grade (p = 0.03), lymphovascular invasion (LVI) (p < 0.0001), a greater number of positive ALN (p < 0.0001), extranodal invasion (p < 0.0001), and macroscopic ALN metastases (p < 0.0001). With a median follow-up of 7 years, PMRT and no-PMRT groups were similar in LRR (p = 0.57), RFS (p = 0.70), and OS (p = 0.28). On multivariate analysis of the no-PMRT group, age ≤50 years (p = 0.002) and presence of LVI (p < 0.0001) were associated with LRR. Stratified by age and LVI, patients ≤50 years old and with LVI had the highest 5-year LRR, 10.1 versus 1.1 %, than in patients >50 years old without LVI (p < 0.001).

Conclusions

By using clinicopathologic features, clinicians delivered PMRT to a select group of patients with T1–T2 tumors and 1 to 3 positive ALN, resulting in similarly low rates of 5-year LRR. Among patients not receiving PMRT, age ≤50 years and LVI were associated with increased LRR rates and warrant PMRT consideration.

Recht A, Edge SB, Solin LJ, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001;19:1539–69.PubMed

Taylor ME, Haffty BG, Rabinovitch R, et al. ACR appropriateness criteria on postmastectomy radiotherapy. Expert panel on radiation oncology-breast. Int J Radiat Oncol Biol Phys. 2009;73:997–1002.PubMedCrossRef

Truong PT, Olivotto IA, Whelan TJ, et al. Clinical practice guidelines for the care and treatment of breast cancer: 16. Locoregional post-mastectomy radiotherapy. CMAJ. 2004;170:1263–73.PubMed

Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;366(9503):2087–106.PubMed

Overgaard M, Nielsen HM, Overgaard J. Is the benefit of postmastectomy irradiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DBCG 82 b&c randomized trials. Radiother Oncol. 2007;82:247–53.PubMedCrossRef

Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med. 1997;337:949–55.PubMedCrossRef

Overgaard M, Jensen MB, Overgaard J, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet. 1999;353(9165):1641–8.PubMedCrossRef

Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med. 1997;337:956–62.PubMedCrossRef

Killander F, Anderson H, Ryden S, et al. Efficient reduction of loco-regional recurrences but no effect on mortality twenty years after postmastectomy radiation in premenopausal women with stage II breast cancer—a randomized trial from the South Sweden Breast Cancer Group. Breast. 2009;18:309–15.PubMedCrossRef

10.

Fodor J, Polgar C, Major T, et al. Locoregional failure 15 years after mastectomy in women with one to three positive axillary nodes with or without irradiation the significance of tumor size. Strahlenther Onkol. 2003;179:197–202.PubMedCrossRef

11.

Dragun AE, Huang B, Gupta S, et al. One decade later: trends and disparities in the application of post-mastectomy radiotherapy since the release of the American Society of Clinical Oncology clinical practice guidelines. Int J Radiat Oncol Biol Phys. 2012;83:e591–6.PubMedCrossRef

12.

Sharma R, Bedrosian I, Lucci A, et al. Present-day locoregional control in patients with t1 or t2 breast cancer with 0 and 1 to 3 positive lymph nodes after mastectomy without radiotherapy. Ann Surg Oncol. 2010;17:2899–908.PubMedCrossRef

13.

Cuzick J, Stewart H, Peto R, et al. Overview of randomized trials of postoperative adjuvant radiotherapy in breast cancer. Cancer Treat Rep. 1987;71:15–29.PubMed

14.

Gyenes G, Rutqvist LE, Liedberg A, et al. Long-term cardiac morbidity and mortality in a randomized trial of pre- and postoperative radiation therapy versus surgery alone in primary breast cancer. Radiother Oncol. 1998;48:185–90.PubMedCrossRef

15.

Paszat LF, Mackillop WJ, Groome PA, et al. Mortality from myocardial infarction after adjuvant radiotherapy for breast cancer in the surveillance, epidemiology, and end-results cancer registries. J Clin Oncol. 1998;16:2625–31.PubMed

16.

Sautter-Bihl ML, Souchon R, Budach W, et al. DEGRO practical guidelines for radiotherapy of breast cancer II. Postmastectomy radiotherapy, irradiation of regional lymphatics, and treatment of locally advanced disease. Strahlenther Onkol. 2008;184:347–53.PubMedCrossRef

17.

Eifel P, Axelson JA, Costa J, et al. National Institutes of Health consensus development conference statement: adjuvant therapy for breast cancer, November 1–3, 2000. J Natl Cancer Inst. 2001;93:979–89.PubMedCrossRef

18.

Shirvani SM, Pan IW, Buchholz TA, et al. Impact of evidence-based clinical guidelines on the adoption of postmastectomy radiation in older women. Cancer. 2011;117:4595–605.

19.

Nagar H, Mittendorf EA, Strom EA, et al. Local-regional recurrence with and without radiation therapy after neoadjuvant chemotherapy and mastectomy for clinically staged T3N0 breast cancer. Int J Radiat Oncol Biol Phys. 2011;81:782–7.PubMedCrossRef

20.

Cosar R, Uzal C, Tokatli F, et al. Postmastectomy irradiation in breast in breast cancer patients with T1–2 and 1–3 positive axillary lymph nodes: is there a role for radiation therapy? Radiat Oncol. 2011;6:28.PubMedCrossRef

21.

Cheng JC, Chen CM, Liu MC, et al. Locoregional failure of postmastectomy patients with 1–3 positive axillary lymph nodes without adjuvant radiotherapy. Int J Radiat Oncol Biol Phys. 2002;52:980–8.PubMedCrossRef

22.

Recht A, Gray R, Davidson NE, et al. Locoregional failure 10 years after mastectomy and adjuvant chemotherapy with or without tamoxifen without irradiation: experience of the Eastern Cooperative Oncology Group. J Clin Oncol. 1999;17:1689–700.PubMed

23.

Taghian A, Jeong JH, Mamounas E, et al. Patterns of locoregional failure in patients with operable breast cancer treated by mastectomy and adjuvant chemotherapy with or without tamoxifen and without radiotherapy: results from five National Surgical Adjuvant Breast and Bowel Project randomized clinical trials. J Clin Oncol. 2004;22:4247–54.PubMedCrossRef

24.

Mamounas EP, Tang G, Paik S, et al. The 21-gene recurrence score predicts risk of locoregional recurrence in node (+), ER (+) breast cancer after adjuvant chemotherapy and tamoxifen: results from NSABP B-28. Paper presented at: 66th SSO Annual Cancer Symposium, Washington, DC, 2013.

25.

Truong PT, Olivotto IA, Kader HA, et al. Selecting breast cancer patients with T1–T2 tumors and one to three positive axillary nodes at high postmastectomy locoregional recurrence risk for adjuvant radiotherapy. Int J Radiat Oncol Biol Phys. 2005;61:1337–47.PubMedCrossRef

26.

Jagsi R, Pierce L. Postmastectomy radiation therapy for patients with locally advanced breast cancer. Semin Radiat Oncol. 2009;19:236–43.PubMedCrossRef

27.

Truong PT, Lee J, Kader HA, et al. Locoregional recurrence risks in elderly breast cancer patients treated with mastectomy without adjuvant radiotherapy. Eur J Cancer. 2005;41:1267–77.PubMedCrossRef

Title: Selection Criteria for Postmastectomy Radiotherapy in T1–T2 Tumors with 1 to 3 Positive Lymph Nodes
Authors: Tracy Ann Moo, MD
Robert McMillan, MD
Michele Lee, BA
Michelle Stempel, MPH
Sujata Patil, PhD
Alice Ho, MD
Mahmoud El-Tamer, MD
Publication date: 01-10-2013
Publisher: Springer US
Published in: Annals of Surgical Oncology / Issue 10/2013
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-013-3117-0

At a glance: The STEP trials

Springer Medicine

Selection Criteria for Postmastectomy Radiotherapy in T1–T2 Tumors with 1 to 3 Positive Lymph Nodes

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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