Advertisement

Outcome After Conservative Surgery and Breast Irradiation in 5,717 Patients With Breast Cancer: Implications for Supraclavicular Nodal Irradiation

      Purpose

      To evaluate the outcome and predictive factors of patients who underwent breast-conserving surgery and adjuvant radiotherapy to the whole breast only, without supraclavicular nodal irradiation.

      Methods and Materials

      A total of 5,717 patients with pT1–T4 breast cancer were treated at the University of Florence. The median age of the patient population was 55 years (range, 30–80 years). All patients were followed for a median of 6.8 years (range, 1–27 years). Adjuvant chemotherapy was recommended in 1,535 patients (26.9%). Tamoxifen was prescribed in 2,951 patients (51.6%). The patients were split into three groups according to number of positive axillary nodes (PAN): P1, negative axillary lymph nodes; P2, one to three PAN; P3, more than three PAN.

      Results

      The P3 patients had a higher incidence of supraclavicular fossa recurrence (SFR) compared with P2 and P1 patients. However, the incidence of SFR in P3 patients was low (only 5.5%), whereas the incidence of distant metastases (DM) was 27.2%. Distant metastasis was the only independent prognostic factor for breast cancer survival. Additionally, in the subgroup of patients who developed local recurrence, DM was the most important death predictor.

      Conclusion

      Our series suggests that isolated SFR in patients who did not receive supraclavicular radiotherapy is infrequent, as well as in those patients who have more than three PAN, and SFR seems not to influence the outcome, which depends on DM occurrence.
      To read this article in full you will need to make a payment
      ASTRO Member Login
      ASTRO Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features.
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Galimberti V.
        International Breast Cancer Study Group Trial of sentinel node biopsy.
        J Clin Oncol. 2006; 24: 210-211
        • Gentilini O.
        • Botteri E.
        • Rotmensz N.
        • et al.
        Conservative surgery in patients with multifocal/multicentric breast cancer.
        Breast Cancer Res Treat. 2009; 113: 577-583
        • Intra M.
        • Rotmensz N.
        • Mattar D.
        • et al.
        Unnecessary axillary node dissections in the sentinel lymph node era.
        Eur J Cancer. 2007; 43: 2664-2668
        • Belkacémi Y.
        • Chauvet M.P.
        • Giard S.
        • et al.
        Partial breast irradiation as sole therapy for low risk breast carcinoma: Early toxicity, cosmesis and quality of life results of a MammoSite brachytherapy phase II study.
        Radiother Oncol. 2009; 90: 23-29
        • Ivaldi G.B.
        • Leonardi M.C.
        • Orecchia R.
        • et al.
        Preliminary results of electron intraoperative therapy boost and hypofractionated external beam radiotherapy after breast-conserving surgery in premenopausal women.
        Int J Radiat Oncol Biol Phys. 2008; 72: 485-493
        • Livi L.
        • Paiar F.
        • Buonamici F.B.
        • et al.
        Accelerated intensity-modulated external radiotherapy as a new technical approach to treat the index quadrant after conserving surgery in early breast cancer: A preliminary study.
        Tumori. 2005; 91: 227-232
        • Ragaz J.
        • Jackson S.M.
        • Le N.
        • et al.
        Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer.
        N Engl J Med. 1997; 337: 956-962
        • Overgaard M.
        • Hansen P.S.
        • 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: 949-955
        • Overgaard M.
        • Jensen M.B.
        • 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: 1641-1648
        • Pierce L.J.
        • Glatstein E.
        Postmastectomy radiotherapy in the management of operable breast cancer.
        Cancer. 1994; 74: 477-485
        • Early Breast Cancer Trialists' Collaborative Group
        Effects of radiotherapy and surgery in early breast cancer: An overview of the randomized trials.
        N Engl J Med. 1995; 333: 1444-1455
        • Early Breast Cancer Trialists' Collaborative Group
        Favourable and unfavourable effects on long-term survival of radiotherapy for early breast cancer: An overview of the randomised trials.
        Lancet. 2000; 355: 1757-1770
        • Eifel P.
        • Axelson J.A.
        • Costa J.
        • et al.
        National Institutes of Health Consensus Development Statement: Adjuvant therapy for breast cancer, November 1-3, 2000.
        J Natl Cancer Inst. 2001; 93: 978-979
        • Whelan T.J.
        • Julian J.
        • Wright J.
        • et al.
        Does locoregional radiotherapy improve survival in breast cancer? A meta-analysis.
        J Clin Oncol. 2000; 18: 1220-1229
        • Kingsmore D.B.
        • Hole D.J.
        • Gillis C.R.
        • et al.
        Axillary recurrence in breast cancer.
        Eur J Oncol. 2005; 31: 226-231
        • Axelsson C.K.
        • Mouridsen H.T.
        • Zedeler K.
        Axillary dissection for level I and II lymph nodes is important in breast cancer classification. The Danish Breast Cancer Cooperative Group (DBCG).
        Eur J Cancer. 1992; 28: 1415-1418
        • Strom E.A.
        • Woodward W.A.
        • Katz A.
        • et al.
        Clinical investigation: regional nodal failure patterns in breast cancer patients treated with mastectomy without radiotherapy.
        Int J Radiat Oncol Biol Phys. 2005; 63: 1508-1513
        • International Commission of Radiation Units and Measurements
        Dose specification for reporting external beam therapy with photons and electrons.
        Report 50. ICRU, Bethesda, MD1992
        • Hellman S.
        Stopping metastases at their source.
        N Engl J Med. 1997; 337: 996-997
        • Koscielny S.
        • Tubiana M.
        The link between local recurrence and distant metastases in human breast cancer.
        Int J Radiat Oncol Biol Phys. 1999; 43: 11-24
        • Arriagada R.
        • Lê M.G.
        Adjuvant radiotherapy in breast cancer. The treatment of lymph node areas.
        Acta Oncol. 2000; 39: 295-305
        • Mamounas E.P.
        NSABP breast cancer clinical trials: Recent results and future directions.
        Clin Med Res. 2003; 1: 309-326
        • Wang C.W.
        • Kuo W.H.
        • Chang K.J.
        • et al.
        Should adjuvant radiotherapy to the supraclavicular fossa be routinely give in patients with breast conservative treatment?.
        J Surg Oncol. 2007; 96: 144-150
        • Galimberti V.
        • Leonardi M.C.
        • Rotmensz N.
        • et al.
        Can axillary and supraclavicular radiotherapy be avoided after breast-conserving surgery and axillary dissection in women with multiple involved axillary nodes? Experience at the European Institute of Oncology.
        Tumori. 2008; 94: 52-58
        • Early Breast Cancer Trialists' Collaborative Group
        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: 2087-2106
        • Pergolizzi S.
        • Adamo V.
        • Russi E.
        • et al.
        Prospective multicenter study of combined treatment with chemotherapy and radiotherapy in breast cancer women with the rare clinical scenario of ipsilateral supraclavicular node recurrence without distant metastases.
        Int J Radiat Oncol Biol Phys. 2006; 65: 25-32
        • Truong P.T.
        • Jones S.O.
        • Kader H.A.
        • et al.
        Patients with T1 to T2 breast cancer with one to three positive nodes have higher local and regional recurrence risk compared with node-negative patients after breast conserving surgery and whole breast radiotherapy.
        Int J Radiat Oncol Biol Phys. 2009; 73: 357-364
        • Stranzl H.
        • Ofner P.
        • Peintinger F.
        Postoperative irradiation in breast cancer patients with one to three positive axillary lymph nodes. Is there an impact of axillary extranodal tumour extension on locoregional and distant control?.
        Strahlenther Onkol. 2006; 182: 583-588
        • Truong P.T.
        • Olivotto I.A.
        • Whelan T.J.
        • et al.
        Clinical practice guidelines for the care and treatment of breast cancer: 16. Loco-regional postmastectomy radiotherapy.
        CMAJ. 2004; 170: 1263-1273
        • Ragaz J.
        • Olivotto I.A.
        • Spinelli J.J.
        • et al.
        Loco-regional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial.
        J Natl Cancer Inst. 2005; 97: 116-126
        • Nielsen H.M.
        • Overgaard M.
        • et al.
        • Danish Breast Cancer Cooperative Group
        Study of failure pattern among high-risk breast cancer patients with or without postmastectomy radiotherapy in addition to adjuvant systemic therapy: Long-term results from the Danish Breast Cancer Cooperative Group DBCG 82b and c randomized studies.
        J Clin Oncol. 2006; 24: 2268-2275
        • Whelan T.
        • Levine M.
        More evidence that loco-regional radiation therapy improves survival: What should we do?.
        J Natl Cancer Inst. 2005; 97: 82-84
        • Vicini F.A.
        • Horwitz E.M.
        • Lacerna M.D.
        • et al.
        The role of regional nodal irradiation in the management of patients with early-stage breast cancer treated with breast-conserving therapy.
        Int J Radiat Oncol Biol Phys. 1997; 39: 1069-1076
        • Grills I.S.
        • Kestin L.L.
        • Goldstein N.
        • et al.
        Risk factors for regional nodal failure after breast-conserving therapy: Regional nodal irradiation reduces rate of axillary failure in patients with four or more positive lymph nodes.
        Int J Radiat Oncol Biol Phys. 2003; 56: 658-670
        • Ampil F.L.
        • Caldito G.
        • Li B.D.
        • et al.
        Supraclavicular nodal relapse of breast cancer: Prevalence, palliation, and prognosis.
        Eur J Gynaecol Oncol. 2003; 24: 233-235
        • Pejavar S.
        • Wilson L.D.
        • Haffty B.G.
        Regional node recurrence in breast cancer patients treated with conservative surgery and radiation therapy (BCS+RT).
        Int J Radiat Oncol Biol Phys. 2006; 66: 1320-1327
        • Early Breast Cancer Trialists' Collaborative Group (EBCTCG)
        Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: An overview of the randomized trials.
        Lancet. 2005; 365: 1687-1717
        • Coen J.J.
        • Taghian A.G.
        • Kachnic L.A.
        • et al.
        Risk of lymphedema after regional nodal irradiation with breast conservation therapy.
        Int J Radiat Oncol Biol Phys. 2003; 55: 1209-1215
        • Pierce S.M.
        • Recht A.
        • Lingos T.I.
        • et al.
        Long term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer.
        Int J Radiat Oncol Biol Phys. 1992; 23: 915-923
        • Chua B.
        • Ung O.
        • Boyages J.
        Competing considerations in regional nodal treatment for early breast cancer.
        Breast J. 2002; 8: 15-22
        • Acharya C.R.
        • Hsu D.S.
        • Anders C.K.
        • et al.
        Gene expression signatures, clinicopathological features, and individualized therapy in breast cancer.
        JAMA. 2008; 299: 1574-1587

      Comments

      Commenting Guidelines

      To submit a comment for a journal article, please use the space above and note the following:

      • We will review submitted comments as soon as possible, striving for within two business days.
      • This forum is intended for constructive dialogue. Comments that are commercial or promotional in nature, pertain to specific medical cases, are not relevant to the article for which they have been submitted, or are otherwise inappropriate will not be posted.
      • We require that commenters identify themselves with names and affiliations.
      • Comments must be in compliance with our Terms & Conditions.
      • Comments are not peer-reviewed.