Patient subsets with T1-T2, node-negative breast cancer at high locoregional recurrence risk after mastectomy

PURPOSE: To identify patient subsets with T1-T2N0 breast cancer at high risk of locoregional recurrence (LRR) who may warrant consideration for postmastectomy radiotherapy. METHODS AND MATERIALS: Data were analyzed for 1505 women referred between 1989 and 1999 with pathologic T1-T2N0M0 breast cancer treated with mastectomy with clear margins and no adjuvant radiotherapy. Logistic regression analysis was performed to identify statistically significant factors associated with LRR. Recursive partitioning was used to develop a classification tree model for LRR given the prognostic variables. RESULTS: The median follow-up was 7.0 years. The 10-year Kaplan-Meier LRR rate was 7.8%. On logistic regression analysis, the statistically significant factors predicting LRR were histologic grade (p <0.0001), lymphovascular invasion (LVI) (p <0.0001), T stage (p = 0.05), and systemic therapy use (p = 0.01). In the recursive partitioning model, the first split in the classification tree was histologic grade. For 972 patients without high-grade histologic features, the 10-year Kaplan-Meier LRR rate was 5.5%. For 533 patients with Grade 3 disease (LRR rate 12.1%), the concomitant presence of LVI was associated with a LRR rate of 21.2% (n = 126). In patients with Grade 3 disease without LVI, T2 tumors conferred a LRR rate of 13.4% (n = 194), which increased to 23.2% for patients who did not receive systemic therapy (n = 63). CONCLUSION: Women with pT1-T2N0 breast cancer experienced a LRR risk of approximately 20% in the presence of Grade 3 disease with LVI or Grade 3 disease, T2 tumors, and no systemic therapy. These subsets of node-negative patients warrant consideration of for postmastectomy radiotherapy.     

Locoregional recurrence rates and prognostic factors for failure in node-negative patients treated with mastectomy: implications for postmastectomy radiation

PURPOSE: Postmastectomy radiation therapy (PMRT) reduces locoregional recurrence (LRR) of breast cancer. Survival appears improved in patients at higher risk for LRR. This study addresses whether subsets of node-negative patients with sufficiently high risk of LRR might benefit from PMRT. METHODS: Retrospective analysis of a cohort of 877 cases of node-negative breast cancer treated with mastectomy, without adjuvant radiation, from 1980 to 2000. RESULTS: Median follow-up was 100 months. Ten-year cumulative incidence of LRR as first event was 6.0%. Size greater than 2 cm, margin less than 2 mm, premenopausal status, and lymphovascular invasion (LVI) were independently significant prognostic factors. Ten-year LRR was 1.2% for those with 0 risk factors, 10.0% for those with 1 risk factor, 17.9% for those with 2 risk factors, and 40.6% for those with 3 risk factors. The chest wall was the site of failure in 80% of patients. CONCLUSION: Postmastectomy radiation therapy has not been recommended for node-negative patients because the LRR rate is low in that population overall. This study suggests, however, that node-negative patients with multiple risk factors, including close margins, T2 or larger tumors, premenopausal status, and LVI, are at higher risk for LRR and might benefit from PMRT. Because the chest wall is the most common site of failure, treating the chest wall alone in these patients to minimize toxicity is reasonable.     

Post-mastectomy radiotherapy benefits subgroups of breast cancer patients with T1–2 tumor and 1–3 axillary lymph node(s) metastasis

Background

To determine the role of postmastectomy radiotherapy (PMRT) in breast cancer patients with T1–2 and N1 disease.

Patients and methods.

A total of 207 postmastectomy women were enrolled. The 5-year Kaplan-Meier estimates of locoregional recurrence rate (LRR), distant recurrence rate (DRR) and overall survival (OS) were analyzed by different tumor characteristics. Multivariate analyses were performed using Cox proportional hazards modeling.

Results

With median follow-up 59.5 months, the 5-year LRR, DRR and OS were 9.1%, 20.3% and 84.4%, respectively. On univariate analysis, age < 40 years old (p = 0.003) and Her-2/neu over-expression (p = 0.016) were associated with higher LRR, whereas presence of LVI significantly predicted higher DRR (p = 0.026). Negative estrogen status (p = 0.033), Her-2/neu overexpression (p = 0.001) and LVI (p = 0.01) were significantly correlated with worse OS. PMRT didn’t prove to reduce 5-year LRR (p = 0.107), as well as 5-year OS (p = 0.918). In subgroup analysis, PMRT showed significant benefits of improvement LRR and OS in patients with positive LVI.

Conclusions

For patients with T1–2 and N1 stage breast cancer, PMRT can decrease locoregional recurrence and increase overall survival only in patients with lymphovascular invasion.     

Selecting breast cancer patients with T1-T2 tumors and one to three positive axillary nodes at high postmastectomy locoregional recurrence risk for adjuvant radiotherapy

PURPOSE: To define the individual factors and combinations of factors associated with increased risk of locoregional recurrence (LRR) that may justify postmastectomy radiotherapy (PMRT) in patients with T1-T2 breast cancer and one to three positive nodes. METHODS AND MATERIALS: The study cohort comprised 821 women referred to the British Columbia Cancer Agency between 1989 and 1997 with pathologic T1-T2 breast cancer and one to three positive nodes treated with mastectomy without adjuvant RT. The 10-year Kaplan-Meier estimates of isolated LRR and LRR with or without simultaneous distant recurrence (LRR +/- SDR) were analyzed according to age, histologic findings, tumor location, size, and grade, lymphovascular invasion status, estrogen receptor (ER) status, margin status, number of positive nodes, number of nodes removed, percentage of positive nodes, and systemic therapy use. Multivariate analyses were performed using Cox proportional hazards modeling. A risk classification model was developed using combinations of the statistically significant factors identified on multivariate analysis. RESULTS: The median follow-up was 7.7 years. Systemic therapy was used in 94% of patients. Overall, the 10-year Kaplan-Meier isolated LRR and LRR +/- SDR rate was 12.7% and 15.9%, respectively. Without PMRT, a 10-year LRR risk of >20% was identified in women with one to three positive nodes plus at least one of the following factors: age <45 years, Stage T2, histologic Grade 3, ER-negative disease, medial location, more than one positive node, or >25% of nodes positive (all p < 0.05 on univariate analysis). On multivariate analysis, age <45 years, >25% of nodes positive, medial tumor location, and ER-negative status were statistically significant predictors of isolated LRR and LRR +/- SDR. In the classification model, the first split was according to age (<45 years vs. >/=45 years), with 29.3% vs. 13.7% developing LRR +/- SDR (p < 0.0001). Of 123 women <45 years, the presence of >25% of nodes positive was associated with a risk of LRR +/- SDR of 58.0% compared with 23.8% for those with 45 years, the presence of >25% of nodes positive also conferred a greater LRR +/- SDR risk (26.7%) compared with women with 45 years with 25% of nodes positive, a medial tumor location, and ER-negative status were statistically significant independent factors associated with greater LRR, meriting consideration and discussion of PMRT. Combinations of these factors further augmented the LRR risk, warranting recommendation of PMRT to optimize locoregional control and potentially improve survival. The absence of high-risk factors identifies women who may reasonably be spared the morbidity of PMRT.     

Postmastectomy radiotherapy reduces locoregional recurrence in elderly women with high-risk breast cancer

AimsClinical trials of adjuvant radiotherapy after mastectomy have largely excluded women aged 70 years or over, even though they comprise 30% of the breast cancer population. This study examined outcomes in elderly women with high-risk breast cancer treated with or without postmastectomy radiotherapy (PMRT).Materials and methodsData were analysed for 233 women aged 70 years or over with high-risk breast cancer (tumours >5 cm or ≥4 positive axillary nodes) treated with mastectomy and referred to the British Columbia Cancer Agency from 1989 to 1997. Tumour and treatment characteristics were compared between two cohorts: women treated with PMRT (n = 147) vs women treated without PMRT (n = 86). Univariate and multivariate analyses of 10-year Kaplan–Meier locoregional recurrence (LRR), distant recurrence, breast cancer-specific survival and overall survival were carried out.ResultsMedian follow-up time was 5.5 years. The distribution of tumour sizes was similar in the two groups. Compared with women treated without PMRT, higher proportions of women who underwent PMRT had four or more positive nodes (83% vs 67%, P = 0.01) and positive surgical margins (14% vs 4%, P = 0.02). Systemic therapy, used in 94% of women, was comparable in the two cohorts (P = 0.63). Elderly women treated with PMRT had significantly lower LRR compared with women treated without PMRT (16% vs 28%, P = 0.03). No differences in distant recurrence, breast cancer-specific survival or overall survival were observed in the two treatment groups (all P > 0.05). On multivariate analysis, the omission of PMRT and the presence of high-grade histology were significant predictors of LRR, whereas an increasing number of positive nodes was significantly associated with distant recurrence and overall survival.ConclusionsIn women aged 70 years or over with tumours greater than 5 cm or four or more positive nodes, significantly lower LRR was observed in women treated with radiotherapy compared with women treated without radiotherapy. PMRT should be considered in the management of elderly women with these high-risk characteristics.     

乳腺癌改良根治术后T1-2N1期患者局部区域复发的部位分析

目的 分析乳腺癌改良根治术后T1-2N1患者的局部区域复发(LRR)部位分布,探讨放疗的照射范围。方法 1997年9月至2015年4月中国医学科学院肿瘤医院收治2472例改良根治术后T1-2N1女性乳腺癌患者,均未行新辅助治疗。1898例未行术后放疗的患者纳入本研究,分析患者的局部和区域复发部位。采用Kaplan-Meier法进行局部复发率和区域复发率计算,采用Log-Rank法对影响患者局部复发和区域复发的各因素分别进行单因素分析,纳入单因素分析P值小于0.05的因素进行Cox回归法多因素分析。结果 中位随访时间71.3个月,164例(8.6%)患者发生局部和(或)区域复发。其中复发在锁骨上106例(65%),胸壁69例(42%),腋窝39例(24%),内乳19例(12%)。多因素分析显示年龄(>45岁/≤45岁)、肿瘤位置(其他象限/内象限)、T分期(T1/T2)、腋窝阳性淋巴结数(1个/2~3个)、激素受体(阳性/阴性)是局部复发和区域复发共同的影响因素。结论 乳腺癌改良根治术后T1-2N1期患者的LRR部位主要是锁骨上,其次是胸壁,腋窝和内乳少见。影响局部和区域复发的高危因素基本相似,放疗患者建议照射锁骨上区和胸壁。     

乳腺癌改良根治术后T1-2N1期患者局部区域复发的部位分析

目的 分析乳腺癌改良根治术后T1-2N1患者的局部区域复发(LRR)部位分布,探讨放疗的照射范围。方法 1997年9月至2015年4月中国医学科学院肿瘤医院收治2472例改良根治术后T1-2N1女性乳腺癌患者,均未行新辅助治疗。1898例未行术后放疗的患者纳入本研究,分析患者的局部和区域复发部位。采用Kaplan-Meier法进行局部复发率和区域复发率计算,采用Log-Rank法对影响患者局部复发和区域复发的各因素分别进行单因素分析,纳入单因素分析P值小于0.05的因素进行Cox回归法多因素分析。结果 中位随访时间71.3个月,164例(8.6%)患者发生局部和(或)区域复发。其中复发在锁骨上106例(65%),胸壁69例(42%),腋窝39例(24%),内乳19例(12%)。多因素分析显示年龄(>45岁/≤45岁)、肿瘤位置(其他象限/内象限)、T分期(T1/T2)、腋窝阳性淋巴结数(1个/2~3个)、激素受体(阳性/阴性)是局部复发和区域复发共同的影响因素。结论 乳腺癌改良根治术后T1-2N1期患者的LRR部位主要是锁骨上,其次是胸壁,腋窝和内乳少见。影响局部和区域复发的高危因素基本相似,放疗患者建议照射锁骨上区和胸壁。     

Radiotherapy to the chest wall following mastectomy for node-negative breast cancer: A systematic review

Background. Although nodal status is the major determinant of risk of locoregional relapse (LRR), other factors also contribute, and these assume a greater significance for those with node-negative breast cancer. Previous reviews of post-mastectomy radiotherapy have included studies using radiotherapy techniques or doses no longer considered clinically appropriate. Objectives. To determine the effectiveness of post-mastectomy radiotherapy in women with node-negative breast cancer with particular reference to those patient and tumour factors which contribute to an increased risk of LRR. Methods. A systematic literature review was conducted. Trials using inadequate or orthovoltage radiotherapy were excluded. Data linking potential risk factors, either individually or in combination, to the occurrence of LRR were handled qualitatively. Data from randomised trials of post-mastectomy radiotherapy were included in a meta-analysis. Results. Baseline risk of LRR is increased in the presence of lymphovascular invasion, a grade 3 tumour, tumours greater than 2 cm or a close resection margin and in patients who are pre-menopausal or aged less than 50. Those with no risk factors have a baseline risk of LRR of approximately 5% or less rising to a risk of 15% or more for those with two or more risk factors. In the meta-analysis of three randomised trials of mastectomy and axillary clearance (667 patients), the addition of radiotherapy resulted in an 83% reduction in the risk of LRR (P < 0.00001) and in a 14% improvement in survival (P = 0.16). Conclusion. The use of post-mastectomy radiotherapy for women with node-negative breast cancer requires re-evaluation. Radiotherapy should be considered for those with two or more risk factors.     

中高危老年乳腺癌患者改良根治术后放疗的意义

目的 探讨中高危老年(≥65岁)乳腺癌患者改良根治术后放疗(PMRT)的意义.方法 收集874例改良根治术后中高危乳腺癌患者的临床资料,回顾性分析不同年龄组患者接受PMRT的情况和PMRT的作用,其中T3～T4和(或)N2～N3为高危组,T1～T2N1为中危组.结果 ≥65岁的患者108例,占12.4%.与＜65岁的患者相比,≥65岁的患者中,病理学分级为Ⅲ级、N3、高危和化疗患者所占的比例低,而合并其他疾病和有恶性肿瘤史者所占的比例高.≥65岁的患者中,中危组和高危组患者接受放疗的比例分别为15.3%和52.2%;＜65岁的患者中,中危组和高危组患者接受放疗的比例分别为18.1%和82.7%.≥65岁的患者中,中危组放疗和未放疗者的5年局部区域复发率分别为0和14.2%(P=0.242),5年总生存率分别为100%和75.2%(P=0.159);高危组放疗和未放疗者的5年局部区域复发率分别为0和14.1%(P=0.061),5年总生存率分别为84.6%和77.4%(P=0.597).＜65岁的患者中.中危组放疗和未放疗者的5年局部区域复发率分别为0和9.9%(P=0.035),5年总生存率分别为87.0%和82.1%(P=0.739);高危组放疗和未放疗者的5年局部区域复发率分别为7.2%和26.1%(P=0.000),5年总生存率分别为79.2%和57.7%(P=0.000).结论 不同年龄的中危组患者实施PMRT的比例相仿,但对于高危组患者,接受PMRT的比例随着患者年龄的增长而降低.高危老年乳腺癌患者实施PMRT可能可以降低局部区域复发率,应支持放疗.     

局部晚期乳腺癌新辅助化疗和改良根治术后放疗价值分析

目的 分析局部晚期乳腺癌患者neoCT和改良根治术后放疗的价值,以及探讨能否根据化疗疗效进行个体化放疗。 方法 选取本院1999—2013年收治的临床Ⅲ_A、Ⅲ_B期乳腺癌病例,完成neoCT和改良根治术的 523例纳入分析,其中 404例术后行放疗,119例未行放疗。用Kaplan-Meier法计算复发率和生存率,Logrank法单因素预后分析,Cox模型多因素预后分析。 结果 放疗组患者 5年LRR显著低于未放疗组(13.9%∶24.8%,P=0.013),DFS显著高于未放疗组(64.1%∶53.9%,P=0.048),OS相近(83.2%∶78.2%,P=0.389)。ypT₃—T₄、ypN₂—N₃以及病理Ⅲ期亚组中放疗患者 5年LRR显著低于未放疗患者(P<0.05),放疗患者 5年OS显著高于未放疗患者(P<0.05)。158例ypN₀期放疗患者 5年LRR显著低于未放疗患者(P=0.004)。41例ypCR患者仅 2例LRR,均未放疗。多因素分析显示放疗是影响全组及ypN₀期患者LRR的因素。 结论 放疗显著降低临Ⅲ_A、Ⅲ_B期乳腺癌neoCT和改良根治术后患者LRR,同时降低ypT₃—T₄、ypN₂—N₃和病理Ⅲ期亚组患者复发率、死亡率。目前尚无充足证据可以根据化疗反应免除ypN₀期和pCR患者术后放疗。     

Low local recurrence rate without postmastectomy radiation in node-negative breast cancer patients with tumors 5 cm and larger

PURPOSE: To assess the need for adjuvant radiotherapy following mastectomy for patients with node-negative breast tumors 5 cm or larger. METHODS AND MATERIALS: Between 1981 and 2002, a total of 70 patients with node-negative breast cancer and tumors 5 cm or larger were treated with mastectomy and adjuvant systemic therapies but without radiotherapy at three institutions. We retrospectively assessed rates and risk factors for locoregional failure (LRF), overall survival (OS), and disease-free survival (DFS) in these patients. RESULTS: With a median follow-up of 85 months, the 5-year actuarial LRF rate was 7.6% (95% confidence interval, 3%-16%). LRF was primarily in the chest wall (4/5 local failures), and lymphatic-vascular invasion (LVI) was statistically significantly associated with LRF risk by the log-rank test (p=0.017) and in Cox proportional hazards analysis (p=0.038). The 5-year OS and DFS rates were 83% and 86% respectively. LVI was also significantly associated with OS and DFS in both univariate and multivariate analysis. CONCLUSIONS: This series demonstrates a low LRF rate of 7.6% among breast cancer patients with node-negative tumors 5 cm and larger after mastectomy and adjuvant systemic therapy. Our data indicate that further adjuvant radiation therapy to increase local control may not be indicated by tumor size alone in the absence of positive lymph nodes. LVI was significantly associated with LRF in our series, indicating that patients with this risk factor require careful consideration with regard to further local therapy.     

靶向治疗对HER-2阳性改良根治术后未放疗乳腺癌患者复发影响——单中心大宗病例倾向评分匹配回顾分析

目的 评估乳腺癌抗HER-2靶向治疗的局部区域作用及对放疗决策的影响。方法 回顾分析2009-2014年本中心诊治的HER-2阳性、改良根治术后未放疗患者 1398例,其中接受辅助靶向者 370例。靶向治疗以单药曲妥珠单抗为主。结果 接受靶向治疗显著改善无瘤生存、总生存,也降低局部区域复发(LRR),多因素分析发现靶向治疗提高LRRFS (P=0.06)。倾向评分匹配其他预后因素后,有、无靶向治疗 5年LRR率分别为4.4%、6.6%(P=0.070)。亚组分析显示靶向治疗的局控优势在病理分级Ⅰ-Ⅱ级患者中显著(2.5%、5.9%,P=0.046);而原本需考虑放疗的亚组(pN1)靶向治疗后复发风险依旧相对高,有、无靶向治疗 5年LRR率分别为8.2%、12.3%(P=0.150)。激素受体阳性者靶向治疗的获益明显。接受靶向治疗且有良好预后因素的患者 5年LRR率可在5%以下。结论 以单药曲妥珠单抗为主的抗HER-2靶向治疗可提高改良根治术后患者LRRFS,但有放疗适应证的患者因复发率较高暂不能免于放疗,新开展的双单抗辅助靶向有望进一步改善局控,亦需进一步亚组分析寻找低危患者。     

Locoregional recurrence after doxorubicin-based chemotherapy and postmastectomy: Implications for breast cancer patients with early-stage disease and predictors for recurrence after postmastectomy radiation

PURPOSE: To compare rates of locoregional recurrence (LRR) after mastectomy, doxorubicin-based chemotherapy, and radiation with those of patients receiving mastectomy and doxorubicin-based chemotherapy without radiation and to determine predictors of LRR after postmastectomy radiation. METHODS: Kaplan-Meier freedom-from-LRR rates were calculated for 470 patients treated with mastectomy, doxorubicin-based chemotherapy, and postmastectomy radiation in five single-institution clinical trials. The LRR rates in these patients were compared to previously reported rates in 1031 patients treated without radiation in the same trials. RESULTS: Median follow-up was 14 years. Irradiated patients had significantly less favorable prognostic factors for LRR than did unirradiated patients. Despite this, in all subsets of node-positive patients, postmastectomy radiation led to lower rates of LRR. This included patients with T1 or T2 tumors and one to three positive nodes (10-year LRR rates of 3% vs. 13%, p = 0.003). Multivariate analysis of LRR for patients with this stage of disease revealed that no radiation, close/positive margins, gross extracapsular extension, and dissection of <10 nodes predicted for increased LRR (hazard ratios 6.25, 4.61, 3.27, and 2.66, respectively). Significant predictors of LRR for patients treated with postmastectomy radiation were higher number and >or=20% positive nodes, larger tumor size, lymphovascular space invasion, and estrogen receptor (ER)-negative disease. Recursive partitioning analysis revealed ER-negative status to be the most powerful discriminator of LRR in irradiated patients. CONCLUSIONS: Postmastectomy radiation decreases LRR for patients with breast cancer, including those with Stage II breast cancer and one to three positive lymph nodes.     

Optimizing locoregional control and survival for women with breast cancer: a review of current developments in postmastectomy radiotherapy

For women who opt for mastectomy as primary surgery in breast cancer, indications for adjuvant radiotherapy are also being redefined in light of evidence demonstrating that postmastectomy radiotherapy (PMRT), when given in conjunction with systemic therapy, improves, not only locoregional control, but also survival. However, in certain settings, particularly in patients wih intermediate-risk disease, and in some patients treated with neoadjuvant chemotherapy, the role of PMRT remains controversial. Here, the authors review modern data pertaining to the benefits and risks of PMRT and discuss controversies related to the indications for PMRT, focusing on patients with T1–2 breast cancer with 0–3 positive nodes and patients treated with neoadjuvant chemotherapy. They also summarize key issues related to the integration of PMRT with other treatment modalities.     

T4期乳腺癌患者改良根治术后胸壁放疗加量的疗效及预后分析

目的分析T4期乳腺癌患者改良根治术后胸壁放疗加量的疗效。方法回顾分析2000-2016年收治的148例T4期、改良根治术后放疗的乳腺癌患者资料,胸壁放疗加量组57例,不加量组91例。放疗采用常规+胸壁电子线、三维适形+胸壁电子线、调强放疗+胸壁电子线照射,加量组EQD2>50Gy。全组患者均接受新辅助化疗。Kaplan-Meier法生存分析并Logrank检验差异,Cox模型多因素预后分析。结果中位随访时间67.2个月,5年胸壁复发(CWR)、局部区域复发(LRR)、无瘤生存(DFS)、总生存(OS)率分别为9.9%、16.2%、58.0%、71.4%。胸壁放疗加量和不加量的5年CWR、LRR、DFS、OS率分别为14%和7%、18%和15%、57%和58%、82%和65%(P>0.05)。多因素分析显示胸壁加量与否对预后无显著影响(P>0.05)。45例复发高危组患者中放疗加量组似乎有较高的OS率(P=0.058)、DFS率(P=0.084)和较低的LRR率(P=0.059)。结论T4期乳腺癌患者异质性较强,胸壁放疗加量对全组患者无明显获益。对于有脉管瘤栓阳性、pN2-N3、激素受体阴性中2~3个高危因素患者胸壁放疗加量有改善疗效趋势。     

Optimizing locoregional control and survival for women with breast cancer: a review of current developments in postmastectomy radiotherapy

For women who opt for mastectomy as primary surgery in breast cancer, indications for adjuvant radiotherapy are also being redefined in light of evidence demonstrating that postmastectomy radiotherapy (PMRT), when given in conjunction with systemic therapy, improves, not only locoregional control, but also survival. However, in certain settings, particularly in patients wih intermediate-risk disease, and in some patients treated with neoadjuvant chemotherapy, the role of PMRT remains controversial. Here, the authors review modern data pertaining to the benefits and risks of PMRT and discuss controversies related to the indications for PMRT, focusing on patients with T1-2 breast cancer with 0-3 positive nodes and patients treated with neoadjuvant chemotherapy. They also summarize key issues related to the integration of PMRT with other treatment modalities.     

Locoregional recurrence risk factors in breast cancer patients with positive axillary lymph nodes and the impact of postmastectomy radiotherapy

Background

Locoregional recurrence (LRR) after mastectomy reduces the patient’s quality of life and survival. There is a consensus that postmastectomy radiotherapy (PMRT) helps establish locoregional control and reduces LRR in patients with ≥4 metastatic nodes. However, in patients with 1–3 metastatic nodes, the incidence of LRR and the role of PMRT have been the subject of substantial controversy. This study assessed the risk factors for LRR and the efficacy of PMRT in Japanese breast cancer patients with metastatic nodes.

Methods

This study analyzed 789 cases of invasive breast carcinoma with metastatic nodes from 1998 to 2008. We divided the study population into 4 groups: 1–3 positive nodes with/without chemotherapy and ≥4 positive nodes with/without chemotherapy. Risk factors for LRR were identified and the relationship between LRR and PMRT was analyzed.

Results

During the median follow-up of 59.6 months, 61 (7.7%) patients experienced LRR. In patients who received chemotherapy, independent LRR risk factors were high nuclear grade, severe lymphatic invasion, vascular invasion, and progesterone receptor-negative status in patients with 1–3 positive nodes, and severe lymphatic invasion and estrogen receptor-negative status in patients with ≥4 nodes. Although patients treated with PMRT had good outcomes, there was no significant difference, and PMRT did not significantly improve the outcome of the patients with all risk factors.

Conclusions

With systemic therapy and adequate dissection, PMRT by itself was of limited value in establishing locoregional control. The indication for PMRT in patients with 1–3 positive nodes remains controversial.     

皮肤受侵非炎性和炎性乳腺癌的放疗结果

目的 分析现有放疗技术和剂量对皮肤受侵乳腺癌的控制作用.方法 回顾分析53例改良根治术后病理证实为乳腺浸润癌患者资料.其中炎性乳腺癌10例,非炎性乳腺癌43例.非炎性乳腺癌中临床皮肤受侵19例,病理诊断皮肤受侵24例.30例原发肿瘤最大径≤5 cm,13例>5 cm.全组33例接受术后放疗,中位剂量50 Gy,胸壁硅胶填充的6例20 Gy、21例>20 Gy,6例不详.45例行化疗.结果 随访率87%.全组5年局部区域复发率(LRR)、无瘤生存率(DFS)和总生存率(OS)分别为18%、45%和64%.非炎性乳腺癌比炎性乳腺癌有较高的5年DFS(49%:30%;χ2=4.29,P=0.038)和OS(71%:37%;χ2=5.92,P=0.015).非炎性乳腺癌中肿瘤≤5 cm比>5 cm患者有较低的5年LRR(11%:33%;χ2=3.75,P=0.053)和较高的5年OS(90%:38%;x24.44,P=0.035);临床诊断和单纯病理诊断皮肤受侵患者的局部区域复发率、DFS和OS相似.腋窝淋巴结0～3个阳性比≥4个阳性患者有较高的5年DFS(80%:29%;χ2=6.71,P=0.010)和OS(93%:52%;χ2=6.00,P=0.014).Rec+/Her2-比三阴或Her2+患者有较低的5年LRR(7%:34%;χ2=5.70,P=0.017)和较高DFS(54%:32%;χ2=8.82,P=0.003).放疗和未放疗患者的5年LRR分别为12%和30%(χ2=2.45,P=0.118).但放疗患者胸壁硅胶填充剂量>20 Gy和20 Gy患者的5年胸壁复发率为0%和50%(χ2=9.15,P=0.002).结论 皮肤受侵乳腺癌是一组异质性很强的患者,非炎性乳腺癌、原发肿瘤≤5 cm、腋窝淋巴结0～3个阳性和rec+/Her2-患者预后较好.临床诊断和病理诊断皮肤受侵患者的预后无差别.为降低胸壁复发率,胸壁放疗硅胶填充剂量应>20 Gy.     

The prognostic significance of the percentage of positive/dissected axillary lymph nodes in breast cancer recurrence and survival in patients with one to three positive axillary lymph nodes

BACKGROUND: Adjuvant therapy for women with T1-T2 breast carcinoma and 1-3 positive lymph nodes is controversial due to discrepancies in reported baseline locoregional recurrence (LRR) risks. This inconsistency has been attributed to variations in lymph node staging techniques, which have yielded different numbers of dissected lymph nodes. The current study evaluated the prognostic impact of the percentage of positive/dissected lymph nodes on recurrence and survival in women with one to three positive lymph nodes. METHODS: The study cohort was comprised of 542 women with pathologic T1-T2 breast carcinoma who had 1-3 positive lymph nodes and who had undergone mastectomy and received adjuvant systemic therapy without radiotherapy. Ten-year Kaplan-Meier (KM) LRR, distant recurrence (DR), and overall survival (OS) rates stratified by the number of positive lymph nodes, the number of dissected lymph nodes, and the percentage of positive lymph nodes were examined using different cut-off levels. Multivariate analysis was performed to evaluate the prognostic significance of the percentage of positive lymph nodes in disease recurrence and survival. RESULTS: The median follow-up was 7.5 years. LRR, DR, and OS rates correlated significantly with the number of positive lymph nodes and the percentage of positive lymph nodes, but not with the number of dissected lymph nodes. The cut-off level at which the most significant difference in LRR was observed was 25% positive lymph nodes (the 10-year KM LRR rates were 13.9% and 36.7% in women with < or = 25% and > 25% positive lymph nodes, respectively; P < 0.0001). Higher DR rates and lower OS rates were observed among patients who had > 25% positive lymph nodes compared with patients who had < or = 25% positive lymph nodes (DR: 53.0% vs. 30.3%, respectively; P < 0.0001; OS: 43.4% vs. 62.6%, respectively; P < 0.0001). In the multivariate analysis, the percentage of positive lymph nodes and the histologic grade were significant, independent factors associated with LRR, DR, and OS. CONCLUSIONS: The presence of > 25% positive lymph nodes was an adverse prognostic factor in patients with 1-3 positive nodes and may be used to identify patients at high risks of postmastectomy locoregional and distant recurrence who may benefit with adjuvant radiotherapy and more aggressive systemic therapy regimens.     

Evidence and controversies in the use of post-mastectomy radiation

Radiation after mastectomy is recommended for women with positive nodes, larger tumors, or positive margins. In addition to its role in reducing the risk for locoregional recurrence, it has an additive effect to the survival benefit seen with adjuvant systemic therapy. This article reviews the role of post-mastectomy radiation (PMRT) based on the recommendations in the 2007 NCCN Breast Cancer Clinical Practice Guidelines in Oncology and addresses the risk factors for recurrence after mastectomy. The data supporting both improvement in locoregional failure and survival are reviewed in detail. This article also discusses controversial areas in PMRT, including regional nodal radiation in women with 1 to 3 positive lymph nodes, PMRT in node-negative women with large tumors, and inclusion of internal mammary nodes. The final section discusses radiation field design and potential complications.