A case of Left LABC underwent Left MRM foolowed by 8 cycles chemotherapy. Pathologically diagnosed as pT2pN3M0, IDC grade III 14 out of 25 nodes positive. systemic work up negative. For post op radiotherapy. Is full axilla ie. including level II & I need to be treated despite adequate lymphnode dissection. Kindly opine and if possible present evidence.
If axillary dissection is complete,in this case scenario what literature is chance of supraclavicle, chest wall recurrence and distant metastasis.So in our department we donot treat.In these case HER2 Receptor status ,herceptin and to include taxol in chemo protocol will be more important with chest wall and supraclavicle radiotherapy.
There are department where more than 10 nodes,extracapsular extension,axillary fat tumor deposit are indication for axillary radiotherapy.
We include axillary radiotherapy when resection margin is positive in axillary dissection,incomplete clearance where further surgery is not feasible.
when we delinate axillary node supraclavicle node and put supraclavicle field and chest wall radiotherapy axillary nodes get radiation.so adding posterior axillary field and extending lateral border covering pectoralis minor insertion for axillary radiotherapy to cover axilla only increase morbidity.
The evidence in the literature suggests that there is no added benifit of radiation therapy if complete axillary clearance is done. It only increases the complication rate.
I agree with Rajesh and Ashwini, No role of axillary RT in this case.
I agree fully with all the above replies. extranodal spread is an indicator for more nodal positivity and nodal positivity is more of an indicator for chest wall failure or distant failure rather than axillary failure.I myself do not treat the whole axilla after adequate dissection. But if you guys have any new guidelines or any latest literature mentioning this fact kindly forward to me.
Clinical investigation: Regional nodal failure patterns in breast cancer patients treated with mastectomy without radiotherapy
International Journal of Radiation OncologyBiologyPhysics, Volume 63, Issue 5, Pages 1508-1513
E. Strom, W. Woodward, A. Katz, T. Buchholz, G. Perkins, A. Jhingran, R. Theriault, E. Singletary, A. Sahin, M. McNeese
I got 1 article from the red journal favouring what we said. also this is mentioned in Textbook perez Vth edition page 1312.
Right, this is a relatively controversial topic and lets see if i can add some spice to it.
Traditional teaching (prior to 2000) mentioned about restricted indications for RT to Axilla
1. Inadequate Axillary dissection ( node positive but < 6 nodes removed)
2. No Axillary dissection performed
3. R2 dissection when surgeon has not been able to clear the disease, or is uncertain and concerned about completeness of his dissection.
The first 2 indications seem to be obsolete and we hardly ever come across pts for whom such an indication isrequired to treat the axilla, but you may come across an adamant pt refusing surgery once in a blue moon.
Indication No.3 remains a true non-controversial indication for RT to axilla beyond doubt for any oncologist.
In the past Extracapsular extension has been considered as another relative indication, however in multiple studies it has been proven that probably ECE should not be the deciding factor for Regional RT.
Ref: http://www.ncbi.nlm.nih.gov/pubmed/8334631
Conclusion: It is concluded that ECE has limited influence on prognosis independent of the number of positive nodes and is not an indication for radiation therapy of the axilla after a complete axillary dissection
http://www.ncbi.nlm.nih.gov/pubmed/7799041
Conclusion: These results show that ECE is associated with decreased survival and increased recurrence rates regardless of the extent of the radiation therapy field. Also, ETE does not necessarily indicate a significantly increased incidence of axillary recurrence. Therefore, axillary irradiation based on this pathologic finding may not be indicated.
http://www.ncbi.nlm.nih.gov/pubmed/10656369
Conclusion: In this population of patients with nodal involvement, the presence of ECE correlates with the number of involved LN but does not appear to add predictive power to models of local, regional, or distant recurrence when the number of positive LN is included.
http://www.ncbi.nlm.nih.gov/pubmed/10506712
Conclusion: The risk of axillary recurrence, either as an isolated event or as part of simultaneous failure, is extremely low, even in patients with ETE. These data suggest that patients with ETE frequently have higher numbers of positive axillary lymph nodes and on that basis are at risk for local recurrence and as a rule would be considered for postmastectomy irradiation. However, these data suggest that the presence of ETE is not an indication for routine postmastectomy axillary lymph node irradiation.
There have been one more recent emerging relative indications for RT to the axilla
4. Percentage of nodes involved / total nodes removed.
Ref: >40% involved nodes if N1–3 and ≥50% involved nodes if N>3 nodes.
http://www.radiologysource.org/periodicals/medima/article/S0360-3016(05)03087-7/abstract
In general, Ten-year axillary control rates were 97% and 91% when the percentage of involved nodes was <50% and ≥50%, respectively (p = 0.007). In addition, regional radiotherapy is always significantly associated with a decrease in overall regional failure (axillary and/or supraclavicular), regardless of the percentage of involved nodes. However, regional radiotherapy reduced the axillary failure rate (2% vs. 9%, p = 0.007) only when more than a specific percentage of nodes was involved (≥40% if N1–3 and ≥50% if N>3 nodes).
http://informahealthcare.com/doi/pdf/10.1080/02841860701678761
Conclusion: Percent positive nodal involvement was found to be a significant prognositc factor for survival in all end points.
http://www.ncbi.nlm.nih.gov/pubmed/17449196
Conclusion: This is the first study demonstrating that for patients with > or =10 nodes examined, SART significantly improved the survival for the medium and high NR groups but not for the low NR group.
What is this percent positive nodal ratio ?
Its the number of invloved nodes divided by the total number of axillary nodes removed.
Low risk : < 25%
Medium Risk: 25-75%
High risk: > 75%
My personal Conclusion from review of literature is that this last Indication is an emerging notorious prognostic factor which cannot be simply ignored and this needs to be tested in a randomised trial which will involve at least a minimum of 1000 pts to prove and demostrate a survival benefit in this scenario.
So to be frank and fair there does seem to be some Level 3 evidence for treating this Axilla as your pt has a nodal ratio >50%
The opinion in the UK seems divided, and only a handful of oncologists believe in ever treating the axilla.
The centres in which i ve worked who offer Axillary RT are Bristol Oncology Centre and a few breast oncologists at Beatson Oncology Centre in Glasgow. In London (Royal Marsden and Mount Vernon, St Guys and Thomas they do not entertain this idea).
What i ve mentioned so far was just the bright side of the coin, however as mentioned earlier there is a significant morbidity esp of Lymphedema which needs to be accouted for, making an oncologist think Is it worth treating the Axilla ?
Thats another huge topic for debate as would you be prepared with a 38-55% risk of significant lympedema if you use Axillary surgery + Axillary RT.
There may be additional factors like Her2+ etc, in such pts where ultimately these pts would relapse systemically making any regional treatment unrewarding.
I gather that the general consensus is no role of Axillary RT if complete axillary dissection has been performed.
I am not against this consensus as i have no Level 1 evidence as there has nt been any modern trial looking into this last indication i mentioned in select group of pts.
The last canadian study i mentioned is worth reading
Nodal Ratios in Node-Positive Breast Cancer—Long-Term Study to Clarify Discrepancy of Role of Supraclavicular and Axillary Regional Radiotherapy
Int J Radiat Oncol Biol Phys, Volume 68, Issue 3, Pages 662-666 (1 July 2007). doi: 10.1016/j.ijrobp.2007.01.057
Abstract
Purpose: To study the absolute number of involved nodes/the number of nodes examined or the nodal ratio (NR) in breast cancer. The primary study endpoint was to evaluate the role of supraclavicular and axillary radiotherapy (SART) according to the NR.
Methods and materials: From the Saskatchewan provincial registry of 1981-1995, the charts of 5,996 consecutive patients were retrieved to collect detailed prognostic factors. Among these patients, 1,985 were node positive. Because the NRs are more reliable the greater the number of nodes examined, we analyzed 1,255 patients with > or =10 nodes examined. Of these 1,255 patients, 667, 389, and 199 were categorized into three NR groups—low (< or =25%), medium (>25% to < or =75%), and high (>75%) nodal involvement, respectively.
Results: The NR correlated significantly with the primary tumor size (< or =2 cm, >2 to < or =5 cm, and >5 cm; p = 2.2 x 10(-16)), clinical stage group (p = 5.5 x 10(-16)), pathologic stage group (p < 2.2 x 10(-16)), and the risk of any first recurrence (p = 5.0 x 10(-15)) using chi-square tests. For a low NR, the 10-year overall survival rate with and without SART was 57% and 58% (p = 0.18), and the cause-specific survival rate was 68% and 71% (p = 0.32), respectively. For a medium NR, the 10-year overall survival rate with and without SART was 48% and 34% (p = 0.007), and the cause-specific survival rate was 57% and 43% (p = 0.002), respectively. For a high NR, the 10-year overall survival rate with and without SART was 19% and 10% (p = 0.005), and the cause-specific survival rate was 26% and 14% (p = 0.005), respectively.
Conclusion: This is the first study demonstrating that for patients with > or =10 nodes examined, SART significantly improved the survival for the median and high NR groups but not for the low NR group.
excellent review of literature. Kindly clear one point here - as i do not yet have this article that did they compare Supraclav+ AxIII RT against SC+ complete axilla and did this show that the survival benefit for the 'SART' arm compared to 'SC+ AxillaIII' arm???
Thank you for your kind comment.
Lets see if you can use this link to get the full paper
http://download.journals.elsevierhealth.com/pdfs/journals/0360-3016/PIIS0360301607003136.pdf
If this does nt work , go to the web page of one of the authors of this article, Edward Yu
http://works.bepress.com/edwardyu/32/
From here click on Full text
If you still cant get the full text, i m happy to email this to you.
Over and out !
Rohit Malde
thanks a lot all who participated in the discussion . I think my query has been replied effectively.
"Thats another huge topic for debate as would you be prepared with a 38-55% risk of significant lympedema if you use Axillary surgery + Axillary RT."
that's a gross over-estimate! The rate for arm expansion >2cm is ~30% (Australian data in IJROBP, less for USA data), but this not "significant" lymphoedema.
I am interested that the tailor-made all-comers randomised data from Denmark and Canada is not included in this discussion. Recent data presented at San Antonio still provides a survival advantage for nodal RT over an above the best chemotherapy. All other data presented is retrospective and not an order of magnitude bigger than the randomised data.
As for axillary surgery, I wasn't aware that any axillary dissection was ever "complete", but rather that the nodal ratio gave a risk estimate for remaining disease.
As for whole or part axilla radiotherapy, I was unaware that there is a separation between levels 1, 2 or 3 that makes any difference to outcomes. Which trials used SCF only RT?
1. References for my 38-55% risk of significant lympedema if you use Axillary surgery + Axillary RT.
Arm circumference measurements are inaccurate. Arm volume measurement 15 cm above the lateral epicondyle is the most accurate method of assessing differences in size of the operated and normal arm.
This is what is mentioned in this first reference where the incidence is 38%
http://www.ncbi.nlm.nih.gov/pubmed/3730795
The other study mentioning 55% is http://www.ncbi.nlm.nih.gov/pubmed/1627817
2. You are right, i somehow missed the Danish and British Columbia data. But you know, what they did.
they treated everything, Axilla, Supraclavicular regions AND the damn Internal mammary Nodes as well.
I am sure you also know the data showing that regional lymph node irradiation can be safely omitted in patients with positive axillary nodes from NSABP-06 where they showed the LRR was as low as 5.1% (overall)
Hence i would nt levy too much on these large pivotal randomised trials in my discussion FOR or AGAINST Axillary RT.
Things may of course change once this large EORTC trial seeking the answer about Internal mammary node radiation of more than 4000 pts matures and gives us survival figures in 2014
3. I have nt read about this recent data presented at San Antonio providing a survival advantage for nodal RT over and above the best chemotherapy.
The bottom line is the landscape for Axillary RT may be undergoing a paradigm shift, but its routine use in oncology departments may not be seen for decades until a large modern age trial is designed to ask this question which may or may not be clinically viable for large international oncology Groups
Dear Rohit,
regarding the canadian study by Prof Petrecia Tai published in Red journal in 2007 :
Int J Radiat Oncol Biol Phys, Volume 68, Issue 3, Pages 662-666 (1 July 2007). doi: 10.1016/j.ijrobp.2007.01.057
i communicated directly with Prof Tai and they say that they are themselves not giving radiotherapy after full axillary dissection in even high ( >75%NR) NR group outside a clinical trail because they did not compare SART with S/C + Ax III RT with SART. So they also advised me to give only S/C + AX III in this case.
So i think we were correct in our decision.
