Postmastectomy Radiation Therapy for Patients With Locally Advanced Breast Cancer

doi:10.1016/j.semradonc.2009.05.009

Seminars in Radiation Oncology

Volume 19, Issue 4, October 2009, Pages 236-243

https://doi.org/10.1016/j.semradonc.2009.05.009 Get rights and content

Radiation therapy is an integral component of the multimodal treatment of locally advanced breast cancer. Even after mastectomy and systemic therapy, occult residual disease in the chest wall and/or regional lymph nodes may serve as the source of morbid locoregional recurrence as well as the source of distant seeding or reseeding of metastases. Thus, postmastectomy radiation therapy offers substantial benefits in appropriately selected patients. This review article summarizes the data from randomized trials revealing a significant benefit from postmastectomy radiation therapy in patients with locally advanced disease as well as results from other relevant studies. It concludes with a summary of consensus guideline recommendations in this important area.

Section snippets

Evidence From Randomized Trials

PMRT has been a subject of considerable study over the past several decades. Multiple randomized trials have consistently revealed a substantial reduction in the risk of locoregional recurrence of breast cancer with the use of PMRT.4, 5, 6

However, most early studies failed to show an improvement in OS, and meta-analyses suggested that the benefits of PMRT in cancer control were offset by treatment-related toxicity, especially cardiotoxicity.⁷ Outdated radiation techniques, such as anterior

Patients Treated With Neoadjuvant Chemotherapy

Because none of the patients enrolled on the randomized trials of PMRT just discussed were treated with neoadjuvant systemic therapy, appropriate patient selection for PMRT after neoadjuvant therapy is more complicated than when pathologic staging has been unaffected by disease response to systemic agents. In the absence of prospective trials, decisions regarding the role of PMRT in patients treated with neoadjuvant chemotherapy have largely been guided by retrospective analyses.

Investigators

Consensus Guidelines

The complexities of the data described earlier motivated several professional societies to develop practice guidelines regarding the use of PMRT. The American Society of Clinical Oncology (ASCO) Health Services Research Committee commissioned a multidisciplinary panel of breast cancer experts for an in-depth review of worldwide data on locoregional failure from breast cancer and the ability of PMRT to reduce risk of locoregional as well as distant relapse.³¹ When evidence-based data were

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Cited by (22)

Influence of individualized stabilization on the consistency of supraclavicular fossa positioning in breast radiation therapy: A retrospective study
2014, Journal of Medical Imaging and Radiation Sciences
Citation Excerpt :
Radiotherapy plays a vital role in the management of breast carcinoma. In light of published evidence, it has also become increasingly common to irradiate the supraclavicular fossa (SCF), and sometimes the axilla, of breast patients who have at least four positive nodes involved in an effort to improve locoregional control [1–6]. Results of two randomized trials conducted in Denmark showed the significant impact on survival rates of postmastectomy radiotherapy (PMRT) to the chest wall and SCF nodes.
The accurate stabilization of breast patients who are also undergoing supraclavicular fossa treatment is essential and can be challenging. Discrepancy in setup error for these patients often lies with the position of the clavicle in relationship with other anatomic structures. This study was performed to assess how individualized stabilization can improve patient's stability and reproducibility.
Thirty patients stabilized with an individualized vacfix located on a Civco wing board (Civco Medical Solutions, Kalona, IA) were compared with 30 patients stabilized in the traditional manner on a Civco breast board (Civco Medical Solutions). Each of these patients underwent daily imaging using the Varian Clinac iX On-board Imaging System (Varian Medical Systems, Palo Alto, CA), and image mismatch data for each session were collected. Additionally, the relationship between the clavicle and vertebrae was assessed for each stabilization solution on a daily basis. Statistical analysis of this data was then performed using a mixed effects approach to take account of data grouping by patient specifically for the displacement error in each direction.
The use of an individualized vacfix decreased the overall systematic and random setup errors and displayed a reduction in the standard deviation of setup error. Patients positioned using breast board stabilization with the clavicle as the match method were exposed in the longitudinal direction to a systematic error of a 95% confidence interval (CI) of 2.6–4.5 mm and a random error of a 95% CI of 2.7–3.2 mm. This was significantly reduced for vacfix stabilization with a systematic error of a 95% CI of 1.2–2.3 mm and a random error of a 95% CI of 1.8–2.3 mm. These data amount to a reduction of the systematic error by 40% (P = .02) and a random error by 25% (P = .003) when using the vacfix method compared with the breast board. The data displaying the relationship between the clavicle and other anatomy within the treatment volume appear to be more consistent with the individualized vacfix approach.
Reproducible and consistent stabilization for the breast/supraclavicular fossa technique is vital in terms of ensuring accurate patient position. Analysis of the setup error for clavicle and spinous process matching strongly indicates a reduction in both the systematic and random setup error achieved by the vacfix. This illustrates the increased stability and reproducibility of patient positioning when an individualized vacfix is used.
Une stabilisation précise des patientes atteintes d’un cancer du sein et qui reçoivent aussi un traitement de la fosse supraclaviculaire est essentielle et peut présenter des défis. Les différences dans les erreurs de positionnement pour ces patientes proviennent souvent de la position de la clavicule par rapport aux autres structures anatomiques. Cette étude a été réalisée dans le but d'évaluer de quelle façon la stabilisation individualisée peut permettre d’améliorer la stabilité de la patiente et la reproductibilité des résultats.
Trente patientes stabilisées au moyen d’un vacfix individualisé situé sur un système WingBoard de Civco par rapport à l’approche traditionnelle sur plan incliné Civco breastboard. Chacune de ces patientes a fait l’objet d’une imagerie quotidienne au moyen du système Varian Clinac iX On-board Imaging System et les données de décalage des images ont été recueillies pour chaque séance. De plus, la relation entre la clavicule et les vertèbres a été évaluée chaque jour pour chaque solution de stabilisation. Une analyse statistique de ces données a ensuite été effectuée selon l’approche des effets contrastés afin de tenir compte du regroupement des données par patiente, particulièrement pour l’erreur de déplacement dans chaque direction.
Le recours à un vacfix individualisé a permis de diminuer globalement les erreurs de positionnement systématiques et aléatoires et d’afficher une réduction de l’écart type des erreurs de positionnement. Les patientes positionnées en utilisant une stabilisation sur plan incliné, avec la clavicule comme base d’appariement, ont été exposées dans la direction longitudinale à une erreur systématique de 95%CI:2,6 -4,5 mm et à une erreur aléatoire de 95%CI:2,7-3,2 mm. Ces données ont affiché une réduction significative avec la stabilisation par vacfix, avec une erreur systématique de 95%CI:1,2 -2,3 mm et une erreur aléatoire de 95%CI:1,8 -2,3 mm. Ces données correspondent à une réduction de 40 % de l’erreur systématique (p=0,02) et de 25 % de l’erreur aléatoire (p= 0,003) pour l’utilisation du vacfix comparativement au plan incliné. Les données affichant la relation entre la clavicule et les autres structures anatomiques dans le volume de traitement semblent plus stables avec l’approche par vacfix individualisé.
Une stabilisation reproductible et constante pour les techniques d’imagerie du sein/SCF est cruciale pour assurer un positionnement précis de la patiente. L’analyse des erreurs de positionnement pour l’appariement de la clavicule et de l’apophyse épineuse laisse fortement croire que le vacfix permet d’obtenir une réduction de l’erreur systématique et de l’erreur aléatoire. Ceci illustre une augmentation de la stabilité et de reproductibilité du positionnement de la patiente lorsqu’un vacfix individualisé est utilisé.
Electrochemotherapy of chest wall breast cancer recurrence
2012, Cancer Treatment Reviews
Citation Excerpt :
The beneficial effect of chemotherapy after locoregional treatment for isolated locoregional recurrence is still an open question being currently investigated in a joint study by the International Breast Cancer Study Group (IBSCG) and the National Surgical Adjuvant Breast and Bowel Project (NSABP), under the umbrella of the Breast International Group (BIG). When surgical excision of CWR is not possible, radiotherapy,9 radiotherapy with hyperthermia,10 topical chemotherapy11 and electrochemotherapy might be taken into account. Radiotherapy can only be applied if the area has not been previously irradiated.
Chest wall breast cancer recurrence after mastectomy is a disease difficult to treat. Its incidence varies between 5% and 30% in different subset of patients. When possible, radical surgical therapy represents the main treatment approach, however when the disease progresses and/or treatments are not successful, ulceration, bleeding, lymphedema and psychological distress of progressive disease significantly decrease the quality of the remaining life of a patient. When surgical excision of chest wall recurrence is not possible, other local treatments such as radiotherapy, radiotherapy with hyperthermia, topical chemotherapy and electrochemotherapy might be taken into account. Electrochemotherapy provides safe, efficient and non-invasive locoregional treatment approach for chest wall breast cancer recurrence. Several clinical studies have demonstrated high efficacy and a good safety profile of electrochemotherapy applied in single or multiple consecutive sessions, till clinical response was reached. Electrochemotherapy can be performed either with cisplatin injected intratumorally or with bleomycin given intratumorally or intravenously. Furthermore, it can be effectively used in heavily pre-treated areas, after surgery, radiotherapy or systemic chemotherapy. These are the advantages that might demand its use especially in patients with pre-treated extensive disease and in frail elderly patients. With development of the technology electrochemotherapy could even be suggested as a primary local therapy in patients not suitable for surgical removal of the primary tumor.
Early Breast Cancer in the Older Woman
2012, Clinics in Geriatric Medicine
Citation Excerpt :
When combined with whole-breast radiation, BCS has equivalent survival compared with mastectomy alone. Additionally, it is standard to administer radiation to the chest wall following mastectomy if the tumor size is greater than 5 cm or if there are four or more positive lymph nodes.43 Radiation is used as an adjunct to surgery and decreases the risk of both local recurrence and subsequent metastatic spread.
Present clinical practice of breast cancer radiotherapy in Italy: a nationwide survey by the Italian Society of Radiotherapy and Clinical Oncology (AIRO) Breast Group
2020, Radiologia Medica
Dosimetric Considerations in Respiratory-Gated Deep Inspiration Breath-Hold for Left Breast Irradiation
2017, Technology in Cancer Research and Treatment
Lymph node status in different molecular subtype of breast cancer: Triple negative tumours are more likely lymph node negative
2017, Oncotarget

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Postmastectomy Radiation Therapy for Patients With Locally Advanced Breast Cancer

Section snippets

Evidence From Randomized Trials

Patients Treated With Neoadjuvant Chemotherapy

Consensus Guidelines

Eur J Cancer

Lancet

Int J Radiat Oncol Biol Phys

Radiother Oncol

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Cancer Staging Manual and Handbook

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

Adjuvant radiotherapy and chemotherapy in breast cancer

Br J Surg

The 5-year results of a randomized trial of adjuvant radiation therapy after chemotherapy in breast cancer patients treated with mastectomy

J Clin Oncol

Cause-specific mortality in long-term survivors of breast cancer who participated in trials of radiotherapy

J Clin Oncol

The role of radiotherapy in the management of operable locally advanced breast carcinoma: Results of a randomized trial by the Eastern Cooperative Oncology Group

Cancer