De-escalation of Radiation in Positive Axilla for Breast Cancer Radiation de escalation breast cancer

Abstract

Introduction: There has been a trend towards de-escalation in the management of axilla over the last two decades in the form of shift from axillary lymph node dissection to sentinel lymph node dissection in early stage breast cancer. This de-escalation has main advantage in terms of reducing the incidence of lymphedema without compromising the local control. However, when it comes to axillary radiation, there is lack of consensus regarding its use . In this context we reviewed our prospectively maintained data base for axillary recurrences, without radiation to axilla in axillary node positive patient cohort. Materials and methods: The data of breast cancer patients treated at Medanta, Cancer Institute from 2010 till 2020 was analyzed by querying the electronic health records. Minimum follow up was 2 years after completion of radiation treatment. During follow up, patients were assessed clinically and underwent yearly mammogram, bi-annual ultrasound abdomen and annual chest X-Ray. In case of clinically palpable or suspicious lymph nodes in axilla, a histopathological confirmation was required. The axilla was not irradiated intentionally except in very few cases where the decision was individualized as per surgical and pathological findings after discussion in the tumour board meeting. Results: Of the 2400 breast cancer patients treated from 2010-2020, final analysis included 1422 patients as per the inclusion criteria. Pathological node positive cases were 827(58.15%). Of which 446/827(53.9%) had N1, 283/827(34.2%) were N2 and 98/827(11.8%) were with N3 disease status. 69.19% patients had undergone axillary dissection. A total of 35 patients received axillary radiation, 7 of them had early stage disease, underwent sentinel lymph node biopsy and were treated before 2013, and rest of them had advanced local disease, post axillary dissection with high axillary burden and presence of high risk features. None (0%) of the patients developed ipsilateral axillary relapse. Conclusion: The results of this study are a step further in de-escalation of axillary management in terms of radiation, and provide robust data in support of omitting the axillary radiation for breast cancer patients even when sentinel node biopsy shows (1-2) positive nodes for early stage breast disease and in locally advanced breast disease when adequate axillary dissection (even with heavy axillary node burden) has been performed.