Axillary Failure Research Articles

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

Purpose To determine the incidence of, and risk factors for, regional nodal failure (RNF) and to evaluate the effectiveness of, and indications for, regional nodal irradiation (RNI) in patients with Stage I–II breast cancer treated with breast-conserving therapy. Methods and materials A total of 1500 cases of Stage I–II breast cancer were treated with breast-conserving therapy between February 1980 and December 2000. All patients underwent excisional biopsy, and 925 (62%) underwent re-excision. Level I–II axillary lymph node dissection was done in 94% of patients. The lymph nodes were pathologically involved in 335 patients (22%); 255 with 1–3 nodes and 80 with ≥4 nodes involved. All patients received whole breast irradiation to a median dose of 45 Gy, and 97% received a tumor bed boost to a median dose of 61 Gy. Treatment included the breast only in 1309 patients (87%), and the breast and regional lymphatics in 191 (13%). Results With a median follow-up of 8.1 years, 35 patients had failure within the regional nodes: 12 patients (6%) who received RNI and 23 patients (2%) who did not. The 5- and 10-year rate for any RNF was 1.9% and 2.8%, respectively. The 5 and 10-year rates of axillary failure and supraclavicular failure were 0.6% and 1.0% and 0.9% and 1.6%, respectively. In patients with ≥4 positive lymph nodes, RNI reduced the 10-year rate of any RNF from 11% to 2% ( p = 0.024), the rate of axillary failure from 5% to 0% ( p = 0.019), and the rate of supraclavicular failure from 11% to 2% ( p = 0.114). RNI did not affect the rate of axillary failure or supraclavicular failure in patients with 1–3 positive nodes. In node-negative patients, the rate of RNF was significantly greater if <6 nodes were removed at the time of axillary dissection. Multiple clinical, pathologic, and treatment-related factors were analyzed for association with RNF. On univariate analysis, RNF was associated with the number of nodes excised, number of positive nodes, percentage of positive nodes, size of nodal metastasis, presence of angiolymphatic invasion, estrogen receptor status, age, systemic chemotherapy, and RNI. Three subsets of patients had unusually high rates of RNF, those with ≥67% nodes positive (16%), nodal metastasis ≥2.0 cm (44%), or age ≤35 years (14%). On multivariate analysis, the only significant predictor of RNF was the maximal size of the nodal metastasis. RNI did not improve the overall survival for any subset of patients. The number of lymph nodes excised had an impact on overall survival, with a 10-year survival rate of 33%, 65%, and 69% in patients with <6, 6–10, and >10 nodes excised, respectively ( p = 0.05) Conclusion Failure within the regional lymph nodes as an isolated site of first relapse is uncommon in patients with Stage I–II breast cancer treated with breast-conserving therapy. RNI can significantly reduce the rate of RNF (axillary failure) in patients with ≥4 positive lymph nodes. The maximal size of the lymph node metastasis was found to be the only significant independent predictor of RNF, with nodal metastases ≥2.0 cm associated with extremely high regional failure rates. Despite this, young age and the extent of axillary dissection (particularly as related to the number of positive nodes) also appear to be important and should be considered when evaluating patients for RNI. Inadequate axillary dissection was not only associated with increased regional failure, but also reduced survival.

Risk factors for regional nodal failure after breast conserving therapy: regional nodal irradiation reduces the rate of axillary failure in patients with four or more positive nodes

Purpose/Objective: To determine the incidence of and risk factors for regional nodal failure (RNF), as well as to evaluate the effectiveness of and indications for regional nodal irradiation (RNI) in patients with Stage I and II breast cancer treated with breast-conserving therapy (BCT).

Adjuvant irradiation for axillary metastases from malignant melanoma

Purpose: To evaluate the outcome and treatment-related toxicity for patients with axillary lymph node metastases from malignant melanoma treated with surgery and radiation, with or without systemic therapy.Methods and Materials: The medical records of 89 consecutive patients with axillary lymph node metastases from malignant melanoma were retrospectively reviewed. All patients underwent axillary dissection and postoperative radiation to a median dose of 30 Gy at 6 Gy/fraction delivered twice weekly. In 3 patients referred with microscopic residual disease, a single boost (4–6 Gy) was given to a reduced field. All but 2 patients were referred because their axillary dissections revealed features believed to predict a 30–50% risk of subsequent axillary recurrence: lymph nodes ≥3 cm in size (54 patients), ≥4 lymph nodes positive (44), the presence of extracapsular extension (69), recurrent disease after initial surgical resection (23), or multiple risk factors (77). Fifty-one patients received systemic therapy before or after radiation therapy.Results: At a median follow-up of 63 months, 47 patients had relapsed and 43 patients had died. The actuarial overall and disease-free survival rates at 5 years were 50% and 46%, respectively. The actuarial axillary control and distant metastasis-free survival rates at 5 years were 87% and 49%, respectively. Univariate analysis revealed that the probability of axillary control was inferior when the axillary disease measured >6 cm in size (72% vs. 93%, p = 0.02), the location of the primary tumor was unknown (74% vs. 93%, p = 0.02), the axillary failure occurred within 18 months from diagnosis of the primary melanoma (84% vs. 100%, p = 0.04), or the Breslow thickness was >4 mm (80% vs. 96%, p = 0.04). Additionally, there was an inferior distant metastasis-free and disease-free survival when there were >2 nodes positive for metastatic disease, the primary lesion had a Breslow thickness >4 mm, or the axillary failure occurred within 18 months from diagnosis of the primary melanoma. On multivariate analysis, the significantly inferior distant metastasis-free and disease-free survival seen when >2 nodes were positive or the recurrence occurred within 18 months remained significant. The small number of axillary failures precluded multivariate analysis for axillary control; however, stratified analysis suggested that size >6 cm was the factor most closely associated with subsequent axillary failure. Twenty-six patients developed treatment-related arm edema. Classification according to the severity of edema yielded 5-year actuarial arm edema rates of 21%, 19%, and 1%, for Grade 1 (transient or asymptomatic), Grade 2 (requiring medical intervention), or Grade 3 (requiring surgical intervention) edema, respectively.Conclusion: Adjuvant radiation therapy using a hypofractionated regimen resulted in an 87% 5-year axillary control rate, superior to the 50–70% local control achieved with surgery alone for lymph node metastases from melanoma when high-risk features are present. Improvements are needed for patients with bulky nodal masses >6 cm in size. Mild-to-moderate arm edema was common, but manageable. The degree to which radiotherapy adds to the risk of arm edema after axillary dissection alone cannot be addressed in the present analysis.

Sentinel lymph node biopsy in breast cancer: an overview of the Japanese experience.

This paper reviews the Japanese literature regarding sentinel lymph node (SLN) biopsy in an attempt to provide an overview of existing controversies and to suggest a method for the identification of the SLN and the detection of micrometastases in the SLN to eliminate unnecessary axillary lymph node dissection (ALND). The combined dye- and gamma probe-guided method resulted in the accurate identification of the SLN in 96% of patients, compared with 80% when the dye-guided method alone was used. Although neither 99m-Tc sulfur colloid nor 99m-Tc colloidal albumin is commercially available in Japan, 99m-Tc stannous phytate and 99m-Tc rhenium colloid appear to be ideal tracers for identifying SLNs. Moreover, subdermal injection over the primary tumor or subareolar injection was found to enhance SLN identification, although these injection routes do not lead to detection of internal mammary SLNs. Furthermore, the accuracy of SLN diagnosis using frozen sections as well as imprint cytology improved with an increase in the number of sections, and could attain a sensitivity comparable to that obtained with routine histologic examination of permanent sections. As a result, several surgeons have begun to offer the option of forgoing ALND to patients with negative SLN. Although subsequent relapse in the axilla has not yet been reported, longer follow-up periods are needed to assess accurately the incidence of axillary failure in these negative SLN patients.

Follow-up of sentinel node negative breast cancer patients without axillary lymph node dissection.

The purpose of this study was to evaluate the feasibility of sentinel lymph node biopsy in breast cancer patients at our institution and to report the follow-up status of node-negative patients with removal of only the sentinel node. A total of 247 breast cancer patients underwent sentinel node (SN) mapping between June of 1996 and September of 2000. The SN was identified by using a combination of vital blue dye and a radiolabeled colloid. A SN was identified in 227 of 247 patients (91.9%). One hundred forty-five were SN negative, 82 were SN positive. All SN-positive patients underwent axillary dissection of level I and II, whereas 83 patients with a negative SN had SN biopsy only. Median follow-up of these patients at 22 months revealed no axillary recurrence; the morbidity resulting from SN biopsy was negligible. Although the follow-up is very short, SN biopsy only in node-negative breast cancer patients had no negative impact on the axillary failure rate and resulted in negligible morbidity.

Axillary Recurrence Following Conservative Surgery and Radiotherapy in Early Breast Cancer

At the institute, since the late 1980s, there has been a uniform treatment protocol for the management of the regional lymph nodes in patients referred for radiotherapy following breast-conserving surgery. An analysis of 2277 consecutive patients referred for radiotherapy between 1989 and 1992, with particular reference to regional lymph node management, has been undertaken. Axillary surgery alone was used in 517 patients (23%); 1191 (52%) patients had no axillary surgery but had radiotherapy to the axilla, and infraclavicular and supraclavicular fossae by a single anterior field, delivering 40 Gy in 15 daily fractions over 3 weeks; and 474 patients (21%) had axillary surgery followed by radiotherapy. Ninety-five patients (4%) underwent no axillary treatment. There was a total of 155 axillary recurrences with a median follow-up of 5.9 years, giving an actuarial nodal control rate of 94% at 5 years (95% confidence interval (CI) 93.1–95.1). The overall survival at 5 years was 86% (95% CI 84.6–87.5). There was a trend towards improved axillary control with surgery alone compared with radiotherapy alone (4.5% versus 5.9% actuarial axillary failure rate at 5 years). An extremely low incidence of brachial plexus neuropathy secondary to radiotherapy was reported. The multidisciplinary treatment protocol used gave a high rate of regional node control, with minimal recorded morbidity.

Factors associated with regional nodal failure in patients with early stage breast cancer with 0–3 positive axillary nodes following tangential irradiation alone

Purpose: Recent randomized trials have suggested that improved local-regional control after radiation therapy significantly increases survival for breast cancer patients with positive axillary nodes treated with adjuvant systemic therapy (1, 2). It has been our policy to use a third radiation field only in patients with 4 or more positive nodes. The purpose of this study was to assess whether there are any clinical or pathologic factors associated with an increased risk of regional nodal failure (RNF) in patients with 0–3 positive nodes treated with tangential radiotherapy (RT) alone with or without systemic therapy. Methods and Materials: We retrospectively analyzed the incidence of RNF for 691 patients with clinical Stage I or II invasive breast cancer treated with complete gross excision of the primary tumor and tangential RT alone between 1978–87; 12% also received systemic therapy. All had 0–3 positive nodes on axillary dissection that had histologic examination of ≥ 6 nodes, and all had potential 8-year follow-up. The median number of axillary nodes removed was 11 (range 6–36). RNF was defined as any recurrence in ipsilateral axillary, internal mammary, supraclavicular, or infraclavicular nodes in the absence of recurrence in the breast, with or without simultaneous distant metastasis. Crude rates for first sites of failure within the first 8 years after treatment were calculated. A polychotomous logistic regression was used to identify factors prognostic for RNF and other sites of first failure. Results: Within 8 years, RNF was the first site of failure for 27 patients for a crude 8-year rate of 3.9%. Isolated axillary failure occurred in 8 patients (1.2%). Isolated supraclavicular and/or infraclavicular failure occurred in 5 (1.3%) and 3 (0.4%) patients, respectively. Isolated internal mammary node failure occurred in 2 patients (0.3%). A polychotomous logistic regression model of first site of failure (local failure, regional nodal, distant/opposite breast, dead without recurrence, no evidence of disease) within 8 years found age <50 years, moderate or marked necrosis, size greater than 1 cm, and presence of an extensive intraductal component (EIC) to be significantly correlated with site of first failure, but only the last two were associated with a significantly larger relative risk of RNF versus being no evidence of disease at 8 years. The incidence of RNF was 0.7% for patients with tumors ≤ 1 cm compared to 5.7% among patients with larger tumors. Among patients with EIC-positive tumors the incidence of RNF was 7.6% compared to 3.1% among those whose tumors were EIC-negative. Conclusions: Although the incidence of RNF has been shown to be somewhat higher in patients with tumors measuring greater than 1 cm and those with an EIC, RNF is uncommon among all subsets of patients with negative or 1–3 positive lymph nodes treated with conservative surgery, axillary dissection, and only tangential RT fields. Therefore, giving only tangential RT (without a separate nodal field) appears generally acceptable for patients with 0–3 positive nodes.

A cost-effectiveness analysis of axillary node dissection in postmenopausal woman with estrogen receptor–positive breast cancer and clinically negative axillary nodes

Abstract Purpose: The purpose of this study was to examine the cost-effectiveness of immediate axillary lymph node dissection (ALND) in estrogen receptor–positive women with clinically negative nodes. Methods: We constructed a Markov model comparing hypothetical cohorts of postmenopausal women who were estrogen receptor positive with clinically negative axillae. The women underwent immediate ALND or watchful waiting, with ALND performed only for those patients developing palpable axillary nodes. Recurrence risks, chemotherapeutic benefits, and treatment costs were estimated from the published literature. The main outcome measures were quality-adjusted survival and incremental cost per quality-adjusted life-year (QALY). Results: For 55-year-old women with palpable (3 cm) tumors, immediate ALND results in improved survival (10.3 versus 10.05 QALYs) and a cost-effectiveness ratio of $36,700 per QALY, if chemotherapy is given to those with histologically positive lymph nodes. The benefits of ALND are greatest for younger women with larger palpable tumors. Because of the lower risk of nodal metastases, patients with 1-cm nonpalpable tumors experience minimal benefit at markedly higher incremental costs ($308,000 per QALY). If chemotherapy will not be given to patients with histologically positive lymph nodes because of a patient's or a physician's wishes, then there is no benefit to immediate ALND in any patient subgroup. Conclusion: When the results of ALND are used to guide postoperative decisions, immediate ALND results in considerable benefit at a reasonable cost for most women with palpable tumors. Because the benefits are lower in patients with nonpalpable tumors, ALND should not be considered mandatory for that subgroup. Decisions for ALND should be based on patient age, tumor size and palpability, individual patient preferences, the likelihood of receiving postoperative chemotherapy, and other prognostic factors. (Surgery 1999;126:568-76.)

Significance of axillary lymph node extranodal soft tissue extension and indications for postmastectomy irradiation.

Extranodal soft tissue extension of axillary lymph node metastases (ETE) has been considered an indication for postmastectomy radiotherapy, including the axilla. However, it is unclear whether patients with ETE are at an increased risk of axillary recurrence. From a single institutional database of 2362 patients with breast carcinoma treated between 1974-1994, a total of 487 patients who underwent mastectomy for lymph node positive, infiltrating (T1-T3) breast carcinoma was found. All the patients had pathologically confirmed axillary lymph node metastases and negative surgical margins; none had received postoperative irradiation. Of these patients, 50 had histologically documented axillary ETE. Forty-three patients had a minimum follow-up of at least 1 year and comprise the study population. The median follow-up time of surviving ETE positive patients was 79 months. Twenty-five patients (58.1%) received adjuvant systemic therapy. Sites of first failure were local or distant. Local failure was categorized further as chest wall failure, axillary failure, supraclavicular lymph node failure, or internal mammary lymph node failure. For the 43 patients with ETE, the median patient age was 59.5 years (range, 38-81 years) and the median tumor size was 3.6 cm (range, 0.5-12.0 cm). The median number of positive axillary lymph nodes was 6 (range, 1-36 lymph nodes) versus 2 (range, 1-30 lymph nodes) for all T1-T3 ETE positive patients compared with ETE negative patients (P < 0. 001). The risk of ETE increased significantly with increasing numbers of axillary lymph node metastases (P < 0.001). Of the patients with ETE, 16 (37.2%) developed recurrent disease. ETE positive patients with disease recurrence had significantly greater numbers of positive axillary lymph nodes (median, 10 lymph nodes) than those patients who were recurrence free (median, 4 lymph nodes) (P = 0.02). The site of first failure was local in 7 patients (16. 3%) and distant in 9 patients (20.9%). All patients with local recurrence had chest wall failures; there were no isolated lymph node recurrences. The only simultaneous local and distant failure was in one patient presenting with supraclavicular and intraabdominal metastases. 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.

Postmastectomy irradiation: Rationale for treatment field selection

The goal of postmastectomy irradiation is to eliminate residual viable tumor in tissue remaining after standard mastectomy. Because this subclinical disease is, by definition, not detectable by current technology, the choice of patients and treatment volumes for postmastectomy irradiation must be inferred from a variety of data sources. The absolute risk of locoregional recurrence is related to the stage of disease, the extent of lymphatic involvement, and other treatment received. Patterns of failure analyses consistently identify the chest wall as the most important target for treatment with radiation therapy in high-risk patients. When patients with multiple locoregional sites of recurrence are included, the chest wall may be involved in as many as 60% to 80% of patients. The second most common place for locoregional failure is the undissected lymphatics of the paraclavicular region. The cumulative probability of failure in this region ranges from 10% to 35% of the patients treated for locoregional recurrence. Microscopic tumor metastases in the internal mammary chain are theorized to represent a potential source for distant metastases. Each of the prospective trials of postmastectomy irradiation that have shown survival benefit included the internal mammary chain within their target volume. Nonetheless, local failure in the internal mammary nodes is an uncommon finding. Similarly, after a level I and II axillary dissection, axillary failure is a minor component of local recurrence risk, and it is probable that only a subset of patients may benefit from axillary irradiation.

Incidence and time of occurrence of regional recurrence in stage i-ii breast cancer: value of adjuvant irradiation

Purpose: The value of adjuvant radiation therapy (RT) of the axilla and supraclavicular fossa is controversial in early-stage breast cancer. This retrospective study was undertaken to identify pathological risk factors that would predict which subsets of patients would benefit from regional nodal irradiation (RNI). Methods and Materials: A total of 1309 women with Stage I/II breast cancer underwent full axillary dissection and either mastectomy ( n = 894) or breast-conserving surgery ( n = 415). Of these, 712 patients received RNI. The median axilla/supraclavicular fossa dose was 50 Gy. Results: The 10-year actuarial rate of axillary failure (AXF) was 0.5% in N0 and 2.8% in N1 patients ( p = 0.0014). The number of retrieved nodes, ≤ 5 vs. > 5, also correlated with AXF; the respective rate was 4.3% vs. 1.2% ( p = 0.0142). Neither the incidence of AXF nor the time to AXF was affected significantly by the use of RNI, but in N1 patients with retrieved nodes ≤ 5, the rate of AXF was 8.3% without RNI vs. 0% with RNI ( p = 0.2340). The 10-year actuarial rate of supraclavicular failure (SCF) was 1.2% in N0 and 6.3% in N1 patients ( p = 0.0000). SCF was also associated with the extent of nodal involvement ( p = 0.0031). The incidence of SCF was not significantly affected by the use of RNI. However, when the results of N1bii and N1biv patients were evaluated as a single group, the effect of RNI was significant ( p = 0.0358). The rates of SCF without RNI were high in patients with N1bii or N1biv stage: 10% and 37.5% and, with RNI, 3.2% and 18.2%, respectively. These findings were reinforced by the various combinations of T- and N1-stage. The mean time to SCF was 53.6 months in the irradiated and 24.9 months in the nonirradiated patients ( p = 0.0007). Conclusions: After a complete axillary dissection, only N1 patients with retrieved nodes ≤ 5 may be considered for axillary RT. Elective supraclavicular RT is suggested for patients with N1bii or N1biv stage. Supraclavicular irradiation decreases the incidence and delays the appearance of SCF.

The role of regional nodal irradiation in the management of patients with early-stage breast cancer treated with breast-conserving therapy

To determine the incidence of regional nodal failure (RNF) and indications for regional nodal irradiation (RNI) in patients with Stage I and II breast cancer treated with breast-conserving therapy (BCT). Four hundred fifty-six patients with Stage I/II breast cancer were treated with BCT at William Beaumont Hospital. All patients underwent excisional biopsy and 288 (63%) were reexcised. A Level I/II ipsilateral axillary lymph node dissection was performed on 431 patients (95%). Pathologically involved nodes were found in 106 (23%) cases (69 with one to three nodes and 37 with > or = four nodes involved). All patients received whole breast irradiation (median dose 50 Gy) and 415 (91%) were boosted to the tumor bed (median total dose 60.4 Gy). Three hundred and sixty (79%) patients received breast alone irradiation and 96 (21%) also received RNI. The median axilla/supraclavicular fossa dose was 50 Gy. With a median follow-up of 83 months, 15 patients developed a RNF for a 5- and 8-year actuarial rate of 3 and 4%, respectively. The 5- and 8-year actuarial rates of axillary failure (AF) were 0.7 and 1.0%, respectively. The incidence of RNF or AF was not affected by the use of RNI in N0 or N1 patients with one to three positive nodes. Only in patients with four or more positive nodes was there a trend towards improved regional control with RNI (p = 0.09). However, patient numbers were extremely small, and this improvement was limited to a reduction in the rate of failure in the supraclavicular fossa (SCF) (20 vs. 0%, p = 0.04). Multiple clinical, pathologic, and treatment related factors were analyzed for an association with AF. On univariate analysis, AF was associated with the number of lymph nodes excised (p < 0.0001) estrogen receptor status (p = 0.0016), and pathologic node status (p = 0.0021). Regional nodal failure as the first site of failure is uncommon in patients with early-stage breast cancer treated with BCT with < or = three positive lymph nodes and appears unaffected by RNI. For patients with four or more positive lymph nodes, a trend towards improved RNF was noted with RNI, primarily in the SCF. However, patient numbers were extremely small in all subsets analyzed. Additional studies are needed to further define the need for RNI in these patients and help determine other factors associated with RNF.

0-33. Can sentinel lymph node biopsy avoid axillary dissection in node negative breast cancer patients?

parameters examined (age, estrogen and/or progestorone receptor status, histologic grade, nuclear grade) showed a significant relationship to axillary failure, with a reasonable rate of local control in small tumors. Therefore, in these cases, wide excision without AD is a reasonable treatment, in order to avoid the arm morbidity of AD. On the basis of these results, a clinical trial including a breast-conserving surgical treatment arm without AD has been implemented in early breast cancer, cl.5 cm in size and with clinically negative nodes.

Clinical behavior of untreated axillary nodes after local treatment for primary breast cancer.

The purpose of this study was to examine the rate of axillary failure in patients with primary breast cancer treated without axillary dissection or radiation and to determine what factors may be associated with axillary failure. We studied 112 patients with invasive breast cancer treated for primary disease with breast-conserving surgery without axillary dissection or radiation to the breast or axilla, accrued between 1977 and 1986. Data for these patients were prospectively gathered for a research database and reviewed retrospectively to determine axillary failure. The effects of age, tumor size, estrogen receptor (ER) status, progesterone receptor (PgR) status, histologic grade, nuclear grade, and tumor emboli on time to axillary failure were examined. The median follow-up was 9.6 years. There were 26 axillary recurrences, resulting in a 10-year actuarial nodal control rate of 72%. Patients with nodal failure proceeded to axillary dissection with minimal morbidity. In both univariate and multivariate analyses, only tumor size was significantly associated with axillary failure (p = 0.04 and p = 0.06, respectively). This study demonstrates a significant effect of tumor size on axillary failure and a reasonable rate of local control in small tumors. Further research should examine the utility of axillary dissection in women with small breast cancers.

Axillary Metastatic Spread in Connection with Local Recurrence of a Renal Cell Carcinoma 22 Years after the First Diagnosis – Case Report and Survey of the Literature

Background: Manifold metastatic spread of renal cell carcinoma, even after long-term latency, is feared and unpredictable. Late recurrence after more than 10 years is not rare and then often initially misdiagnosed. Patient and Material: We are reporting on a 76-year-old male patient in whom an axillary lymph node metastasis was diagnosed 20 years after tumor nephrectomy and preoperative radiotherapy for a renal cell carcinoma. After tumor extirpation and 6 cycles of interferon therapy axillary failure recurred. Due to unexplained upper abdominal symptoms, an abdominal CT was carried out and a tentative diagnosis of a local recurrence in the former renal bed was made. Laparotomy was necessary due to a blocked passage resulting from a duodenal stenosis. Results: A local recurrence with compression of the duodenum was histologically confirmed. A duo-denojejunostomy was carried out for passage reconstruction. Conclusions: Regular follow-up care is particularly important for patients with renal cell carcinomas, since isolated late metastases can occur after 20 years or more. However, the diagnosis is often delayed, since a malignant disease originating from the primary is not expected after such a long interval. With aggressive therapy for those late recurrences/metastases, some patients can still survive for years depending on their general condition.

Axillary lymph nodes and breast cancer. A review

The value of surgical staging and treatment of the axillary lymph nodes with either surgery or radiotherapy in the initial management of patients with Stage I or II invasive breast cancer is controversial. A review of retrospective and prospective clinical studies was performed to assess the risks of axillary lymph node involvement and the effectiveness and morbidity of various treatment options. The risk of axillary lymph node involvement is substantial for most patients, even those with small tumors. The morbidity resulting from a careful Level I/II axillary dissection or moderate-dose axillary radiotherapy is limited. Such treatment is highly effective in preventing axillary recurrence. The symptoms resulting from axillary failure can be controlled in many, but not all, patients. The available data suggest, but do not prove, that the initial use of effective axillary treatment may result in a small improvement in long term outcome in some patient subgroups. Most patients should be treated with either axillary surgery or irradiation. Highly selected subgroups of patients may have such low risks of involvement that specific axillary treatment is of little value. However, such subgroups have not yet been well defined. Treatment approaches that do not involve specific axillary treatment should be considered investigational at present, and the patients should be informed as to their potential risks. Prospective clinical studies of these issues should be pursued.

Microscopic extracapsular extension in the axilla: Is this an indication for axillary radiotherapy?

Purpose : Although the axilla is often treated with radiotherapy (RT) postoperatively when microscopic extracapsular extension (EC) of lymph nodal metases is present, little data are available to assess axillary failure in the absence of such treatment. As it has been the practice at this institution to withhold axillary irradiation in the presence of microscopic extracapsular spread, we retrospectively analyzed our results for axillary recurrence, disease-free survival (DFS), and overall survival (OS). Methods and Materials : Clinical records were reviewed of 82 women with Stage II node positive breast cancer treated with lumpectomy, axillary dissection, and RT in addition to systemic chemo/hormonal therapy. Axillary surgery consisted of a level I, II, ±III dissection, with a 16.5 nodes removed. Tangential radiotherapy fields were used to treat the breast. All patients were also treated with an abbreviated supraclavicular field with the lateral border medial to the humeral head. Pathological sections were available for review in 72 of the 82 women Results : Twenty-seven of 72 (37.5%) had evidence of ECE; 45 of 72 (62.5%) had metastic carcinoma confined within the nodal capsule. Clinical characteristics were comparable between the patients with and without ECE with the exception of (a) pathologic subtype, with a greater percentage of infiltrating ductal tumors associated with ECE ( p = 0.044), and (b) number of positive lymph nodes, with 93% of patients without ECE having one to three positive nodes vs. only 56% among patients with ECE ( p < 0.001). With a median follow-up of 40 months, 1 of 27 patients (4%) with ECE experienced an axillary failure as a component of first failure compared to 0 to 45 patients without ECE ( p = 0.4). There were no isolated axillary failures. Five-year disease-free survival (72% without ECE vs. 57% with ECE, p = 0.12) and overall survival (83% vs. 53%, respectively, p = 0.068) suggested a less favorable outcome for patients with ECE. Microscopic ECE appears to be associated with increased axillary involvement and decreased survival rather than subsequent axillary failure. Our data suggest that radiotherapy to a dissected axilla may be omitted for the sole indication of microscopic extracapsular disease.

Breast conservation treatment of early stage breast cancer: patterns of failure

Purpose : This study retrospectively assesses the patterns of failure in conservatively treated early stage breast cancer patients by correlating various clinical, pathologic, and treatment-related factors with local, axillary, and distant relapse. Methods and Materials : Between 1973 and 1990, 796 patients (817 breasts) received breast conservation surgery followed by radiotherapy. Local recurrences were counted as events even if they occurred simultaneously or after the appearance of axillary or distant metastases. Results : The 10-year actuarial relative disease-free survival (DFS) rate for T1N0, T2N0, and T1-2N1 was 82%, 71%, and 54%, respectively. Stage N0 patients had a significant DFS advantage over N1 patients ( p = 0.02). The 15-year actuarial local recurrence-free rate for T1 and T2 tumors was 82% and 87%, respectively ( p = nonsignificant). Univariate analysis identified three significant risk factors for local relapse: (a) 48 breasts with tumors showing an extensive intraductal component had a crude local recurrence rate of 23% compared to 8% for 769 breasts without intraductal component ( p = 0.0016); (b) the actuarial 10-year local recurrence-free rate for patients under age 40 years was 64% compared to 88% for patients over 40 years ( p < 0.0001); (c) the 10-year actuarial local recurrence-free rate for 416 postmenopausal women without adjuvant tamoxifen was 83% compared to 97% for 107 postmenopausal women with tamoxifen ( p = 0.0479). Salvage therapy for operable local recurrent patients resulted in a 8-year actuarial DFS rate of 47%, significantly lower than that obtained with primary treatment. The incidence of axillary relapse as the first sign of recurrence was 2%, and could be correlated with the lack of axillary dissection ( p < 0.0000005) and primary tumor size ( p = 0.03). Radiotherapy to the axilla did not influence axillary relapse. Actuarial 5-year DFS rate after treatment of isolated axillary recurrence was 27%. Axillary failure was a marker for distant failure. Contralateral breast cancer occurred in 8% of patients and did not have a detrimental effect on survival. Adjuvant tamoxifen decreased the 9-year actuarial incidence of contralateral breast cancer from 10% to 4% ( p = 0.053). Conclusions : Tumors with extensive intraductal component, age under 40 years, and the omission of adjuvant tamoxifen in postmenopausal women increased local recurrence rate. Stage T2 and the lack of axillary dissection increased axillary recurrence rate. Stage N+ and local or axillary relapse increased distant failure rate. Axillary irradiation did not influence locoregional control nor survival. Improved therapy is needed for relapsing patients.

Management of the Axilla in Patients with Breast Cancers One Centimeter or Smaller

Very small breast cancers are being diagnosed with increased frequency, and, until recently, little information regarding the incidence of axillary lymph node metastases in these most favorable tumors was available. Moreover, scarce data exist regarding axillary failure in this cohort as a function of initial treatment, be it surgery, radiation, or simply observation. In the present study, limited to women with invasive cancers measuring no more than 10 mm, the incidence of pathologically positive axillary nodes was 12.3%. The incidence of nodal metastases was influenced by tumor size (albeit not quite significantly, p = .08); not one patient with a tumor < or = 5 mm had axillary node metastases, compared to 14.7% in those with cancers 6 to 10 mm. The histologic grade and tumor location were also important in predicting nodal positivity. The incidence of positive nodes was 38% in those with poorly differentiated cancers, compared to 8% and 7% in women with well and moderately differentiated cancers, respectively, p = .03. Axillary nodal positivity was seen in 17% of outer quadrant vs 3% of central and inner quadrant primaries, p < .01. The axilla was managed with surgery alone (76%), radiation alone (6%), surgery and radiation (6%), or simply observation (10%). With a median follow-up of 55 months, not one patient has suffered a nodal recurrence, and in our experience, survival free of distant relapse was not adversely affected by the omission of axillary surgery.

Regional nodal failure after conservative surgery and radiotherapy for early-stage breast carcinoma.

We retrospectively analyzed the likelihood of regional nodal failure (RNF) for 1,624 patients with stage I or II invasive breast carcinoma treated with conservative surgery and radiotherapy (RT) at the Joint Center for Radiation Therapy (JCRT) between 1968 and 1985. The median follow-up time was 77 months. RNF was the first site of failure for 38 of the 1,624 patients (2.3%). The incidence of axillary failure for patients undergoing axillary dissection (AXD) who were irradiated to the breast only was 2.1% (nine of 420) for patients with negative nodes and 2.1% (one of 47) for patients with one to three positive nodes. The incidence of supraclavicular failure in these two groups was 1.9% (eight of 420) and 0% (zero of 47), respectively. The incidences of axillary and supraclavicular failure in patients without clinically suspicious axillary involvement who did not have AXD but were treated with RT were 0.8% (three of 355) and 0.3% (one of 364), respectively. Despite various combinations of salvage surgery, RT, and systemic therapy, only 47% of patients (18 of 38) achieved complete regional control after nodal relapse. We conclude that RNF is uncommon in patients treated to the breast alone following an adequate AXD when the axillary nodes are negative or when one to three nodes are positive. RNF is also uncommon in patients with a clinically uninvolved axilla treated with nodal RT without AXD. Symptoms of RNF can be controlled in most but not all patients. Further study is needed to determine if the benefits of RT in preventing a small number of symptomatic RNF outweigh the potential toxicity for any subgroup of patients.