Indications For Postmastectomy Radiation Therapy Research Articles

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy

AimDemand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario. MethodsA large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology. ResultsThe panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR. ConclusionsThe panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR

Clinical outcomes and prognostic factors in patients with stage II-III breast cancer treated with neoadjuvant chemotherapy followed by surgery and postmastectomy radiation therapy in the modern treatment era

PurposeThere are no randomized studies on the indication for postmastectomy radiation therapy (PMRT) in patients who receive neoadjuvant chemotherapy (NAC) followed by a mastectomy. The aim of this study was to determine clinical outcomes and identify reliable prognostic factors in patients with locally advanced breast cancer treated with NAC followed by a mastectomy and PMRT. Methods and materialsWe retrospectively evaluated the relationship between clinicopathological factors and outcomes in 351 patients with stage II or III breast cancer who underwent NAC followed by radical mastectomy and PMRT between March 2005 and December 2013. ResultsThe median follow-up duration was 81 months (Range, 12-156 months). For all patients, the 5-year locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS) rates were 91.3 %, 69.8 %, and 83.4 %, respectively. On multivariate analysis, estrogen-receptor positivity, and complete response of cancer in axillary nodes (ypN0) were significant prognostic factors for better LRFS, while lympho-vascular invasion and clinical stage IIIC were independent prognostic factors for worse LRFS. The number of axillary node metastasesafter surgery was an independent prognostic factor of DMFS and OS. Patients with hormone receptor- and human epidermal growth factor receptor 2 positivity had significantly better 5-year LRFS rates. ConclusionsWe identified several prognostic factors in our study. In particular, the number of axillary node metastases is significantly related to OS.

A component of lobular carcinoma in clinically lymph node–negative patients predicts for an increased likelihood of upstaging to pathologic stage III breast cancer

PurposePhysical examination and diagnostic imaging are often less precise in determining the extent of disease in invasive lobular carcinoma (ILC) relative to nonlobular histologies. Anecdotally, surgical axillary evaluation frequently reveals positive lymph nodes in clinically N0 patients with ILC; however, few studies quantify the likelihood of finding unsuspected disease at the time of surgery. In this study, we evaluate whether the presence of lobular histology increases the incidence of surgical upstaging to pathologic stage IIIA or greater in patients with a clinically node-negative axilla and positive sentinel lymph node (SLN) biopsy. Methods and materialsWe examined patients from our institution between 1997 and 2009 treated specifically with mastectomy, SLN biopsy, and completion axillary lymph node dissection due to a positive SLN. For analysis, patients were grouped according to the presence of any lobular component on surgical pathology. The number of total positive lymph nodes, cancer stage, age, final tumor size, and ER/PR/HER2 status were assessed based on tumor histology. ResultsWe evaluated 345 previously untreated women with clinical T0-T2 and N0 disease at the time of surgery. A total of 110 patients (32%) had a component of ILC on surgical pathology. In addition, 295 patients (85.5%) had ER + breast carcinoma, 243 (70.4%) had PR + disease, 56 (16.2%) were HER2 + , and 28 (8.1%) were triple negative. At the time of surgery, women with lobular disease were observed to have a greater number of positive lymph nodes (2.79 vs 2.26; P = .009) and were more frequently upstaged to at least pathologic stage IIIA compared with nonlobular patients (30.9% vs 17.4%; P = .007). ConclusionsIn this cohort, patients with a component of lobular carcinoma were more often surgically upstaged to pathologic stage IIIA or higher, which is a classical indication for postmastectomy radiation therapy. Our findings suggest that ILC is often more extensive than it appears clinically and has significant implications for management of patients with lobular carcinoma after the discovery of a positive SLN.

Postmastectomy Radiation Therapy: Are We Ready to Individualize Radiation?

Contemporary recommendations for postmastectomy radiation have undergone a shift in thinking away from simple stage based recommendations (one size fits all) to a system that considers both tumor biology and host factors. While surgical staging has traditionally dictated indications for postmastectomy radiation therapy (PMRT), our current understanding of tumor biology, host, immunoprofiles, and tumor microenvironment may direct a more personalized approach to radiation. Understanding the interaction of these variables may permit individualization of adjuvant therapy aimed at appropriate escalation and deescalation, including recommendations for PMRT. This article summarizes the current data regarding tumor and host molecular biomarkers in vitro and in vivo that support the individualization of PMRT and discusses open questions that may alter the future of breast cancer treatment.

Trends in use and outcome of postoperative radiotherapy following mastectomy: A population-based study

PurposeThe objective of the present population-based study was to evaluate the role and effectiveness of postmastectomy radiation therapy (PMRT) in clinical practice. MethodsThe study included 16,675 patients diagnosed with invasive breast cancer from 1988 to 2012 and resident within the catchment area of the Munich Cancer Registry. Use of PMRT, local recurrence-free survival (LRFS), cumulative incidence of time to local recurrence, relative survival and conditional overall survival (cOS), were analysed for different time periods (1988–1997 and 1998–2012). ResultsVariables favouring the use of PMRT on multivariate logistic regression analysis included young age, large tumour size, positive resection margin and positive nodal status. Over time, a significant increase of PMRT was registered for patients with ⩾4 positive lymph nodes. Moreover, the present findings track a less frequent use of PMRT in elderly patients.After adjusting for age, tumour characteristics and therapies, the Cox regression analysis for LRFS identified PMRT as an independent predictor for improved local control (HR: 2.145; 95% CI: 1.787–2.574, p<0.0001). Patients with 1–3 involved lymph nodes had a 10-year cumulative incidence of local recurrence of 13.7% following mastectomy, compared to 6.5% following PMRT (p=0.0001). Comparable findings were obtained for patients presenting with ⩾4 positive lymph nodes. All effects were smaller or extinct in elderly patients aged ⩾70years. On multivariate analysis for cOS, no significant advantage for PMRT could be detected (HR: 1.084; 95% CI: 0.986–1.191, p=0.095). ConclusionThe present study was useful in providing an overview on trends in the adoption of PMRT over a 25-year period. An increase in the use of PMRT from 1988 to 2012 was observed, especially in high-risk patients with ⩾4 positive lymph nodes. Patients selected for PMRT had an improved local control and an equivalent relative survival compared to patients who had no indication for PMRT.

Breast cancer multifocality-multicentricity and locoregional recurrance.

1029 Background: The impact of multifocality (MF) and multicentricity (MC) on locoregional (LR) control for invasive breast cancer, and the optimal local treatment strategy for these tumors, is unknown. In particular, there is disagreement in the literature regarding the use of Breast Conservation Therapy (BCT). We evaluated a large single institution cohort of MF and MC breast cancers to determine if they had inferior LR control rate when compared to their unifocal counterparts. Methods: MF and MC were defined pathologically as more than one lesion in the same quadrant and more than one lesion in separate quadrants, respectively. Patients were categorized by presence or absence of MF or MC disease and by the LR treatment modality received – BCT (n=256), mastectomy alone (n=466), or mastectomy plus post-mastectomy radiation therapy (n=184). 10 patients who underwent BCT for MC disease against physician advice were excluded. MF and MC tumors were analyzed both as a group and as separate entities. Kaplan-Meier product limit method was used to calculate 5-year LR control rate. Cox proportional hazards models were fit to determine independent associations of MF/MC disease with LR control. Results: Median follow up was 52 months. Out of 3722 patients with stage I-III disease who did not receive neoadjuvant chemotherapy, 906 (24%) had MF (n=673) or MC (n=233) disease. 5-year rate of LR control rate was 99% in the MF group, 96% in the MC group, and 98% in the unifocal group, (P = 0.44). Subset analysis revealed no statistical difference in LR control regardless of the type of LR treatment, (P = 0.67 in the BCT group, P = 0.37 in the mastectomy alone group, and P = 0.29 in the mastectomy plus post-mastectomy radiation therapy group). There were 21 in-breast recurrences after BCT (8.2%). After controlling for other risk factors, MF and MC did not have an independent impact on LR control rate. Conclusions: MF and MC disease are not independent risk factors for LR recurrence. Patients with MF and MC breast cancer had similar rates of LR control to their unifocal counterparts, regardless of LR treatment modality. Our data suggest that BCT is a safe option for patients with MF tumors and that MF or MC disease alone is not an indication for post-mastectomy radiation therapy.

Implications of postmastectomy radiation therapy on optimal timing and approach for breast reconstruction

Despite advances in early detection and ample data demonstrating the long-term safety of breast-conservation therapy, mastectomy continues to be increasingly utilized in the treatment of breast cancer. Studies have shown significant psychosocial and emotional health benefits for breast reconstruction after mastectomy. Skin-sparing mastectomy is a safe technique that facilitates immediate breast reconstruction (IBR). Although IBR does not increase local recurrence rates or delay the initiation of adjuvant chemotherapy or radiotherapy, there is some evidence that it is linked to increased complications in the setting of postoperative radiotherapy. With the growing recognition of the importance of local tumor control on long-term survival, an emphasis is being placed on identifying women who may benefit from postmastectomy radiation therapy (PMRT). Although PMRT can undeniably improve breast cancer outcomes in high-risk patients, it may have a deleterious effect on reconstruction complications and aesthetic outcomes. As the indications for PMRT continue to evolve, determining the best timing for and type of reconstruction after mastectomy has never been more important.

Postmastectomy Radiation Therapy and Breast Reconstruction: An Analysis of Complications and Patient Satisfaction.

Abstract Introduction: The indications for postmastectomy radiation therapy (PMRT) have expanded over the past decade. Plastic surgeons are reluctant to perform an immediate reconstruction followed by radiation because of their perception this sequence results in worse results. This study examines the relationship between the use and sequencing of radiation therapy on complication rates and patient satisfaction following reconstrucion.Methods: A retrospective chart review was performed of all women at an academic institution who underwent mastectomy and reconstruction from 1999-2006. The 769 reconstructed breasts were separated into 4 groups: PMRT prior to delayed reconstruction (n = 60); immediate reconstruction then PMRT (n = 56); reconstruction without PMRT (n = 540); and reconstruction after breast-conserving therapy with RT (BCT-RT, n = 113). The median length of follow-up was 44 months. All operative complications were categorized into early (≤90 days) or late. A questionnaire based on the Michigan Breast Reconstruction Outcomes Study assessed general and aesthetic satisfaction (response rate, 73.2%). Dichotomous variables were evaluated using the Fisher's exact or chi-squared test; statistical significance was set at p &amp;lt;0.05.Results: The overall complication rate for patients having PMRT (given before or after reconstruction) was higher than for patients with reconstruction only (36% vs. 27%, p = 0.048). The overall complication rate for women receiving PMRT then reconstruction was lower than for reconstruction then PMRT, although this was not statistically significant (28% vs. 45%, p = 0.068). Patients having reconstruction then PMRT had increased overall and late complication rates compared to patients having reconstruction only (45% vs.27.%, p = 0.006; 34% vs. 21%, p = 0.023, respectively). Results were similar when subdivided by the kind of reconstruction, except for increased late complications for patients having implant/expanders who had reconstruction then PMRT (62%, 8/13) compared to reconstruction alone (20%, 26/129) (p=0.003). General satisfaction was similar among all four groups. Aesthetic satisfaction was significantly lower in the PMRT then reconstruction group, compared to reconstruction only (48% vs. 65%, p = 0.029). Patients who underwent reconstruction then PMRT had similar aesthetic satisfaction compared to patients having reconstruction only (62% vs. 65%).Conclusions: Patients who have reconstruction prior to PMRT have increased overall and late complication rates compared to patients having reconstruction without radiation, but they have similar rates of general and aesthetic satisfaction. In contrast, patients who receive PMRT prior to delayed reconstruction have similar complication rates and general satisfaction levels to patients undergoing reconstruction only; however, the former patients report decreased aesthetic satisfaction. Patients requiring PMRT should consider both the risk of complications and likelihood of satisfaction in their decision-making process. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4102.

Advances and surgical decision‐making for breast reconstruction

In patients who undergo breast reconstruction after mastectomy, choosing the appropriate timing and the best method of reconstruction are essential to optimize outcomes and to minimize the potential for postoperative complications. At The University of Texas M. D. Anderson Cancer Center, the clinicopathologic factors that are used in the surgical decision-making for breast reconstruction after mastectomy include the breast cancer stage, status of axillary sentinel lymph node, smoking status, body habitus, preexisting scars, prior radiation therapy, and planned or previous chemotherapy. Immediate breast reconstruction after mastectomy is preferable for patients who have a low risk of requiring postmastectomy radiation therapy (PMRT) (Stage I breast cancer). Delayed reconstruction may be preferable in patients who are deemed preoperatively to require PMRT (Stage III breast cancer) to avoid difficulties associated with radiation delivery after an immediate breast reconstruction. In patients who are deemed preoperatively to be at an increased risk of requiring PMRT (Stage II breast cancer), delayed-immediate breast reconstruction may provide an additional option. The approach to breast reconstruction will need to be adapted to maintain an appropriate balance between minimizing the risk of recurrence and providing the best possible aesthetic outcomes as the indications for PMRT and other treatment modalities continue to change.

The Role of Radiation Therapy in Breast Cancer Patients Treated with Neoadjuvant Chemotherapy

Radiation therapy is an important component of multi-modality therapy for most patients with nonmetastatic breast cancer. However, most data concerning the efficacy of radiation therapy and the indications for its use have been obtained in patients who received surgical treatment as their initial therapy. The increasing use of neoadjuvant chemotherapy has sparked many new questions, largely because this treatment sequence affects the surgical pathology findings, and because these pathological findings are one of the most important factors that guide radiation treatment decisions. However, data are now emerging that are answering some of these questions. For example, a number of studies have now shown that breast conservation surgery plus radiation therapy can make breast preservation possible in carefully selected patients with advanced disease who respond favorably to neoadjuvant chemotherapy. In addition, although no randomized trials have been conducted that assess the benefits of radiation therapy in patients also treated with neoadjuvant chemotherapy and mastectomy, data from single-institution studies do suggest that postmastectomy radiation therapy reduces the probability of local-regional recurrence and may improve survival in patients with locally advanced disease. Furthermore, data suggest that indications for postmastectomy radiation therapy should be based both on the initial clinical extent of disease and the residual extent of pathological disease, rather than just considering either factor alone.