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Is There a Role for Postmastectomy Radiation Therapy After Complete Pathologic Response to Neoadjuvant Chemotherapy?

  • Local-Regional Evaluation and Therapy (KK Hunt, Section Editor)
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Abstract

Patients with locally advanced breast cancer who undergo neoadjuvant chemotherapy and who are found to have a pathologic complete response (pCR) at the time of mastectomy pose a unique challenge to the radiation oncologist. Whereas patients with node-negative disease and small primary tumors treated immediately by mastectomy do not generally require postmastectomy radiation (PMRT), radiation indications are unclear for patients who present initially with more advanced disease and become node-negative after chemotherapy. Consequently, guidelines and patterns of practice for PMRT after neoadjuvant vary substantially among institutions and clinicians both nationally and internationally. Although some retrospective data suggest that patients with a pCR are at low risk of local failure and may not require adjuvant PMRT, there are conflicting data suggesting a role for PMRT, depending on the initial clinical stage at presentation. A national multi-institutional trial is currently investigating this question.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. (2000) Favourable and unfavourable effects on long-term survival of radiotherapy for early breast cancer: an overview of the randomised trials. Early breast cancer trialists’ collaborative group. Lancet 355: 1757–1770.

  2. Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med. 1997;337:949–55.

    Article  CAS  PubMed  Google Scholar 

  3. Overgaard M, Jensen MB, Overgaard J, Hansen PS, Rose C, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet. 1999;353:1641–8.

    Article  CAS  PubMed  Google Scholar 

  4. Ragaz J, Olivotto IA, Spinelli JJ, Phillips N, Jackson SM, et al. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst. 2005;97:116–26.

    Article  PubMed  Google Scholar 

  5. Recht A, Edge SB, Solin LJ, Robinson DS, Estabrook A, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001;19:1539–69.

    CAS  PubMed  Google Scholar 

  6. Taylor ME, Haffty BG, Rabinovitch R, Arthur DW, Halberg FE, et al. ACR appropriateness criteria on postmastectomy radiotherapy expert panel on radiation oncology-breast. Int J Radiat Oncol, Biol, Phys. 2009;73:997–1002.

    Article  Google Scholar 

  7. Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310:1455–61.

    Article  CAS  PubMed  Google Scholar 

  8. Fisher B, Brown A, Mamounas E, Wieand S, Robidoux A, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol. 1997;15:2483–93.

    CAS  PubMed  Google Scholar 

  9. Bear HD, Anderson S, Brown A, Smith R, Mamounas EP, et al. The effect on tumor response of adding sequential preoperative docetaxel to preoperative doxorubicin and cyclophosphamide: preliminary results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2003;21:4165–74.

    Article  CAS  PubMed  Google Scholar 

  10. Rastogi P, Anderson SJ, Bear HD, Geyer CE, Kahlenberg MS, et al. Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project Protocols B-18 and B-27. J Clin Oncol. 2008;26:778–85.

    Article  PubMed  Google Scholar 

  11. Clarke M, Collins R, Darby S, Davies C, Elphinstone P, et al. 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. 2005;366:2087–106.

    CAS  PubMed  Google Scholar 

  12. Harris JR, Halpin-Murphy P, McNeese M, Mendenhall NP, Morrow M, et al. Consensus Statement on postmastectomy radiation therapy. Int J Radiat Oncol, Biol, Phys. 1999;44:989–90.

    Article  CAS  Google Scholar 

  13. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Breast Cancer, Version 3.2013. http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.

  14. Buchholz TA, Katz A, Strom EA, McNeese MD, Perkins GH, et al. Pathologic tumor size and lymph node status predict for different rates of locoregional recurrence after mastectomy for breast cancer patients treated with neoadjuvant versus adjuvant chemotherapy. Int J Radiat Oncol, Biol, Phys. 2002;53:880–8.

    Article  Google Scholar 

  15. Fisher B, Bryant J, Wolmark N, Mamounas E, Brown A, et al. Effect of preoperative chemotherapy on the outcome of women with operable breast cancer. J Clin Oncol. 1998;16:2672–85.

    CAS  PubMed  Google Scholar 

  16. Bear HD, Anderson S, Smith RE, Geyer Jr CE, Mamounas EP, et al. Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2006;24:2019–27.

    Article  CAS  PubMed  Google Scholar 

  17. Kuerer HM, Newman LA, Smith TL, Ames FC, Hunt KK, et al. Clinical course of breast cancer patients with complete pathologic primary tumor and axillary lymph node response to doxorubicin-based neoadjuvant chemotherapy. J Clin Oncol. 1999;17:460–9.

    CAS  PubMed  Google Scholar 

  18. Huang EH, Tucker SL, Strom EA, McNeese MD, Kuerer HM, et al. Postmastectomy radiation improves local-regional control and survival for selected patients with locally advanced breast cancer treated with neoadjuvant chemotherapy and mastectomy. J Clin Oncol. 2004;22:4691–9.

    Article  PubMed  Google Scholar 

  19. Wright JL, Takita C, Reis IM, Zhao W, Saigal K, et al. Predictors of locoregional outcome in patients receiving neoadjuvant therapy and postmastectomy radiation. Cancer. 2013;119:16–25.

    Article  PubMed  Google Scholar 

  20. Nagar H, Mittendorf EA, Strom EA, Perkins GH, Oh JL, et al. Local-regional recurrence with and without radiation therapy after neoadjuvant chemotherapy and mastectomy for clinically staged T3N0 breast cancer. Int J Radiat Oncol, Biol, Phys. 2011;81:782–7.

    Article  Google Scholar 

  21. Buchholz TA, Tucker SL, Masullo L, Kuerer HM, Erwin J, et al. Predictors of local-regional recurrence after neoadjuvant chemotherapy and mastectomy without radiation. J Clin Oncol. 2002;20:17–23.

    Article  CAS  PubMed  Google Scholar 

  22. McGuire SE, Gonzalez-Angulo AM, Huang EH, Tucker SL, Kau SW, et al. Postmastectomy radiation improves the outcome of patients with locally advanced breast cancer who achieve a pathologic complete response to neoadjuvant chemotherapy. Int J Radiat Oncol, Biol, Phys. 2007;68:1004–9. This is a retrospective series from the M.D. Anderson Cancer Center which compares the rates of LRR in patients with a pCR after NAC.

  23. Bae SH, Park W, Huh SJ, Choi DH, Nam SJ, et al. Radiation treatment in pathologic n0-n1 patients treated with neoadjuvant chemotherapy followed by surgery for locally advanced breast cancer. J Breast Cancer. 2012;15:329–36.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Le Scodan R, Selz J, Stevens D, Bollet MA, de la Lande B, et al. Radiotherapy for stage II and stage III breast cancer patients with negative lymph nodes after preoperative chemotherapy and mastectomy. Int J Radiat Oncol, Biol, Phys. 2012;82:e1–7.

    Article  Google Scholar 

  25. Mamounas EP, Anderson SJ, Dignam JJ, Bear HD, Julian TB, et al. Predictors of locoregional recurrence after neoadjuvant chemotherapy: results from combined analysis of National Surgical Adjuvant Breast and Bowel Project B-18 and B-27. J Clin Oncol. 2012;30:3960–6. This study evaluates the rates of LRR in the NSABP B-18 and B-27 trials.

  26. Xing Y, Foy M, Cox DD, Kuerer HM, Hunt KK, et al. Meta-analysis of sentinel lymph node biopsy after preoperative chemotherapy in patients with breast cancer. Br J Surg. 2006;93:539–46.

    Article  CAS  PubMed  Google Scholar 

  27. Mamounas EP, Brown A, Anderson S, Smith R, Julian T, et al. Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2005;23:2694–702.

    Article  PubMed  Google Scholar 

  28. Hoffman KE, Mittendorf EA, Buchholz TA. Optimising radiation treatment decisions for patients who receive neoadjuvant chemotherapy and mastectomy. Lancet Oncol. 2012;13:e270–6.

    Article  PubMed  Google Scholar 

  29. Bellon JR, Wong JS, Burstein HJ. Should response to preoperative chemotherapy affect radiotherapy recommendations after mastectomy for stage II breast cancer? J Clin Oncol. 2012;30:3916–20.

    Article  PubMed  Google Scholar 

  30. Fowble BL, Einck JP, Kim DN, McCloskey S, Mayadev J, et al. Role of postmastectomy radiation after neoadjuvant chemotherapy in stage II-III breast cancer. Int J Radiat Oncol, Biol, Phys. 2012;83:494–503.

    Google Scholar 

  31. Robidoux A, Tang G, Rastogi P, Geyer CE Jr., Azar CA, et al. Lapatinib as a component of neoadjuvant therapy for HER2-positive operable breast cancer (NSABP protocol B-41): An open-label, randomised phase 3 trial. Lancet Oncol. 2013.

  32. Bear HD, Tang G, Rastogi P, Geyer Jr CE, Robidoux A, et al. Bevacizumab added to neoadjuvant chemotherapy for breast cancer. N Engl J Med. 2012;366:310–20.

    Google Scholar 

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Conflict of Interest

Nadine Housri and Bruce G. Haffty declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School and Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08903-2681, USA

    Nadine Housri & Bruce G. Haffty

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  1. Nadine Housri
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  2. Bruce G. Haffty
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Correspondence to Bruce G. Haffty.

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Housri, N., Haffty, B.G. Is There a Role for Postmastectomy Radiation Therapy After Complete Pathologic Response to Neoadjuvant Chemotherapy?. Curr Breast Cancer Rep 6, 38–44 (2014). https://doi.org/10.1007/s12609-013-0134-8

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  • DOI: https://doi.org/10.1007/s12609-013-0134-8

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