Strahlentherapie und Onkologie

, Volume 188, Issue 5, pp 417–423 | Cite as

Postoperative periclavicular radiotherapy in breast cancer patients with 1–3 positive axillary lymph nodes

Outcome and morbidity
  • A. Biancosino
  • M. Bremer
  • J.H. Karstens
  • C. Biancosino
  • A. Meyer
Original article
First Online:
Received:
Accepted:

Abstract

Purpose

The goal of this work was to examine the possible influence of periclavicular irradiation on outcome of breast cancer patients with 1–3 positive lymph nodes with special emphasis on late toxicity rates.

Patients and methods

Between 1997 and 2000, 235 breast cancer patients (T1–2, 1–3 involved lymph nodes) were treated at our department following breast conservative surgery: 139 patients (59.1%) had one, 62 patients (26.4%) two, and 34 patients (14.5%) three positive lymph nodes. Extracapsular spread (ECS) was described in 72 patients (30.6%). There were 67 patients (28.5%) who received additional radiotherapy to the ipsilateral periclavicular lymph nodes (PCLNI), while 168 patients did not (noPCLNI). Patients were re-examined or contacted by phone with regard to treatment-related late effects.

Results

After a median follow-up of 78 months (range 7–107 months), 22 patients (9.4%) developed local, 9 (3.8%) axillary, 4 periclavicular (1.7%), and 41 distant failure (17.4%). The actuarial 8-year locoregional recurrence-free (LRRFS), disease-free (DFS), and overall survival rates (OS) were 83%, 67%, and 74%, respectively. Survival data for the PCLNI vs. noPCLNI group were 72% vs. 89% (p = 0.3), 56% vs. 73% (p = 0.4), and 86% vs. 70% (p = 0.3), respectively. No higher toxicity rates were reported in the PCLNI group compared to the noPCLNI group.

Conclusion

We could not demonstrate any difference in outcome in breast cancer patients with 1–3 positive axillary lymph node metastases with or without periclavicular lymph node irradiation. In addition, patients with PCLNI did not complain about higher rates of late toxicities. However, patients with ECS, which may predict for locoregional failure, may benefit from adjuvant periclavicular irradiation.

Keywords

Extracapsular spread Late toxicity Lymph nodes Neoplasm metastases Treatment outcome 

Postoperative periklavikuläre Strahlentherapie bei Patientinnen mit Mammakarzinom und 1–3 positiven axillären Lymphknoten

Erkrankungsverlauf und Morbidität

Zusammenfassung

Hintergrund

Ziel dieser Arbeit ist es, den Einfluss der periklavikulären Bestrahlung auf den weiteren Krankheitsverlauf von Brustkrebspatientinnen mit 1–3 positiven Lymphknoten unter besonderer Berücksichtigung der Spättoxizität zu untersuchen.

Patienten und Methoden

Zwischen 1997 und 2000 wurden in unserer Klinik 235 Patientinnen mit einem Mammakarzinom (T1–2, 1–3 positive Lymphknoten) nach brusterhaltender Therapie behandelt. 139 Patientinnen (59,1%) wiesen einen, 62 (26,4%) zwei und 34 (14,5%) drei befallene positive Lymphknoten auf. Ein Lymphknoten-Kapseldurchbruch (ECS) wurde bei 72 Patientinnen (30,6%) beschrieben. Insgesamt 67 Patientinnen (28,5%) erhielten zusätzlich eine periklavikuläre Bestrahlung (PCLNI), bei 168 Patientinnen wurde keine periklavikuläre Bestrahlung durchgeführt (noPCLNI). Die Patientinnen wurden telefonisch kontaktiert oder bezüglich möglicher Spätfolgen untersucht.

Ergebnisse

Nach einem medianen Zeitraum von 78 Monaten (7–107 Monate) entwickelten 22 Patientinnen (9,4%) ein lokales, 9 (3,8%) ein axilläres und 4 (1,7%) ein periklavikuläres Rezidiv. Fernmetastasen zeigten sich bei 41 Patientinnen (17,4%). Die 8-Jahres-Raten für das lokalrezidivfreie („locoregional recurrence-free survival“, LRRFS) und das krankheitsfreie Überleben („disease-free survival“, DFS) sowie für das Gesamtüberleben lagen bei jeweils 83%, 67% und 74%. Das Überleben mit und ohne PCLNI betrug jeweils 72% vs. 89% (p = 0,3), 56% vs 73% (p = 0,4) und 86% vs. 70% (p = 0,3). In der PCLNI-Gruppe zeigte sich im Vergleich zu noPCLNI-Gruppe keine höhere Spättoxizitätsrate.

Schlussfolgerung

Wir konnten keinen Unterschied im weiteren Krankheitsverlauf bei Patientinnen mit und ohne periklavikuläre Bestrahlung zeigen. Patientinnen mit PCLNI wiesen keine höheren Spättoxizitätsraten auf. Dennoch können Patientinnen mit Kapseldurchbruch, welcher für ein höheres Risiko für ein Lokalrezidiv stehen kann, von einer periklavikulären Bestrahlung profitieren.

Schlüsselwörter

Extrakapsuläre Streuung Spättoxizität Lymphknoten Neoplasie, Metastasierung Behandlungsergebnis 
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Notes

Conflict of interest

No statement made.

References

  1. 1.
    Bajrovic A, Rades D, Fehlauer F et al (2004) Is there a life-long risk of brachial plexopathy after radiotherapy of supraclavicular lymph nodes in breast cancer patients? Radiother Oncol 71:297–301PubMedCrossRefGoogle Scholar
  2. 2.
    Brucker SY, Wallwiener M, Kreienberg R et al (2011) Optimizing the quality of breast cancer at certified German breast centers. A benchmarking analysis for 2003–2009 with a particular focus on the interdisciplinary specialty of radiation oncology. Strahlenther Onkol 187:89–99PubMedCrossRefGoogle Scholar
  3. 3.
    Bucci JA, Kennedy CW, Burn J et al (2001) Implications of extranodal spread in node positive breast cancer: a review of survival and local recurrence. Breast 10:213–219PubMedCrossRefGoogle Scholar
  4. 4.
    Chua B, Ung O, Boyages J (2002) Competing considerations in regional nodal treatment for early breast cancer. Breast J 8:15–22PubMedCrossRefGoogle Scholar
  5. 5.
    Clarke M, Collins R, Darby S et al (2005) Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effets 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 366:2087–2106PubMedGoogle Scholar
  6. 6.
    Classen J, Nitzsche S, Wallwiener D et al (2010) Fibrotic changes after postmastectomy radiotherapy and reconstructive surgery in breast cancer. A retrospective analysis in 109 patients. Strahlenther Onkol 186:630–636PubMedCrossRefGoogle Scholar
  7. 7.
    Clavel S, Roy I, Carrier JF et al (2010) Adjuvant regional irradiation after breast-conserving therapy for early stage breast cancer: a survey of Canadian radiation oncologists. Clin Oncol (R Coll Radiol) 22:39–45Google Scholar
  8. 8.
    Coen JJ, Taghian AG, Kachnic LA et al (2003) Risk of lymphedema after regional nodal irradiation with breast conservation therapy. Int J Radiat Oncol Biol Phys 55:1209–1215PubMedCrossRefGoogle Scholar
  9. 9.
    Donegan WL, Stine SB, Samter TG (1993) Implications of extracapsular nodal metastases for treatment and prognosis of breast cancer. Cancer 72:778–782PubMedCrossRefGoogle Scholar
  10. 10.
    Early Breast Cancer Trialists’ Collaborative Group (2000) Favourable and unfavourable effects on long term survival of radiotherapy for early breast cancer: an overview of the randomized trials. Lancet 355:1757–1770CrossRefGoogle Scholar
  11. 11.
    Early Breast Cancer Trialists’ Collaborative Group (2008) Radiotherapy for early breast cancer. Cochrane Database Syst Rev 4:CD004562Google Scholar
  12. 12.
    Fehlauer F, Tribius S, Holler U et al (2003) Long-term radiation sequelae after breast-conserving therapy in women with early-stage breast cancer: an observational study using the LENT-SOMA scoring system. Int J Radiat Oncol Biol Phys 55:651–658PubMedCrossRefGoogle Scholar
  13. 13.
    Fisher B, Bauer M, Wickerham DL et al (1983) Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancer. An NSABP update. Cancer 52:1551–1557PubMedCrossRefGoogle Scholar
  14. 14.
    Fowble B, Solin LJ, Schultz DJ et al (1989) Frequency, sites of relapse, and outcome of regional node failures following conservative surgery and radiation for early breast cancer. Int J Radiat Oncol Biol Phys 17:703–710PubMedCrossRefGoogle Scholar
  15. 15.
    Galper S, Recht A, Silver B et al (1999) Factors associated with regional nodal failure in patients with early stage breast cancer with 0–3 positive axillary nodes following tangential irradiation alone. Int J Radiat Oncol Biol Phys 45:1157–1166PubMedCrossRefGoogle Scholar
  16. 16.
    Gärtner R, Jensen MB, Kronborg L et al (2010) Self-reported arm-lymphedema and functional impairment after breast cancer treatment. A nationwide study of prevalence and associated factors. Breast 19:506–515PubMedCrossRefGoogle Scholar
  17. 17.
    Grills IS, Kestin LL, Goldstein N et al (2003) 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. Int J Radiat Oncol Biol Phys 56:658–670PubMedCrossRefGoogle Scholar
  18. 18.
    Gruber G, Berclaz G, Altermatt HJ et al (2003) Can the addition of reional radiotherapy counterbalance important risk factors in breast cancer patients with extracapsular invasion of axillary lymph node metastases. Strahlenther Onkol 179:661–666PubMedCrossRefGoogle Scholar
  19. 19.
    Gruber G, Menzi S, Forster A et al (2005) Sites of failure in breast cancer patients with extracapsular invasion of axillary lymph node metastases. No need for axillary irradiation? Strahlenther Onkol 181:574–579PubMedCrossRefGoogle Scholar
  20. 20.
    Gruber G, Cole BF, Castiglione-Gertsch M et al (2008) Extracapsular tumor spread and the risk of local, axillary and supraclavicular recurrence in node-positive, premenopausal patients with breast cancer. Ann Oncol 19:1–9CrossRefGoogle Scholar
  21. 21.
    Halverson KJ, Taylor ME, Perez CA et al (1993) Regional nodal management and patterns of failure following conservative surgery and radiation therapy for stage I and II breast cancer. Int J Radiat Oncol Biol Phys 26:593–599PubMedCrossRefGoogle Scholar
  22. 22.
    Hammer J, Track C, Seewald DH et al (2009) Local relapse after breast-conserving surgery and radiotherapy: effects on survival parameters. Strahlenther Onkol 185:431–437PubMedCrossRefGoogle Scholar
  23. 23.
    Hetelekidis S, Schnitt SJ, Silver B et al (2000) The significance of extracapsular extension of axillary lymph node metastases in early-stage breast cancer. Int J Radiat Oncol Biol Phys 46:31–34PubMedCrossRefGoogle Scholar
  24. 24.
    Hiromichi I, Niino K, Hosoya T et al (2006) Results of a questionnaire survey for symptom of late complications caused by radiotherapy in breast conserving therapy. Breast Cancer 13:197–201CrossRefGoogle Scholar
  25. 25.
    Johansson S, Svensson H, Denekamp J (2000) Timescale of evolution of late radiation injury after postoperative radiotherapy of breast cancer patients. Int J Radiat Oncol Biol Phys 48:745–750PubMedCrossRefGoogle Scholar
  26. 26.
    Johansson S, Svensson H, Denekamp J (2002) Dose response and latency for radiation-induced fibrosis, edema, and neuropathy in breast cancer patients. Int J Radiat Oncol Biol Phys 52:1207–1219PubMedCrossRefGoogle Scholar
  27. 27.
    Kim KJ, Huh SJ, Yang JH et al (2005) Treatment results and prognostic factors of early breast cancer treatment with a breast conserving operation and radiotherapy. Jpn J Clin Oncol 35:126–33PubMedCrossRefGoogle Scholar
  28. 28.
    Lilla C, Ambrosone CB, Kropp S et al (2007) Predictive factors for late normal tissue complications following radiotherapy for breast cancer. Breast Cancer Res Treat 106:143–150PubMedCrossRefGoogle Scholar
  29. 29.
    Livi L, Paiar F, Simontacchi G et al (2006) Loco regional failure pattern after lumpectomy and breast irradiation in 4,185 patients with T1 and T2 breast cancer. Implications for nodal irradiation. Acta Oncol 45:564–570PubMedCrossRefGoogle Scholar
  30. 30.
    Livi L, Scotti V, Saieva C et al (2010) Outcome after conservative surgery and breast irradiation in 5,717 patients with breast cancer: implications for supraclavicular nodal irradiation. Int J Radiat Oncol Biol Phys 76:978–983PubMedCrossRefGoogle Scholar
  31. 31.
    Nestle-Krämling C, Bölke E, Budach W et al (2011) Hemangiosarcoma after breast-conserving therapy of breast cancer: Report of four cases with molecular genetic diagnosis and literature review. Strahlenther Onkol 187:656–664PubMedCrossRefGoogle Scholar
  32. 32.
    Recht A, Pierce SM, Abner A et al (1991) Regional nodal failure after conservative surgery and radiotherapy for early stage breast carcinoma. J Clin Oncol 9:988–996PubMedGoogle Scholar
  33. 33.
    Recht A, Houlihan MJ (1995) Axillary lymph nodes and breast cancer: a review. Cancer 76:1491–1512PubMedCrossRefGoogle Scholar
  34. 34.
    Reddy SG, Kiel KD (2007) Supraclavicular nodal failure in patients with one to three positive axillary lymph nodes treated with breast conserving surgery and breast irradiation, without supraclavicular node radiation. Breast J 13:12–18PubMedCrossRefGoogle Scholar
  35. 35.
    RTOG/EORTC Late Effects Working Group (1995) Late effects on normal tissue consensus conference: LENT SOMA scales for all anatomic sites. Int J Radiat Oncol Biol Phys 31:1049–1091CrossRefGoogle Scholar
  36. 36.
    Stranzl H, Mayer R, Ofner P et al (2004) Extracapsular extension in positive axillary lymph nodes in female breast cancer patients. Patterns of failure and indications for postoperative locoregional irradiation. Strahlenther Onkol 180:31–37PubMedCrossRefGoogle Scholar
  37. 37.
    Stranzl H, Peintinger F, Ofner P et al (2004) Regional nodal recurrence in the management of breast cancer patients with one to three axillary lymph nodes. Outcome of patients following tangential irradiation without a separate nodal field. Strahlenther Onkol 180:623–628PubMedCrossRefGoogle Scholar
  38. 38.
    Stranzl H, Ofner P, Peintinger F et al (2006) Postoperative irradiation in breast cancer patients with one to three positive axillary lymph nodes is there an impact of axillary extranodal tumor extension on locoregional and distant control? Strahlenther Onkol 182:583–588PubMedCrossRefGoogle Scholar
  39. 39.
    Tai P, Joseph K, Sadikov E et al (2007) Nodal ratios in node positive breast cancer – long-term study to clarify discrepancy of role of supraclavicular and axillary regional radiotherapy. Int J Radiat Oncol Biol Phys 68:662–666PubMedCrossRefGoogle Scholar
  40. 40.
    Truong PT, Berthelet E, Lee J et al (2005) The prognostic significance of the percentage of positive/dissected axillary lymph nodes in breast cancer recurrence and survival in patients with one to three positive axillary lymph nodes. Cancer 103:2006–2014PubMedCrossRefGoogle Scholar
  41. 41.
    Truong PT, Vinh-Hung V, Cserni G et al (2008) The number of positive nodes and the ratio of positive to excised notes are significant predictors of survival in women with micrometastatic node positive breast cancer. Eur J Cancer 44:1670–1677PubMedCrossRefGoogle Scholar
  42. 42.
    Van der Sangen MJC, Coebergh JW, Roumen RMH et al (2003) Detection, treatment, and outcome of isolated supraclavicular recurrence in 42 patients with invasive breast cancer. Cancer 98:11–18CrossRefGoogle Scholar
  43. 43.
    Van de Steene J, Vinh-Hung V, Cutuli B et al (2004) Adjuvant radiotherapy for breast cancer: effects of longer follow-up. Radiother Oncol 72:35–43CrossRefGoogle Scholar
  44. 44.
    Wapnir IL, Anderson SJ, Mamounas EP et al (2006) Prognosis after ipsiteral breast tumor recurrence in five national surgical adjuvant breast and bowel project node-positive adjuvant breast cancer trials. J Clin Oncol 24(13):2028–2037PubMedCrossRefGoogle Scholar
  45. 45.
    Wazer DE, DiPetrillo T, Schmidt-Ullrich R et al (1992) Factors influencing cosmetic outcome and complication risk after conservative surgery and radiotherapy for early-stage breast carcinoma. J Clin Oncol 10:356–363PubMedGoogle Scholar
  46. 46.
    Whelan TJ, Olivotto I, Ackermann I et al (1992) NCIC-CTG MA.20: an intergroup trial of regional nodal irradiation in early breast cancer. Proceed. Am Soc Clin Oncol abstr. LBA 1003Google Scholar
  47. 47.
    Wittekind C, Bootz F (2002) TNM. Klassifikation maligner Tumoren. 6th edn. Springer, New York, BerlinGoogle Scholar
  48. 48.
    Wo JY, Taghian AG, Nguyen PL et al (2010) The association between biological subtype and isolated regional nodal failure after breast-conserving therapy. Int J Radiat Oncol Biol Phys 77:188–196PubMedCrossRefGoogle Scholar
  49. 49.
    Woodward WA, Vinh-Hung V, Ueno NT et al (2006) Prognostic value of nodal ratios in node-positive breast cancer. J Clin Oncol 24:2910–2916PubMedCrossRefGoogle Scholar
  50. 50.
    Yates L, Kirby A, Crichton S et al (2011) Risk factors for regional nodal relapse in breast cancer patiens with one to three positive axillary nodes. Int J Radiat Oncol Biol Phys [Epub ahead of print]Google Scholar
  51. 51.
    Yoshida K, Yamazaki H, Takenaka T et al (2010) Objective assessment of dermatitis following post-operative radiotherapy in patients with breast cancer treated with breast-conserving treatment. Strahlenther Onkol 186:621–629PubMedCrossRefGoogle Scholar
  52. 52.
    Yu JJ, Park W, Huh SJ et al (2010) Determining which patients require irradiation of the supraclavicular nodal area after surgery for N1 breast cancer. Int Radiat Oncol Biol Phys 78(4):1135–1141CrossRefGoogle Scholar

Copyright information

© Urban & Vogel 2012

Authors and Affiliations

  • A. Biancosino
    • 1
  • M. Bremer
    • 1
  • J.H. Karstens
    • 1
  • C. Biancosino
    • 2
  • A. Meyer
    • 1
  1. 1.Clinic of Radiation OncologyMedical School HannoverHannoverGermany
  2. 2.Department of Thoracic SurgeryDr.Horst-Schmidt-Clinic WiesbadenWiesbadenGermany

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