CT-planned internal mammary node radiotherapy in the DBCG-IMN study: Benefit versus potentially harmful effects

Thorsen, Lise Bech Jellesmark; Thomsen, M.S.; Berg, M.; Jensen, I.; Josipović, Mirjana; Overgaard, Marie; Overgaard, Jens; Skogholt, Peter; Offersen, Birgitte Vrou

doi:10.3109/0284186x.2014.925579

Cited by 78 publications

(57 citation statements)

References 24 publications

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“…However, the recent results from the Danish population-based study in which patients with left-sided node-positive breast cancer underwent only medial supraclavicular irradiation, whereas patients with right-sided node-positive breast cancer underwent both internal mammary and medial supraclavicular irradiation, support the role of including the internal mammary chain in the success of regional nodal radiation therapy. 39,40 When our trial was designed, adjuvant systemic therapy was not as variable as it is today and molecular subtypes were not yet described; thus, we recorded little information about these variables (Table S3 in the Supplementary Appendix). In the current study, the number needed to treat to avoid one death from breast cancer was 39, and the number needed to treat to avoid one relapse of breast cancer was 30.…”

Section: Discussionmentioning

confidence: 99%

Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer

Collette²,

et al. 2015

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BACKGROUND The effect of internal mammary and medial supraclavicular lymph-node irradiation (regional nodal irradiation) added to whole-breast or thoracic-wall irradiation after surgery on survival among women with early-stage breast cancer is unknown. METHODS We randomly assigned women who had a centrally or medially located primary tumor, irrespective of axillary involvement, or an externally located tumor with axillary involvement to undergo either whole-breast or thoracic-wall irradiation in addition to regional nodal irradiation (nodal-irradiation group) or whole-breast or thoracicwall irradiation alone (control group). The primary end point was overall survival. Secondary end points were the rates of disease-free survival, survival free from distant disease, and death from breast cancer. RESULTS Between 1996 and 2004, a total of 4004 patients underwent randomization. The majority of patients (76.1%) underwent breast-conserving surgery. After mastectomy, 73.4% of the patients in both groups underwent chest-wall irradiation. Nearly all patients with node-positive disease (99.0%) and 66.3% of patients with node-negative disease received adjuvant systemic treatment. At a median followup of 10.9 years, 811 patients had died. At 10 years, overall survival was 82.3% in the nodal-irradiation group and 80.7% in the control group (hazard ratio for death with nodal irradiation, 0.87; 95% confidence interval [CI], 0.76 to 1.00; P=0.06). The rate of disease-free survival was 72.1% in the nodal-irradiation group and 69.1% in the control group (hazard ratio for disease progression or death, 0.89; 95% CI, 0.80 to 1.00; P=0.04), the rate of distant disease-free survival was 78.0% versus 75.0% (hazard ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02), and breast-cancer mortality was 12.5% versus 14.4% (hazard ratio, 0.82; 95% CI, 0.70 to 0.97; P=0.02). Acute side effects of regional nodal irradiation were modest. CONCLUSIONS In patients with early-stage breast cancer, irradiation of the regional nodes had a marginal effect on overall survival. Disease-free survival and distant disease-free survival were improved, and breast-cancer mortality was reduced. (Funded by Fonds Cancer; ClinicalTrials.gov number, NCT00002851.).

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Section: Discussionmentioning

confidence: 99%

Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer

Collette²,

et al. 2015

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“…Improved target volume coverage Given these and other potential toxicities of treatment, radiation oncologists may compromise coverage of areas at risk of harboring microscopic breast cancer in order to minimize dose to normal tissues [31]. For example, a retrospective review of previously treated plans in the modern era demonstrated mean coverage of expertly defined consensus target volumes ranging from just 74-96% [32].…”

Section: Second Malignancymentioning

confidence: 99%

“…For example, a prospective population based cohort study recently showed a 3.7% absolute survival advantage at 8 years in patients with right breast cancer who received IMN irradiation compared with left-sided breast cancer patients who did not [36]. Therefore, compromises in target coverage could increase the risk of recurrence [31]. Numerous dosimetric studies clearly support the advantage of PBT at improving target coverage while simultaneously decreasing dose to the heart, coronary vessels, lungs and contralateral normal tissue compared with photon advanced planning techniques.…”

Section: Second Malignancymentioning

confidence: 99%

Proton Therapy for Breast Cancer: Progress & Pitfalls

Corbin

Mutter

2018

Breast Cancer Manag.

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Practice points• Proton therapy is under investigation for early stage and locally advanced breast cancer.• Due to unique physical properties, proton therapy reduces the dose to the heart, lungs, skin, muscle, and bone and is therefore hypothesized to reduce side effects from treatment.• Proton therapy may also enable improved target coverage in some breast cancer patients.• Due to its highly conformal nature, proton therapy requires careful attention to target volume delineation and implementation of strategies to mitigate uncertainties in setup and delivery.• Proton therapy for breast cancer is rapidly evolving with improvements in techniques for treatment delivery and optimizing of dose and fractionation schedules.• Research is ongoing to determine whether proton therapy improves treatment outcomes and quality of life compared with conventional photon techniques.As the number of patients cured from breast cancer increases with improvements in multidisciplinary care, emphasis on reducing late toxicities of treatment has increased, in order to improve long-term quality of life. Proton beam therapy (PBT) is a form of radiotherapy that uses particles with unique physical properties that enable treatment delivery with minimal dose deposition beyond the treatment target. Therefore, PBT has emerged as an exciting radiotherapy modality for breast cancer due to the ability to minimize exposure to the heart, lungs, muscle, and bone. Herein, we review the rationale for PBT in breast cancer, potential clinical applications, and the available clinical data supporting its use. We also address some of the technical and logistical challenges and areas of ongoing research that will ultimately establish the role for PBT for breast cancer in the years ahead.First draft submitted: 5 January 2018; Accepted for publication: 13 March 2018; Published online: 13 April 2018Keywords: breast cancer • cardiotoxicity • heart • particle therapy • pencil-beam scanning • proton therapy • radiation therapyBreast cancer accounts for 30% of new cancer diagnoses in women [1]. Although breast cancer remains the second leading cause of cancer death among women, advances in detection and treatment have resulted in improved outcomes, with 5-year expected survival of 90% [1]. Radiation therapy (RT) is indicated in the management of the majority of women with breast cancer [2]. For early stage breast cancer, breast irradiation following lumpectomy is an essential component of breast conserving therapy, lowering the risk of recurrence and improving breast cancer specific survival [3,4]. Recently published clinical trials also support the oncologic value of regional nodal irradiation (RNI) in some women with high risk node negative or axillary nodal metastases [5,6]. In addition, women with locally advanced breast cancer benefit from RT to the chest wall and regional lymph nodes, delivered in the post mastectomy setting [7]. While RT is widely utilized and improves breast cancer treatment outcomes, RT is also associated with late effects including cardi...

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“…The advances in the sentinel lymph node biopsy (SLN) procedure have led to a re-evaluation of the role of the SLN for staging IMLN basin [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]. In addition, few recent clinical trials demonstrate that post-mastectomy irradiation of IMLNs significantly improved the metastasis-free overall survival of patients with stage I-III breast cancer [34][35][36].…”

Section: Introductionmentioning

confidence: 99%

The clinical significance of internal mammary lymph node (IMLN) biopsy during autologous reconstruction in breast cancer patients

Zhang

Jaffer

Bleiweiss

et al. 2015

Breast Cancer Res Treat

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The clinical significance of IMLN metastases in breast cancer is controversial. Although IMLN status is an integral part of current AJCC staging of breast cancer, the elective sampling of IMLN is not part of routine surgery for breast cancer. The purpose of this study was to determine the incidence of IMLN metastases, associated risk factors if any, and its impact on further management and outcome. We retrospectively studied 470 cases that underwent autologous reconstruction surgery between 2002 and 2014. Of 470 cases, 157 breast cancer cases had histology-confirmed IMLN removal during the reconstruction. Only 9 patients (6 %) showed IMLN metastases as compared to 45 (34 %) that showed axillary nodal metastases (p < 0.01). Interestingly, 4 patients had metastases limited to IMLN without any metastases to axillary nodes. IMLN metastasis was significantly associated with age <40 years, lymphovascular invasion, and negative PR status. IMLN metastasis resulted in upstaging of 2 patients from stage I to III, and 1 from stage II to III. Five patients received additional chest wall radiation to target the positive IMLNs. Nine of 157 (6 %) patients with IMLN removal during reconstruction had loco-regional recurrence/metastasis as compared to 20 of 293 (7 %) patients without IMLN removal (p > 0.05) (follow-up, 1-134 months). The overall rate of IMLN metastases (6 %) is much lower than the rate of axillary node metastases. Selective biopsy of IMLNs in patients with breast cancer, especially if younger than 40 years, and with lymphovascular invasion and negative PR status, may guide adjuvant treatment.

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CT-planned internal mammary node radiotherapy in the DBCG-IMN study: Benefit versus potentially harmful effects

Cited by 78 publications

References 24 publications

Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer

Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer

Proton Therapy for Breast Cancer: Progress & Pitfalls

The clinical significance of internal mammary lymph node (IMLN) biopsy during autologous reconstruction in breast cancer patients

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