Should internal mammary lymph nodes in breast cancer be a target for the radiation oncologist?

Freedman, Gary M.; Fowble, Barbara; Nicolaou, Nicos; Sigurdson, Elin R.; Torosian, Michael H.; Boraas, Marcia; Hoffman, John P.

doi:10.1016/s0360-3016(99)00481-2

Cited by 158 publications

(66 citation statements)

References 50 publications

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“…19 Adjuvant radiotherapy of the IMC is still controversial and under investigation. 20,21 Misclassification of patients as having lymph node negative disease has minor consequences if adjuvant chemotherapy is already indicated. For patients who have no indication for adjuvant chemotherapy, such under-staging results in undertreatment and probably in a higher risk of death from breast cancer.…”

Section: Discussionmentioning

confidence: 99%

Tumor Location of the Lower-Inner Quadrant Is Associated with an Impaired Survival for Women With Early-Stage Breast Cancer

et al. 2006

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Background: There is growing evidence that tumors of the inner quadrants (especially the lower-inner quadrant) metastasize more often to the internal mammary chain (IMC). As these metastases are not investigated, patients with lower-inner quadrant tumors have an increased risk of being under-staged and under-treated and may therefore have a higher risk of death from breast cancer.Methods: We identified all 1522 women operated for stage I breast cancer between 1984 and 2002 recorded at the population-based Geneva Cancer Registry. We compared breast cancer mortality risk by tumor location with multivariate Cox regression analysis that accounted for all factors linked to tumor location and survival.Results: Ten-year disease-specific survival was 93% (95%CI: 91-94%). Patients with breast cancer of the lower-inner quadrant (n = 118; 7.8%) had an importantly increased risk of dying of breast cancer compared to women with breast cancer of the upper-outer quadrant (multiadjusted Hazard Ratio: 2.3, 95%CI: 1.1-4.5, P = 0.0206). The over-mortality associated with this quadrant was particularly evident for tumors >10 mm (multiadjusted HR: 3.6, 95%CI: 1.6-7.9, P = 0.0016). There was no increased breast cancer mortality risk for tumors located in other quadrants.Conclusions: Tumor location in the lower-inner quadrant is an independent and important prognostic factor of stage I breast cancer. Further research is needed to evaluate if the overmortality of patients with stage I cancer of the lower-inner quadrant is indeed a result of under-treatment due to undetected IMC metastases. If so, patients with stage I breast cancer of the lower-inner quadrant are good candidates for systematic IMC investigation.

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Section: Discussionmentioning

confidence: 99%

Tumor Location of the Lower-Inner Quadrant Is Associated with an Impaired Survival for Women With Early-Stage Breast Cancer

et al. 2006

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“…Randomised trials of post-mastectomy radiation encompassing the internal mammary nodes did not result in an improvement in overall survival either (Fisher et al, 1970;Palmer and Ribeiro, 1985;Høst et al, 1986;Veronesi et al, 1986;Arriagada et al, 1996). Obfuscating factors of such studies can be the use of adjuvant systemic treatment and the fact that internal mammary nodes may be situated in the breast irradiation field (Freedman et al, 2000). Another disadvantage of these studies is dilution of the potential benefit of the therapy, because the patients who indeed have lymph node metastases are a minority within these populations.…”

Section: Discussionmentioning

confidence: 99%

Impact of non-axillary sentinel node biopsy on staging and treatment of breast cancer patients

et al. 2002

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The purpose of this study was to evaluate the occurrence of lymphatic drainage to non-axillary sentinel nodes and to determine the implications of this phenomenon. A total of 549 breast cancer patients underwent lymphoscintigraphy after intratumoural injection of 99m Tc-nanocolloid. The sentinel node was intraoperatively identified with the aid of intratumoural administered patent blue dye and a gamma-ray detection probe. Histopathological examination of sentinel nodes included step-sectioning at six levels and immunohistochemical staining. A sentinel node outside level I or II of the axilla was found in 149 patients (27%): internal mammary sentinel nodes in 86 patients, other non-axillary sentinel nodes in 44 and both internal mammary and other non-axillary sentinel nodes in nineteen patients. The intra-operative identification rate was 80%. Internal mammary metastases were found in seventeen patients and metastases in other non-axillary sentinel nodes in ten patients. Staging improved in 13% of patients with non-axillary sentinel lymph nodes and their treatment strategy was changed in 17%. A small proportion of clinically node negative breast cancer patients can be staged more precisely by biopsy of sentinel nodes outside level I and II of the axilla, resulting in additional decision criteria for postoperative regional or systemic therapy.

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“…1,2 Radiotherapy can control or eliminate cancer cells in this region, classically through the intentional inclusion of the IMC in the treatment fields. 3 However, irradiation of the IMC is still a matter of much debate, 3,4 because even with a high incidence of pathological involvement of this nodal region, 5 there are low rates of recurrence at this region even when not irradiated. 6 While the results of most prospective randomized trials that assess the benefits of IMC irradiation have not yet been published (NCT00005957, NCT00002851), therapeutic decisions are guided by one prospective study, 7 some retrospective series evaluating both oncological outcomes and clinical toxicity, 6,8,9 or even dosimetric studies.…”

Section: Introductionmentioning

confidence: 99%

Unintended irradiation of internal mammary chain – Is that enough?

Sapienza

Chen

Gomes

et al. 2016

Reports of Practical Oncology & Radiotherapy

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Should internal mammary lymph nodes in breast cancer be a target for the radiation oncologist?

Cited by 158 publications

References 50 publications

Tumor Location of the Lower-Inner Quadrant Is Associated with an Impaired Survival for Women With Early-Stage Breast Cancer

Tumor Location of the Lower-Inner Quadrant Is Associated with an Impaired Survival for Women With Early-Stage Breast Cancer

Impact of non-axillary sentinel node biopsy on staging and treatment of breast cancer patients

Unintended irradiation of internal mammary chain – Is that enough?

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