The Evolution of Regional Nodal Irradiation in Breast Cancer

Abstract

Breast cancer regional node management has witnessed many changes over the last decade. Advances in surgical techniques establishing sentinel lymph node biopsy as an alternative to axillary dissection, use of microarray technology for subtyping breast cancer to guide systemic therapy selection, and the expansion of the systemic therapy armamentarium including targeted agents have contributed to changing our strategy from one size fits all to a more tailored approach. There have also been recent landmark studies reported that significantly impact clinical practice in the regional nodal management of breast cancer. As the molecular era of personalized medicine is approaching, we hereby revisit the rational, benefit, and controversies of regional nodal irradiation in the light of the most recent publications.

Use of regional nodal irradiation and its association with survival for women with high-risk, early stage breast cancer: A National Cancer Database analysis

“…In conclusion, several clinical trials and reviews have attempted to summarize the clinical implications of using WBI+RNI in the management of early stage breast cancer. 13 , 24 , 25 , 26 , 27 , 28 , 29 Our findings replicate the results of the NCIC MA.20 randomized clinical trial in a larger cohort of patients who were treated throughout the United States and suggest that WBI+RNI as opposed to WBI conferred no additional OS benefit at 5 years for women with either node-positive or high-risk node-negative breast cancer who received BCS followed by adjuvant systemic therapy. Longer follow-up is required, and thoughtful patient selection that is based on all existing data with regard to RNI is recommended.…”

Prognosis of lymphotropic invasive micropapillary breast carcinoma analyzed by using data from the National Cancer Database

“…Importantly, the OS benefit was limited to patients receiving lumpectomy, and no OS benefit was observed among patients receiving mastectomy. Radiotherapy is well known to improve locoregional control and OS after breast-conserving surgery and mastectomy [30–33], but has not been studied specifically in IMPC. It is possible that, due to the high propensity of lymph node involvement in IMPC, EBRT may be important to provide good locoregional control and, subsequently, OS.…”

Routine sampling of internal mammary lymph nodes during microsurgical breast reconstruction—Experience based on 524 microsurgical breast reconstructions

“…Because cancer staging is the major guide to provide adjuvant chemotherapy and/or radiotherapy, modifying adjuvant therapy for some of the patients with positive IMLN metastasis was mentioned both in that report and in earlier series . Currently, even patients with early‐stage invasive breast cancer are considered to benefit from chemotherapy unless they have very favorable factors, such as small nodal negative tumors (less than 5 mm) . Upstaging of their cancer status by inclusion of IMLN metastasis may not necessarily change the therapeutic plans regarding chemotherapy, but it can be significant in other patients whose axillary node involvement is absent or minor .…”