The standard tangential fields used for breast irradiation do not allow optimal coverage and dose distribution in axillary levels I–II and the sentinel node area

Belkacémi, Yazid; Allab-Pan, Q.; Bigorie, V.; Khodari, W.; Beaussart, Pauline; Totobenazara, J.L.; Mège, Jean-Pierre; Caillet, Philippe; Pigneur, F.; T, Dao; Salmon, Rémy; Calitchi, E.; Bosc, Romain

doi:10.1093/annonc/mdt151

Cited by 51 publications

(46 citation statements)

References 18 publications

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“…In fact, the lower part of the axilla is currently irradiated and receives a nearly therapeutic dose, depending on the upper limit of the tangential fields to the breast or chest wall. 23 A meta-analysis by van Wely et al 24 showed that external-beam radiotherapy to the breast was associated with a lower axillary recurrence rate compared to that in patients who did not receive it as part of initial therapy. Although it may not be considered therapeutic, 25 the dose delivered to the region in which the SLNs are normally found could well influence the natural evolution of residual tumor cells.…”

Section: Discussionmentioning

confidence: 99%

Does Conservative Surgery for Breast Carcinoma Still Require Axillary Lymph Node Evaluation? A Retrospective Analysis of 1156 Consecutive Women With Early Breast Cancer

Marrazzo

Damiano

Taörmina³

et al. 2017

Clinical Breast Cancer

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We performed a retrospective analysis of 1156 patients affected by early breast cancer in order to estimate the real incidence of patients with T1 tumors presenting > 2 metastatic lymph nodes. The advantage of axillary surgery seems to be limited only to a specific subgroup of T1 patients who are undergoing conservative surgery plus radiotherapy. Background: The role of axillary surgery for early breast carcinoma treated with conservative surgery and radiotherapy is currently the subject of considerable investigation. Recent studies have supported the noninferiority of avoiding axillary surgery in terms of overall survival when sentinel lymph node biopsy (SLNB) presents 2 positive lymph nodes, thus sparing the patients from complications. There are some ongoing studies investigating the possibility of omitting SLNB. Axillary study seems to be sufficiently replaced by SLNB for staging the disease. Axillary surgery maintains a therapeutic role in the presence of > 2 metastatic lymph nodes at SLNB. Patients and Methods: We performed a retrospective analysis of 1156 patients with early breast cancer to estimate the real incidence of patients with T1 tumors presenting > 2 metastatic lymph nodes. Results: Of the 1156 cases, only 106 (9.2%) had > 2 axillary metastatic lymph nodes. More specifically, 38 (4.3%) of 884 T1 cases, and 6 (2.3%) of 257 of T1b cases had > 2 metastatic lymph nodes. Conclusion: The advantage of axillary surgery seems to be limited only to a specific subgroup of T1 patients who are undergoing conservative surgery plus radiotherapy. The ongoing studies on avoiding SLNB will likely prove the noninferiority of omitting biopsy because these studies are conducted in the whole population of early breast cancers. It is necessary to identify more accurately the subpopulation of patients who may benefit from axillary surgery.

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Section: Discussionmentioning

confidence: 99%

Does Conservative Surgery for Breast Carcinoma Still Require Axillary Lymph Node Evaluation? A Retrospective Analysis of 1156 Consecutive Women With Early Breast Cancer

Marrazzo

Damiano

Taörmina³

et al. 2017

Clinical Breast Cancer

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“…The authors were the first to publish prospective data concerning SLN biopsy area coverage using a protocol of systematic intraoperative clip placement in that region. Data collected from 12 patients showed a mean dose of 13 Gy, with only 1 patient experiencing full dose levels [15].…”

Section: Discussionmentioning

confidence: 99%

“…In the past two decades several studies focused on the evaluation of the axillary lymph node dose after treatment with whole breast radiotherapy with 2 TgF [6][7][8][9][10][11][12][13][14][15]. Regarding modern tridimensional radiation delivering techniques, it is currently accepted that therapeutic doses are not really delivered to the axilla [9][10][11][12][13][14][15].…”

mentioning

confidence: 99%

Evaluation of axillary dose coverage following whole breast radiotherapy: Variation with the breast volume and shape

Aguiar

Pereira

Azevedo

et al. 2015

Radiotherapy and Oncology

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“…In practice, there is significant unintentional irradiation at least to level I of the ipsilateral axilla even with standard tangents [21]. This might contribute to the unexpectedly low axillary recurrence rate after SLNB alone in the ACOSOG Z0011 trial despite a 27% rate of non-SLN metastasis in the control arm [14].…”

Section: What Is the Best Management Of Cn0pn1(sn) Breast Cancer Patimentioning

confidence: 99%

What Is the Best Management of cN0pN1(sn) Breast Cancer Patients

et al. 2018

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Although the majority of breast cancer patients are clinically node-negative (cN0) at diagnosis, 15-20% will have a metastatic sentinel lymph node (SLN, pN1(sn)). While a less radical approach regarding axillary surgery in cN0 patients with a positive SLN biopsy is advocated, the limitations of 5 published trials on axillary management in pN1(sn) are discussed intensely in the literature and support the performance of ongoing validation and extension trials, especially considering the lack of data in the setting of mastectomy. As locoregional radiotherapy has a significant effect on both recurrence and survival, a standardization of locoregional radiotherapy in the situation of SLN biopsy alone in pN1(sn) patients has to be defined in the future, and de-escalation trials should embrace a truly multidisciplinary approach. This is also of utmost importance considering the fact that high-volume nodal disease requires an intensified adjuvant chemotherapy strategy to which patients omitting axillary dissection cannot be stratified. Finally, there is mounting evidence that the therapeutic role of extensive axillary surgery in low-volume nodal disease is negligible, and multidisciplinary and translational efforts must be undertaken to individualize treatment in order to gain a reasonable balance between necessary staging information and unnecessary treatment-related morbidity.

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The standard tangential fields used for breast irradiation do not allow optimal coverage and dose distribution in axillary levels I–II and the sentinel node area

Abstract: TgFs provide a limited coverage of the axilla and the SNLB area. This information should be considered when only TgFs are planned to target the axilla in patients with a positive SLN without ALND. Standardization of locoregional radiotherapy in this situation is urgently needed.

Cited by 51 publications

References 18 publications

Does Conservative Surgery for Breast Carcinoma Still Require Axillary Lymph Node Evaluation? A Retrospective Analysis of 1156 Consecutive Women With Early Breast Cancer

Does Conservative Surgery for Breast Carcinoma Still Require Axillary Lymph Node Evaluation? A Retrospective Analysis of 1156 Consecutive Women With Early Breast Cancer

Evaluation of axillary dose coverage following whole breast radiotherapy: Variation with the breast volume and shape

What Is the Best Management of cN0pN1(sn) Breast Cancer Patients

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