Radiotherapy of the Axilla in Early Breast Cancer When and How? Marc R. Wygoda M.D. Radiotherapy Unit Department of Oncology Hadassah University Hospital Jerusalem May 1 st , 2014
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1. Radiotherapy of the Axilla in Early Breast Cancer When and
How? Marc R. Wygoda M.D. Radiotherapy Unit Department of Oncology
Hadassah University Hospital Jerusalem May 1st, 2014
2. Axillary recurrence rate in studies of SLN+ without
comple:on Axillary Dissec:on Pepels, Breast cancer res Trt 2010
Giuliano AnnSurg 2010
3. Radiotherapy of the Axilla in Early Breast Cancer
4. ACSOG Z0011 Trial ALND: anatomic level I and II dissection
with at least 10 nodes removed Median number of lymph nodes
removed: 17 in the ALND group 2 in the SLND group. Did ALND reveal
more positive lymph nodes? In the ALND group, 27.3% had additional
mets identified by axillary dissection
5. Radiotherapy 2 Opposed Tangeantials Fields No Axillary /
Supra-Clavicular Field
7. Overall Survival Non-inferiority P= 0.008 5-year overall
survival: - 91.8% in ALND group - 92.5% in SLND group.
8. Disease Free Survival 5-yr DFS: 83.9% for SLND-only 82.2%
for ALND (P=.14).
9. Factors Associated with Improved Disease- Free Survival
Factors Not Associated with Disease-Free Survival Estrogen receptor
status Age (50 years) Adjuvant systemic therapy Treatment arm
Progesterone receptor status Tumor size Level 1 lymph nodes
Histologic type Number positive lymph nodes Modified
Bloom-Richardson ACOSOG Z0011: Predictors of Disease-Free Survival
in Multivariate Analysis Giuliano AE, et al. J Clin Oncol.
2010;28:18S
10. ACOSOG Z0011 What are the Conclusions?? 1. No need for
completion ALND in selected Sentinel LN positive pts 2.
Radiotherapy Fields can be limited to Breast tissue only, without
the regional LN
11. Criticism on Z0011 Trial Statistical power Follow up
duration still short Less than expected rate of failures Why
include only patients with less than 3 positive SLNs? What about
patients with palpable lymph nodes?
12. AMAROS Dutch/EORTC Phase III study: After Mapping of the
Axilla, Radiotherapy or Surgery? Invasive Breast cancer T1-2 ( 5cm
( 31% ) or Invasion of skin or Pectoralis fascia Phase III
Randomized Trial: 2 arms MRM + CMF MRM + CMF + XRT (XRT= 50Gy to
chest wall and full lymphatics; Timing: Surgery1CMFXRT5 CMFs)
Overgaard et al. NEJM, 1997
29. Danish Trial 82b: Results
30. The British Columbia Trial 318 pts (Entry: 1979-1986)
Eligibility: premenopausal Node Positive Post Mod. Rad. Mastectomy
All pts given IV CMF Chemo Dose: 600/40/600 mg/m2, Q3w Number of
course: 12 6 Randomization: Surgery + CMF XRT Ragaz et al. JNCI Jan
19, 2005
31. The British Columbia Trial Overall Survival
32. Danish Trial 82c: postmenopausal MRM + TAM XRT DFS and
Overall Survival p30yrs follow-up: Gustave Roussy data
49. Breast Cancer Evolution: 3 The Spectrum Paradigm 10 2
3
50. The Spectrum Paradigm Breast Cancer is a Heterogeneous
Disease Spectrum of Proclivities: From a Local Disease through its
entire course To a Systemic Disease when first detectable
Implications: Lymph nodes can be the source of distant mets
Loco-Regional control is important for Survival
51. Axillary levels: implications on Radiotherapy Extent
52. 3D Delineation of nodal stations
53. Axillary levels: implications on Radiotherapy Extent
Axillary Level I Medial Supra-Clav. Axillary Level II Lateral
Supra-Clav. Axillary Level III Infraclavicular Parasternal
54. Estimations of % of Axillary nodes treated by Tangential
fields Level I Level II Level III Traditional Tangential 50% 20-30%
- High Tangential 80% 60% -
55. Lets be a bit provocative
56. Royal Marsden No Surgery after cCR post NACT
57. Royal Marsden No Surgery after cCR post NACT
58. NSABP B04 Difference ALND vs Axillary RT Rnode - Total
mastectomy + ALND Total mastectomy + RT Total mastectomy n = 1079
Rnode + Total mastectomy + ALND Total mastectomy + RT n = 586
Regional 4 vs 4% Regional 8 vs 11% Fisher NEJM,347; 657, 2002 NSABP
B04
59. morbidity ALND-ART Deutsch, IJROBP, 2008 Rnode - Total
mastectomy + ALND Total mastectomy + RT Total mastectomy n =
1079
60. Dutch experience in LABC and cN+ disease If aTer
neoadjuvant chemotherapy the axilla is clinically and
radiologically nega:ve (yN0).. Treatment without ALND, but only
ART. Kol, poster EBCC 2010 N = 138 (median follow-up: 4yr) 7
regional recurrences (5%) axillary 3 (2%) Non axillay 4 (3%)
61. Conclusions 1. Two Randomized trials in early stage SLN+
patients demonstrate that Completion Axillary Clearance is not
needed and Radiotherapy is as effective with less side effects than
surgery 2. No Consensus on whether Tangeantial fields are enough or
whether an extra axillary/supra field is needed 3. Radiotherapy
contributes to Overall Survival 4. Avoid Double Axillary Treatment
(Surgery + Radiotherapy) 5. Axillary Radiotherapy might replace
Surgery in the future, even in clinical N+ or high burden axillary
disease patients
62. Less is more: - = + Mastectomy vs Lumpectomy + XRT
63. Less is more: Axillary Dissection vs. Sentinel LNB