Skip to main content
SpringerLink
Log in

Radiotherapy and Regional Nodes

  • Chapter
  • First Online:
Changing Paradigms in the Management of Breast Cancer

  • 920 Accesses

Abstract

Comprehensive nodal irradiation to the axillary, supraclavicular, and internal mammary (IM) nodes is necessary in node-positive and certain high-risk patient populations. Since surgery or radiation are both effective in controlling microscopic regional node disease, radiation treatment (RT) is often provided only to the undissected nodal basins. Although IM nodal irradiation is controversial, recent evidence suggests that it confers a local control and survival advantage. In the post-mastectomy setting, chest wall and comprehensive nodal irradiation is standard for patients with T4 disease and ≥4 axillary nodes involved, but randomized studies and meta-analysis data strongly suggest that post-mastectomy radiation therapy (PMRT) benefits patients with any number of nodes involved. Patients with high-risk disease undergoing upfront neoadjuvant chemotherapy also may benefit from comprehensive nodal radiation after surgery, but this data is currently maturing.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  1. Agresti R, Martelli G, Sandri M, Tagliabue E, Carcangiu ML, Maugeri I, et al. Axillary lymph node dissection versus no dissection in patients with T1N0 breast cancer: a randomized clinical trial (INT09/98). Cancer. 2014;120(6):885–93.

    Article  CAS  PubMed  Google Scholar 

  2. Martelli G, Boracchi P, Ardoino I, Lozza L, Bohm S, Vetrella G, et al. Axillary dissection versus no axillary dissection in older patients with T1N0 breast cancer: 15-year results of a randomized controlled trial. Ann Surg. 2012;256(6):920–4.

    Article  PubMed  Google Scholar 

  3. Hughes KS, Schnaper LA, Bellon JR, Cirrincione CT, Berry DA, McCormick B, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31(19):2382–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Martelli G, Miceli R, Costa A, Coradini D, Zurrida S, Piromalli D, et al. Elderly breast cancer patients treated by conservative surgery alone plus adjuvant tamoxifen: fifteen-year results of a prospective study. Cancer. 2008;112(3):481–8.

    Article  PubMed  Google Scholar 

  5. Fisher B, Redmond C, Fisher ER, Bauer M, Wolmark N, Wickerham DL, et al. Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med. 1985;312(11):674–81.

    Article  CAS  PubMed  Google Scholar 

  6. Strom EA, Woodward WA, Katz A, Buchholz TA, Perkins GH, Jhingran A, et al. Clinical investigation: regional nodal failure patterns in breast cancer patients treated with mastectomy without radiotherapy. Int J Radiat Oncol Biol Phys. 2005;63(5):1508–13.

    Article  PubMed  Google Scholar 

  7. Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003;349(6):546–53.

    Article  PubMed  Google Scholar 

  8. Mansel RE, Fallowfield L, Kissin M, Goyal A, Newcombe RG, Dixon JM, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst. 2006;98(9):599–609.

    Article  PubMed  Google Scholar 

  9. Andersson Y, de Boniface J, Jonsson PE, Ingvar C, Liljegren G, Bergkvist L, et al. Axillary recurrence rate 5 years after negative sentinel node biopsy for breast cancer. Br J Surg. 2012;99(2):226–31.

    Article  CAS  PubMed  Google Scholar 

  10. Veronesi U, Viale G, Paganelli G, Zurrida S, Luini A, Galimberti V, et al. Sentinel lymph node biopsy in breast cancer: ten-year results of a randomized controlled study. Ann Surg. 2010;251(4):595–600.

    Article  PubMed  Google Scholar 

  11. Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11(10):927–33.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Kim T, Giuliano AE, Lyman GH. Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis. Cancer. 2006;106(1):4–16.

    Article  PubMed  Google Scholar 

  13. Fleissig A, Fallowfield LJ, Langridge CI, Johnson L, Newcombe RG, Dixon JM, et al. Post-operative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Res Treat. 2006;95(3):279–93.

    Article  PubMed  Google Scholar 

  14. Lyman GH, Giuliano AE, Somerfield MR, Benson AB 3rd, Bodurka DC, Burstein HJ, et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol. 2005;23(30):7703–20.

    Article  PubMed  Google Scholar 

  15. Lyman GH, Temin S, Edge SB, Newman LA, Turner RR, Weaver DL, Benson AB III, Bosserman LD, Burstein HJ, Cody H III, Hayman J, Perkins CL, Podoloff DA, Giuliano AE. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;54:1177.

    Google Scholar 

  16. Galimberti V, Cole BF, Zurrida S, Viale G, Luini A, Veronesi P, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol. 2013;14(4):297–305.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Whitworth PW, Blumencranz PW, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305(6):569–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Jagsi R, Chadha M, Moni J, Ballman K, Laurie F, Buchholz TA, et al. Radiation field design in the ACOSOG Z0011 (Alliance) Trial. J Clin Oncol. 2014;32(32):3600–6.

    Google Scholar 

  19. Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310(14):1455–61.

    Google Scholar 

  20. Mehta K, Haffty BG. Long-term outcome in patients with four or more positive lymph nodes treated with conservative surgery and radiation therapy. Int J Radiat Oncol Biol Phys. 1996;35(4):679–85.

    Article  CAS  PubMed  Google Scholar 

  21. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy,lumpectomy, andlumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233–41.

    Google Scholar 

  22. Galper S, Recht A, Silver B, Manola J, Gelman R, Schnitt SJ, et al. Factors associated with regional nodal failure in patients with early stage breast cancer with 0–3 positive axillary nodes following tangential irradiation alone. Int J Radiat Oncol Biol Phys. 1999;45(5):1157–66.

    Article  CAS  PubMed  Google Scholar 

  23. Reddy SG, Kiel KD. Supraclavicular nodal failure in patients with one to three positive axillary lymph nodes treated with breast conserving surgery and breast irradiation, without supraclavicular node radiation. Breast J. 2007;13(1):12–8.

    Article  PubMed  Google Scholar 

  24. Livi L, Paiar F, Simontacchi G, Barca R, Detti B, Fondelli S, et al. Loco regional failure pattern afterlumpectomy and breast irradiation in 4185 patients with T1 and T2 breast cancer. Implications for nodal irradiation. Acta Oncol. 2006;45(5):564–70.

    Google Scholar 

  25. Yu JI, Park W, Huh SJ, Choi DH, Lim YH, Ahn JS, et al. Determining which patients require irradiation of the supraclavicular nodal area after surgery for N1 breast cancer. Int J Radiat Oncol Biol Phys. 2010;78(4):1135–41.

    Article  PubMed  Google Scholar 

  26. Meier P, Ferguson DJ, Karrison T. A controlled trial of extended radical versus radical mastectomy. Ten-year results. Cancer. 1989;63(1):188–95.

    Article  CAS  PubMed  Google Scholar 

  27. Lacour J, Le M, Caceres E, Koszarowski T, Veronesi U, Hill C. Radical mastectomy versus radical mastectomy plus internal mammary dissection. Ten year results of an international cooperative trial in breast cancer. Cancer. 1983;51(10):1941–3.

    Article  CAS  PubMed  Google Scholar 

  28. Morimoto T, Monden Y, Takashima S, Itoh S, Kimura T, Yamamoto H, et al. Five-year results of a randomized clinical trial comparing modified radical mastectomy and extended radical mastectomy for stage II breast cancer. Surg Today. 1994;24(3):210–4.

    Article  CAS  PubMed  Google Scholar 

  29. Veronesi U, Marubini E, Mariani L, Valagussa P, Zucali R. The dissection of internal mammary nodes does not improve the survival of breast cancer patients. 30-year results of a randomised trial. Eur J Cancer. 1999;35(9):1320–5.

    Article  CAS  PubMed  Google Scholar 

  30. Whelan TJ, Olivotto IA, Parulekar WR, Ackerman I, Chua BH, Nabid A, et al. Regional nodal irradiation in early-stage breast cancer. N Engl J Med. 2015;373(4):307–16.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Poortmans PM, Collette S, Kirkove C, Van Limbergen E, Budach V, Struikmans H, et al. Internal mammary and medial supraclavicular irradiation in breast cancer. N Engl J Med. 2015;373(4):317–27.

    Article  CAS  PubMed  Google Scholar 

  32. Huang O, Wang L, Shen K, Lin H, Hu Z, Liu G, et al. Breast cancer subpopulation with high risk of internal mammary lymph nodes metastasis: analysis of 2269 Chinese breast cancer patients treated with extended radical mastectomy. Breast Cancer Res Treat. 2008;107(3):379–87.

    Article  PubMed  Google Scholar 

  33. Veronesi U, Arnone P, Veronesi P, Galimberti V, Luini A, Rotmensz N, et al. The value of radiotherapy on metastatic internal mammary nodes in breast cancer. Results on a large series. Ann Oncol. 2008;19(9):1553–60.

    Article  CAS  PubMed  Google Scholar 

  34. Budach W, Kammers K, Boelke E, Matuschek C. Adjuvant radiotherapy of regional lymph nodes in breast cancer – a meta-analysis of randomized trials. Radiat Oncol. 2013;8:267.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Thorsen LB, Offersen BV, Dano H, Berg M, Jensen I, Pedersen AN, et al. DBCG-IMN: a population-based cohort study on the effect of internal mammary node irradiation in early node-positive breast cancer. J Clin Oncol. 2016;34(4):314–20.

    Article  PubMed  Google Scholar 

  36. Fracchia AA, Evans JF, Eisenberg BL. Stage III carcinoma of the breast: a detailed analysis. Ann Surg. 1980;192(6):705–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Hortobagyi GN, Strom EA, Buchholz TA. Locally advanced breast cancer. In: Singletary SER, Hortobagyi GN, editors. Advanced therapy of breast disease. 2nd ed. Hamilton: B.C. Decker; 2004. p. 498–508.

    Google Scholar 

  38. Smith BD, Jiang J, McLaughlin SS, Hurria A, Smith GL, Giordano SH, et al. Improvement in breast cancer outcomes over time: are older women missing out? J Clin Oncol. 2011;29(35):4647–53.

    Article  PubMed  Google Scholar 

  39. Overgaard M, Christensen JJ, Johansen H, Nybo-Rasmussen A, Brincker H, van der Kooy P, et al. Postmastectomy irradiation in high-risk breast cancer patients. Present status of the Danish Breast Cancer Cooperative Group trials. Acta Oncol. 1988;27(6A):707–14.

    Article  CAS  PubMed  Google Scholar 

  40. Harris JR, Halpin-Murphy P, McNeese M, Mendenhall NP, Morrow M, Robert NJ. Consensus statement on postmastectomy radiation therapy. Int J Radiat Oncol Biol Phys. 1999;44(5):989–90.

    Article  CAS  PubMed  Google Scholar 

  41. Recht A, Edge SB, Solin LJ, Robinson DS, Estabrook A, Fine RE, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001;19(5):1539–69.

    Article  CAS  PubMed  Google Scholar 

  42. Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347(8):567–75.

    Article  PubMed  Google Scholar 

  43. Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, Bach F, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b trial. N Engl J Med. 1997;337(14):949–55.

    Article  CAS  PubMed  Google Scholar 

  44. Overgaard M, Jensen MB, Overgaard J, Hansen PS, Rose C, Andersson M, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet. 1999;353(9165):1641–8.

    Article  CAS  PubMed  Google Scholar 

  45. Whelan T, Levine M. More evidence that locoregional radiation therapy improves survival: what should we do? J Natl Cancer Inst. 2005;97(2):82–4.

    Article  PubMed  Google Scholar 

  46. Overgaard M, Nielsen HM, Overgaard J. Is the benefit of postmastectomy irradiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DBCG 82 b&c randomized trials. Radiother Oncol. 2007;82(3):247–53.

    Article  PubMed  Google Scholar 

  47. Goldhirsch A, Glick JH, Gelber RD, Coates AS, Thurlimann B, Senn HJ, et al. Meeting highlights: international expert consensus on the primary therapy of early breast cancer 2005. Ann Oncol. 2005;16(10):1569–83.

    Article  CAS  PubMed  Google Scholar 

  48. Overgaard J, Bartelink H. Breast cancer survival advantage with radiotherapy. Lancet. 2000;356(9237):1269–70. author reply 71

    Article  CAS  PubMed  Google Scholar 

  49. Overgaard M. Radiotherapy as part of a multidisciplinary treatment strategy in early breast cancer. Eur J Cancer. 2001;37:33–43.

    Article  Google Scholar 

  50. Ragaz J, Jackson SM, Le N, Plenderleith IH, Spinelli JJ, Basco VE, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med. 1997;337(14):956–62.

    Article  CAS  PubMed  Google Scholar 

  51. Ragaz J, Olivotto IA, Spinelli JJ, Phillips N, Jackson SM, Wilson KS, et al. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst. 2005;97(2):116–26.

    Article  PubMed  Google Scholar 

  52. Kurtz J, Party EW. The curative role of radiotherapy in the treatment of operable breast cancer. Eur J Cancer. 2002;38(15):1961–74.

    Article  CAS  PubMed  Google Scholar 

  53. Ebctcg, McGale P, Taylor C, Correa C, Cutter D, Duane F, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383(9935):2127–35.

    Article  Google Scholar 

  54. Wang J, Shi M, Ling R, Xia Y, Luo S, Fu X, et al. Adjuvant chemotherapy and radiotherapy in triple-negative breast carcinoma: a prospective randomized controlled multi-center trial. Radiother Oncol. 2011;100(2):200–4.

    Article  CAS  PubMed  Google Scholar 

  55. Fisher B, Brown A, Mamounas E, Wieand S, Robidoux A, Margolese RG, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol. 1997;15(7):2483–93.

    Article  CAS  PubMed  Google Scholar 

  56. Bear HD, Anderson S, Smith RE, Geyer CE Jr, Mamounas EP, Fisher B, et al. Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2006;24(13):2019–27.

    Article  CAS  PubMed  Google Scholar 

  57. Bear HD, Anderson S, Brown A, Smith R, Mamounas EP, Fisher B, et al. The effect on tumor response of adding sequential preoperative docetaxel to preoperative doxorubicin and cyclophosphamide: preliminary results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2003;21(22):4165–74.

    Article  CAS  PubMed  Google Scholar 

  58. Colleoni M, Viale G, Zahrieh D, Pruneri G, Gentilini O, Veronesi P, et al. Chemotherapy is more effective in patients with breast cancer not expressing steroid hormone receptors: a study of preoperative treatment. Clin Cancer Res. 2004;10(19):6622–8.

    Article  CAS  PubMed  Google Scholar 

  59. Ring AE, Smith IE, Ashley S, Fulford LG, Lakhani SR. Oestrogen receptor status, pathological complete response and prognosis in patients receiving neoadjuvant chemotherapy for early breast cancer. Br J Cancer. 2004;91(12):2012–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. Huang EH, Tucker SL, Strom EA, McNeese MD, Kuerer HM, Buzdar AU, et al. Postmastectomy radiation improves local-regional control and survival for selected patients with locally advanced breast cancer treated with neoadjuvant chemotherapy and mastectomy. J Clin Oncol. 2004;22(23):4691–9.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, 195 Little Albany Street, New Brunswick, NJ, 08903, USA

    Andrew Zhang MD, Bruce G. Haffty MD & Sharad Goyal MD, MS

Authors
  1. Andrew Zhang MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bruce G. Haffty MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sharad Goyal MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sharad Goyal MD, MS .

Editor information

Editors and Affiliations

  1. Associate Professor of Surgery, Director Breast Care Center, Wake Forest School of Medicine, Winston-Salem, NC, USA

    Marissa Howard-McNatt

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Cite this chapter

Zhang, A., Haffty, B.G., Goyal, S. (2018). Radiotherapy and Regional Nodes. In: Howard-McNatt, M. (eds) Changing Paradigms in the Management of Breast Cancer . Springer, Cham. https://doi.org/10.1007/978-3-319-60336-0_10

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-60336-0_10

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-60335-3

  • Online ISBN: 978-3-319-60336-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation