Risk of Nodal Failure

Axillary Node Failure

RISK OF AXILLARY NODE POSITIVITY RELATIVE TO TUMOR SIZE
Axillary Nodal Risk (at presentation) according to Primary Tumor Size

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IMPACT OF AXILLARY LYMPH NODES ON LOCAL REGIONAL FAILURE
Results of Subgroups Defined by Number of Involved Axillary Lymph Nodes in PMRT Trials (Ref. Recht A)

number of positive axillary lymph nodes local regional failure after radiotherapy local regional failure after surgery (with axillary dissection) alone
0 ~05% [03% - 06%] ~15% [05% - 23%]
1-3 ~ 10% [02% - 13%] ~30% [30% - 33%]
4+ ~ 15% [06% - 21%] ~45% [20% - 46%]
  • For node-negative patients vascular invasion and tumor > 2 cm were factors for local recurrence in all women.
  • For node-positive cohort, number of nodes and tumor grade were factors in local control. (J Clin Oncol. 2003 Apr 1;21(7): 1205-13.)

IMPACT OF AXILLARY LYMPH NODES ON SURVIVAL
Percent Survival at 5-yrs (AJCC 6th ed)
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IMPACT OF AXILLARY LYMPHNODE DISSECTION ON AXILLARY RECURRENCE

  • Danish 82b trial evaluated the impact of axillary dissection on the LRF rate in patients not undergoing PMRT.

The 10-year LRF rate was

  • 40% for 133 patients who had an axillary dissection specimen from 0-3 nodes were recovered
  • 32% for 511 patients in whom 4-9 nodes were recovered
  • 27% for 211 patients in whom 10 or more nodes were examined.

Supraclavicular Failure

Factors Leading to High Surpraclavicular Failure

  • “Multivariate analyses of locoregional recurrences and skin complications after postmastectomy radiotherapy using electrons or photons “
    • use of electron beam therapy and N3 stage were most significant factors for SC recurrence.
  • Eng-Yen Huang M.D, IJROBP 2006, 65(5): 1389-1396 .

Risk of Supraclavicular node positive
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  • For 0-3 LN(+)
    • Failure in SC w/o RT is 2% (Recht JCO 1991, Halverson IJROBP 1993). Also, if ALND is negative as skip metastasis to SC is extremely rare for breast cancer. RT SC can be included (as recommended by French) but is controversial.
  • For 4 or more LN(+)
    • In a retrospective study, for stage I/II Breast CA treated with BCS + RT (no SC RT) the rate of SCF was 11% vs 2% if treated. (IJROP 2003:(56)3:658-670): Most would recommend SC RT in these case.

Internal Mammary Nodal Risk (Handley surgical data)

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  • May be considered in patient with “high” risk > 4 ALN(+), SLN(+) in the IMC. But would only treat first 3 intercostal space and only if heart was not in the field and lung volume was limited.
  • No IMC: per Yale study with 900 patients showed no benefit to IMC RT.
No nodes (N0) 1-3 nodes (N1) 4+ nodes (N2 or N3)
< 2 cm (T1) 95% 90% 65%
< 5 cm (T2) 90% 80% 60%
5+ cm (T3 or T4) 80% 70% 45%
  • Axillary Lymph node has greater effect on survival than tumor size.
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