Regional Nodal Irradiation

Trial Addressing Axillary Node Radiation

B04 –Axilary RT vs ALND


Arms (None of the women received chemotherapy) Local-regional Failure Rate for initially node negative patients Local-regional Failure Rate for Initially node positive patients
Total Mastectomy 18%* N/A
Total Mastectomy + RT 3% 11% (11% in axilla and 0% in SC)
Radical Mastectomy 2% 7% (1% in axilla and 6% in SC)
  • 40% of patient with Radical Mastectomy had LN(+) (ie. 40% had subclinical disease)
  • Excelent control of axilla with ALND and Axillary RT. ALND vs Axillary RT showed 2% vs 3% axillary nodal recurrence rate despite 40% patients having subclinical disease burden.
  • Even without axillary treatmentonly 18% of the patients total mastectomy had axillary failures. (The lower number may represent the fact patient with systemic failures or patient who were treated with salvage ALND were not counted as axillary node failures.)
  • However, for node positive patients RT has some 4% increase in local failure compared to ALND.
  • In node positive patients, RT is worse in the axilla but is better for local control and SC recurrence.

Institute Curie in Paris (Clin Oncol. 2004 Jan 1;22(1): 97-101.)

  • ALND vs Axillary RT showed 1% vs 3% axillary nodal recurrence rate mimicking B04.
  • The 5-year distant disease-free survival rate in the surgery and radiotherapy arms were 97% and 93%, respectively, which was a statistically significant difference (Cabanes, Lancet 339:1245-1248, 1992).
  • However, this difference disappeared in the follow 12 years later.

Axillary RT in Node (+) patients
“High Tangents” – cranial edge 2 cm below humeral head cover 80% of level I/II nodes (Schlembac, IJROBP 51:2001)

Treatment Type Upper limb edema
ALND + RT 25-36%
RT alone 5-10% (CMAJ 2004; 170(8): 1263)
ALND 5-10% (CMAJ 2004; 170(8): 1263)

Controversial regarding Posterior Axillary Boost

  • Give PAB for gross disease and inadequate dissection ( < 10 LN recovered)
  • Softer indications include >20% of nodes positive, 4 nodes +

Treatment of Internal Mammary Nodes


  • Medial: 5 to 6 cm lateral to to mid-line
  • Superior: Inferior border of the supraclavicular field
  • Inferior is at the xiphoid (or 3rd or 4th Intercostal space)
  • Calculate at 4 to 5 cm depth with 12 to 16 MeV electrons.
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