Edinburgh Cancer Centre, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, Scotland, UK.
Breast. 2009 Oct;18 Suppl 3:S112-20. doi: 10.1016/S0960-9776(09)70285-1.
The role of immune surveillance in controlling the spread of breast cancer to the regional nodes is poorly understood. In theory regional nodal irradiation (RNI) might compromise this host function. However the clinical evidence suggests that the risk of regional recurrence is lower in patients with early breast cancer whose axilla has been irradiated compared to no axillary treatment. The role of RNI after breast conserving surgery has not been well studied. A policy of level III clearance and only irradiating the axilla for residual disease and a selective policy of axillary irradiation in node positive patients after sentinel node biopsy or lower axillary node sample is recommended. Irradiation of the medial supraclavicular fossa after axillary dissection is suggested where there are four or more nodes involved on axillary dissection. There is little data to inform selection of patients for RNI after neoadjuvant systemic therapy. The role of postmastectomy radiotherapy (PMRT) was largely established on the basis of comprehensive RNI. It is unclear whether irradiating less than the chest wall and peripheral lymphatics confers the same level of benefit. The role of PMRT in women with 1-3 involved nodes remains controversial and investigational. Biological factors such as oestrogen and progesterone receptor status and HER-2 protein expression may play a role in determining benefits from PMRT. The role of internal mammary nodal irradiation is unclear. The individualisation of RNI based on molecular and genetic factors should be a priority for research. The benefits of RNI need to be carefully balanced against the risks of cardiotoxicity, pneumonitis, lymphoedema, brachial plexopathy and secondary malignancy.
免疫监视在控制乳腺癌向区域淋巴结扩散中的作用还不太清楚。从理论上讲，区域淋巴结照射（RNI）可能会损害这种宿主功能。然而，临床证据表明，与未进行腋窝治疗的患者相比，接受早期乳腺癌腋窝照射的患者区域复发的风险较低。保乳手术后 RNI 的作用尚未得到很好的研究。推荐的方案是对 III 水平的淋巴结进行清扫，仅对残留疾病进行腋窝照射，对于前哨淋巴结活检或较低腋窝淋巴结样本呈阳性的患者，选择性地对腋窝进行照射。建议在腋窝清扫后对锁骨上内侧窝进行照射，如果腋窝清扫中有 4 个或更多的淋巴结受累。在新辅助全身治疗后，选择进行 RNI 的患者的数据很少。术后放疗（PMRT）的作用主要是基于全面的 RNI。目前还不清楚是否照射少于胸壁和外周淋巴系统是否能获得相同水平的益处。PMRT 在 1-3 个受累淋巴结的女性中的作用仍存在争议和研究。生物因素，如雌激素和孕激素受体状态以及 HER-2 蛋白表达，可能在确定 PMRT 的获益方面发挥作用。内乳淋巴结照射的作用尚不清楚。根据分子和遗传因素个体化 RNI 应该是研究的重点。RNI 的益处需要与心脏毒性、放射性肺炎、淋巴水肿、臂丛神经病和继发性恶性肿瘤的风险仔细平衡。
