Department of Radiation Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143-1708, USA.
Int J Radiat Oncol Biol Phys. 2012 Jun 1;83(2):494-503. doi: 10.1016/j.ijrobp.2012.01.068.
To identify a cohort of women treated with neoadjuvant chemotherapy and mastectomy for whom postmastectomy radiation therapy (PMRT) may be omitted according to the projected risk of local-regional failure (LRF).
Seven breast cancer physicians from the University of California cancer centers created 14 hypothetical clinical case scenarios, identified, reviewed, and abstracted the available literature (MEDLINE and Cochrane databases), and formulated evidence tables with endpoints of LRF, disease-free survival, and overall survival. Using the American College of Radiology appropriateness criteria methodology, appropriateness ratings for postmastectomy radiation were assigned for each scenario. Finally, an overall summary risk assessment table was developed.
Of 24 sources identified, 23 were retrospective studies from single institutions. Consensus on the appropriateness rating, defined as 80% agreement in a category, was achieved for 86% of the cases. Distinct LRF risk categories emerged. Clinical stage II (T1-2N0-1) patients, aged >40 years, estrogen receptor-positive subtype, with pathologic complete response or 0-3 positive nodes without lymphovascular invasion or extracapsular extension, were identified as having ≤ 10% risk of LRF without radiation. Limited data support stage IIIA patients with pathologic complete response as being low risk.
In the absence of randomized trial results, existing data can be used to guide the use of PMRT in the neoadjuvant chemotherapy setting. Using available studies to inform appropriateness ratings for clinical scenarios, we found a high concordance of treatment recommendations for PMRT and were able to identify a cohort of women with a low risk of LRF without radiation. These low-risk patients will form the basis for future planned studies within the University of California Athena Breast Health Network.
根据局部区域复发（LRF）的预计风险，确定一组接受新辅助化疗和乳房切除术治疗的女性患者，这些患者可能无需接受术后放射治疗（PMRT）。
来自加利福尼亚大学癌症中心的 7 位乳腺癌医生创建了 14 个假设的临床病例情景，确定、回顾和提取了可用的文献（MEDLINE 和 Cochrane 数据库），并制定了包含 LRF、无病生存和总生存终点的证据表。使用美国放射学院适宜性标准方法，为每个情景分配了 PMRT 的适宜性评分。最后，开发了一个总体风险评估表。
在确定的 24 个来源中，有 23 个是来自单一机构的回顾性研究。对于 86%的病例，达成了适宜性评分的共识，定义为在一个类别中达成 80%的一致。出现了明显的 LRF 风险类别。临床分期 II 期（T1-2N0-1）患者、年龄>40 岁、雌激素受体阳性亚型、病理完全缓解或 0-3 个阳性淋巴结且无淋巴血管侵犯或包膜外扩展，被认为没有放疗的 LRF 风险<10%。有限的数据支持病理完全缓解的 IIIA 期患者为低风险。
在没有随机试验结果的情况下，可以使用现有数据来指导新辅助化疗环境中 PMRT 的使用。使用现有研究来告知临床情景的适宜性评分，我们发现 PMRT 的治疗建议高度一致，并能够确定一组 LRF 风险低的无需放疗的女性患者。这些低风险患者将成为加利福尼亚大学雅典娜乳腺健康网络未来计划研究的基础。
