Departments of Radiation Oncology.
Departments of Radiation Oncology.
Int J Radiat Oncol Biol Phys. 2022 Jul 1;113(3):552-560. doi: 10.1016/j.ijrobp.2022.02.037. Epub 2022 Mar 4.
Patients with breast cancer and ipsilateral axillary and internal mammary (IM) lymph node involvement (cN3b) often forgo IM node resection. Therefore, radiation is important for curative therapy. However, prognosis is not well described in the era of modern systemic therapy, and limited data exist to guide optimal locoregional treatment recommendations.
We retrospectively reviewed 117 patients with nonmetastatic cN3b breast cancer treated at our institution between 2014 and 2019. Staging included ultrasound evaluation of all regional nodal basins. All patients received neoadjuvant chemotherapy, resection of the breast primary, and axillary nodal dissection, followed by adjuvant radiation to the breast/chest wall and regional nodes. Institutional guidelines recommend a 10-Gy boost to radiographically resolved nodes, and a 16-Gy boost to unresolved nodes. Overall survival, recurrence-free survival (RFS), locoregional RFS, internal mammary RFS, and distant metastasis-free survival were evaluated with Kaplan-Meier analysis. A multivariable model for RFS was constructed.
Median follow-up for 117 patients was 3.82 years. Median age at diagnosis was 46 years and 56 patients (48%) were receptor group ER+/HER2-. Mastectomy was performed in 96 patients (82%), 38 (32%) had biopsy-confirmed IMC involvement, and 8 (7%) had IM node dissection. The median initial radiation dose was 50 Gy (range, 50-55 Gy) and IMC boost 10 Gy (range, 0-16 Gy). The 5-year overall survival, IM RFS, locoregional RFS, distant metastasis-free survival, and RFS were 74%, 98%, 89%, 68%, and 67%, respectively. On multivariable analysis, a clinical complete response of the IM nodes or ypN0 (pathologic complete response of nodes) status had improved 5-year RFS with hazard ratios of 0.24 (P = .006) and 0.27 (P = .05), respectively. Extranodal extension or lymphovascular invasion were associated with worse 5-year RFS with hazard ratios of 4.13 (P = .001) and 2.25 (P = .04), respectively.
Multimodality therapy provides excellent locoregional control of 89% at 5 years for patients with cN3b breast cancer. Adjuvant radiation yields a 5-year IM RFS of 98%. Clinical and pathologic response of IM nodes are independently prognostic for RFS.
患有乳腺癌和同侧腋窝及内乳（IM）淋巴结受累（cN3b）的患者常放弃 IM 淋巴结切除术。因此，放射治疗对治愈性治疗很重要。然而，在现代全身治疗时代，预后描述不佳，并且存在有限的数据来指导最佳局部区域治疗建议。
我们回顾性分析了 2014 年至 2019 年期间在我院治疗的 117 例非转移性 cN3b 乳腺癌患者。分期包括所有区域淋巴结盆地的超声评估。所有患者均接受新辅助化疗、乳腺原发肿瘤切除术和腋窝淋巴结清扫术，然后接受乳腺/胸壁和区域淋巴结的辅助放疗。机构指南建议对影像学上已解决的淋巴结给予 10Gy 的增强放疗，对未解决的淋巴结给予 16Gy 的增强放疗。使用 Kaplan-Meier 分析评估总生存期、无复发生存期（RFS）、局部区域 RFS、内乳 RFS 和无远处转移生存期。建立 RFS 的多变量模型。
117 例患者的中位随访时间为 3.82 年。中位诊断年龄为 46 岁，56 例（48%）为受体组 ER+/HER2-。96 例患者行乳房切除术（82%），38 例（32%）经活检证实有 IMC 受累，8 例（7%）行内乳淋巴结清扫术。初始放射剂量中位数为 50Gy（范围，50-55Gy），IMC 增强剂量为 10Gy（范围，0-16Gy）。5 年总生存率、IMRFS、局部区域 RFS、无远处转移生存率和 RFS 分别为 74%、98%、89%、68%和 67%。多变量分析显示，IM 淋巴结临床完全缓解或 ypN0（淋巴结病理完全缓解）状态与 5 年 RFS 改善相关，风险比分别为 0.24（P=0.006）和 0.27（P=0.05）。额外的淋巴结外延伸或淋巴管侵犯与 5 年 RFS 较差相关，风险比分别为 4.13（P=0.001）和 2.25（P=0.04）。
多模式治疗为 cN3b 乳腺癌患者提供了 5 年 89%的局部区域控制。辅助放疗可使 5 年 IMRFS 达到 98%。IM 淋巴结的临床和病理反应是 RFS 的独立预后因素。
