Advertisement

Indications for Postmastectomy Radiation After Neoadjuvant Chemotherapy in ypN0 and ypN1-3 Axillary Node-Positive Women

Published:August 01, 2017DOI:https://doi.org/10.1016/j.clbc.2017.07.016

      Abstract

      Introduction

      Downstaging with neoadjuvant chemotherapy (NAC) might obscure indications for postmastectomy radiation (PMRT). The degree of downstaging that results in local-regional recurrence (LRR) rates low enough to omit PMRT remains controversial. We examined the rate of LRR in women who received NAC who underwent mastectomy without PMRT.

      Patients and Methods

      Between 2004 and 2013, 81 women with stage I to IIIA breast cancer had NAC and mastectomy; 48 patients (59%) were clinical N0 and 33 patients (41%) were clinical N1; median age was 45 years; 33 patients (41%) had hormone receptor-positive (HR+) HER2−, 21 patients (26%) HR+ HER2+, 19 patients (23%) HR− HER2−, and 7 patients (9%) HR− HER2+ disease. We explored how LRR rates varied with age, BRCA status, Grade, receptor status, clinical N status, pathologic response, lymphovascular invasion, and mastectomy margins. Median follow-up was 4.9 years.

      Results

      After NAC, 35 patients (43%) had a pathologic complete response (pCR), 33 patients (41%) were ypN0, and 13 patients (16%) were ypN1-3+. There were 8 LRRs (6 chest wall, 1 axillary, 1 supraclavicular node). The 5-year cumulative incidence of LRR was 8% for all patients, 3% for pCR, 16% for ypN0, 10% for ypN1-3+, 6% for HR+ HER2−, 25% for HR+ HER2+, 0% for HR− HER2−, and 0% for HR− HER2+. LRR was 31% in the ypN0 and 33% in the ypN1-3+ HR+ HER2+ women, and 12% in the ypN0 and 0% in the ypN1 to ypN3+ HR+ HER2− patients.

      Conclusion

      This study is unique. All HER2+ patients received trastuzumab and LRR was analyzed according to treatment response, clinicopathologic factors, and receptor status. pCR patients including young women and clinical stage IIIA had low LRR rates. However, ypN0 and ypN1-3+ HR+ HER2+ patients had higher rates of LRR compared with other receptor subgroups and on the basis of limited data should be considered for PMRT.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Clinical Breast Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • McGale P.
        • Taylor C.
        • et al.
        • EBCTCG (Early Breast Cancer Trialists' Collaborative Group)
        Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials.
        Lancet. 2014; 383: 2127-2135
        • Fowble B.L.
        • Einck J.P.
        • Kim D.N.
        • et al.
        Role of postmastectomy radiation after neoadjuvant chemotherapy in stage II-III breast cancer.
        Int J Radiat Oncol Biol Phys. 2012; 83: 494-503
        • Recht A.
        • Edge S.B.
        • Solin L.J.
        • et al.
        Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology.
        J Clin Oncol. 2001; 19: 1539-1569
        • Truong P.T.
        • Olivotto I.A.
        • Whelan T.J.
        • Levine M.
        • Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer
        Clinical practice guidelines for the care and treatment of breast cancer: 16. Locoregional post-mastectomy radiotherapy.
        CMAJ. 2004; 170: 1263-1273
        • Mamounas E.P.
        • Anderson S.J.
        • Dignam J.J.
        • et al.
        Predictors of locoregional recurrence after neoadjuvant chemotherapy: results from combined analysis of National Surgical Adjuvant Breast and Bowel Project B-18 and B-27.
        J Clin Oncol. 2012; 30: 3960-3966
        • Mamounas E.P.
        • Cortazar P.
        • Zhang L.J.
        • et al.
        Locoregional recurrence (LRR) after neoadjuvant chemotherapy (NAC): pooled-analysis results from the Collaborative Trials in Neoadjuvant Breast Cancer (CTNeoBC).
        J Clin Oncol. 2014; 32: 26
        • Cortazar P.
        • Zhang L.
        • Untch M.
        • et al.
        Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis.
        Lancet. 2014; 384: 164-172
        • Broglio K.R.
        • Quintana M.
        • Foster M.
        • et al.
        Association of pathologic complete response to neoadjuvant therapy in HER2-positive breast cancer with long-term outcomes: a meta-analysis.
        JAMA Oncol. 2016; 2: 751-760
        • Edge S.B.
        • American Joint Committee on Cancer
        AJCC Cancer Staging Manual.
        7th ed. Springer, New York2010
        • Barker A.D.
        • Sigman C.C.
        • Kelloff G.J.
        • Hylton N.M.
        • Berry D.A.
        • Esserman L.J.
        I-SPY 2: an adaptive breast cancer trial design in the setting of neoadjuvant chemotherapy.
        Clin Pharmacol Ther. 2009; 86: 97-100
        • Esserman L.J.
        • Berry D.A.
        • Cheang M.C.
        • et al.
        Chemotherapy response and recurrence-free survival in neoadjuvant breast cancer depends on biomarker profiles: results from the I-SPY 1 TRIAL (CALGB 150007/150012; ACRIN 6657).
        Breast Cancer Res Treat. 2012; 132: 1049-1062
        • Gray R.J.
        A class of K-sample tests for comparing the cumulative incidence of a competing risk.
        Ann Stat. 1988; 16: 1141-1154
        • Krug D.
        • Lederer B.
        • Debus J.
        • et al.
        Relationship of omission of adjuvant radiotherapy to outcomes of locoregional control and disease-free survival in patients with or without pCR after neoadjuvant chemotherapy for breast cancer: a meta-analysis on 3481 patients from the Gepar-trials.
        J Clin Oncol. 2015; 33: 15
        • Recht A.
        • Comen E.A.
        • Fine R.E.
        • et al.
        Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update.
        J Clin Oncol. 2016; 34: 4431-4442
        • Vila J.
        • Teshome M.
        • Tucker S.L.
        • et al.
        Combining clinical and pathologic staging variables has prognostic value in predicting local-regional recurrence following neoadjuvant chemotherapy for breast cancer.
        Ann Surg. 2017; 265: 574-580
        • Diaz D.A.
        • Hurley J.
        • Reis I.
        • Takita C.
        • Zhao W.
        • Wright J.
        Locoregional outcomes in clinical stage IIB breast cancer after neoadjuvant therapy and mastectomy with or without radiation.
        Medicine (Baltimore). 2014; 93: e230
        • Arsenault D.
        • Hurley J.
        • Takita C.
        • et al.
        Predictors of locoregional outcome in HER2-overexpressing breast cancer treated with neoadjuvant chemotherapy.
        Am J Clin Oncol. 2015; 38: 348-352
        • Garg A.K.
        • Strom E.A.
        • McNeese M.D.
        • et al.
        T3 disease at presentation or pathologic involvement of four or more lymph nodes predict for locoregional recurrence in stage II breast cancer treated with neoadjuvant chemotherapy and mastectomy without radiotherapy.
        Int J Radiat Oncol Biol Phys. 2004; 59: 138-145
        • Le Scodan R.
        • Selz J.
        • Stevens D.
        • et al.
        Radiotherapy for stage II and stage III breast cancer patients with negative lymph nodes after preoperative chemotherapy and mastectomy.
        Int J Radiat Oncol Biol Phys. 2012; 82: e1-e7
        • Shim S.J.
        • Park W.
        • Huh S.J.
        • et al.
        The role of postmastectomy radiation therapy after neoadjuvant chemotherapy in clinical stage II-III breast cancer patients with pN0: a multicenter, retrospective study (KROG 12-05).
        Int J Radiat Oncol Biol Phys. 2014; 88: 65-72
        • Taylor M.E.
        • Haffty B.G.
        • Rabinovitch R.
        • et al.
        ACR appropriateness criteria on postmastectomy radiotherapy expert panel on radiation oncology-breast.
        Int J Radiat Oncol Biol Phys. 2009; 73: 997-1002
        • Bellon J.R.
        • Wong J.S.
        • Burstein H.J.
        Should response to preoperative chemotherapy affect radiotherapy recommendations after mastectomy for stage II breast cancer?.
        J Clin Oncol. 2012; 30: 3916-3920
        • Beriwal S.
        • Shinde A.
        • Rajagopalan M.S.
        • Kannan N.
        • Heron D.E.
        • Deutsch M.
        Recommendations for post-mastectomy radiation therapy after neo-adjuvant chemotherapy: an international survey of radiation oncologists.
        Breast J. 2013; 19: 683-684
        • Hoffman K.E.
        • Mittendorf E.A.
        • Buchholz T.A.
        Optimising radiation treatment decisions for patients who receive neoadjuvant chemotherapy and mastectomy.
        Lancet Oncol. 2012; 13: e270-e276
        • Garg A.K.
        • Buchholz T.A.
        Influence of neoadjuvant chemotherapy on radiotherapy for breast cancer.
        Ann Surg Oncol. 2015; 22: 1434-1440
        • Fowble B.
        • Park C.
        • Wang F.
        • et al.
        Rates of reconstruction failure in patients undergoing immediate reconstruction with tissue expanders and/or implants and postmastectomy radiation therapy.
        Int J Radiat Oncol Biol Phys. 2015; 92: 634-641
        • Lam T.C.
        • Hsieh F.
        • Boyages J.
        The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast reconstruction: a systematic review.
        Plast Reconstr Surg. 2013; 132: 511-518
        • Momoh A.O.
        • Ahmed R.
        • Kelley B.P.
        • et al.
        A systematic review of complications of implant-based breast reconstruction with prereconstruction and postreconstruction radiotherapy.
        Ann Surg Oncol. 2014; 21: 118-124
        • Garg A.K.
        • Oh J.L.
        • Oswald M.J.
        • et al.
        Effect of postmastectomy radiotherapy in patients <35 years old with stage II-III breast cancer treated with doxorubicin-based neoadjuvant chemotherapy and mastectomy.
        Int J Radiat Oncol Biol Phys. 2007; 69: 1478-1483