Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Upcoming SlideShare
What to Upload to SlideShare
Next
Download to read offline and view in fullscreen.

0

Share

Download to read offline

Axillary radiotherapy versus axillary surgery in breast cancer

Download to read offline

Management of axilla in breast cancer has evolved over period of time and in many instances now we can use RT with caution

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all
  • Be the first to like this

Axillary radiotherapy versus axillary surgery in breast cancer

  1. 1. Management of Axilla in Ca Breast: Axillary RT v/s Axillary Dissection Dr Ajeet Kumar Gandhi MD (AIIMS), DNB (Gold Medalist), ECMO UICCF (MSKCC,USA) Assistant professor, Radiation oncology Dr RMLIMS, Lucknow
  2. 2. Axillary RT : Rationale • Regional nodal metastasis is effectively treated with RT in many epithelial tumours • IMN and SCF are not surgically addressed: RT is effective in managing these nodal sites • Axillary failure rates are very low in recent series • Incidental doses to axilla in tangential planned RT • Advancement in RT (IMRT/IGRT/VMAT) has made it safe with minimal morbidity
  3. 3. Axillary node +vity rate • Clinically node –ve : Microscopic disease in up to 30-40% of patients • T1-2 breast cancers: 10-40% • Sentinel node –ve cases: 3-12% [NSABP-32: 9.7%] • Sentinel node +ve cases: up to 33%
  4. 4. Assessment of Axilla • Clinical examination unreliable (50 - 75%) • PET/MRI – low sensitivity (75%) • Ultrasound – High sensitivity (97%) • Sentinel Lymph node biopsy • Axillary nodal sampling (ANS)/Blue dye augmented ANS (BDANS): Popular in UK • ALND – ‘Gold standard’
  5. 5. Evolution of Loco-regional treatment in breast cancer • Radical mastectomy  MRM+/- RT BCS + RT [1960s- 2000s] Radical RT with SLNB • No role of PMRT In selected individuals In most cases (expanding with RT for 1-3 lymph node/ T 1-2 high risk) • Axillary dissection (I-III) Limited dissection  SLNB  Axillary RT • Systemic therapy & endocrine therapy: Important role in loco-regional control as well !!
  6. 6. Evolution of Axillary management • Sentinel node biopsy (SLNB) replaced axillary lymph node dissection (ALND) in clinically negative axilla. • Several randomized trails showed : No ALND in SLNB –ve cases. – No difference in survival – Significantly better morbidity profiles • In SLNB +ve cases: (??)ALND is the standard of care What was the need of this evolution: Morbidity, Morbidity, Morbidity!!!
  7. 7. Arm swelling 15 – 40% Decreased shoulder mobility 10 – 30% Shoulder weakness 10 - 40% Numbness 50 – 80% Arm pain 30 – 70% ALND
  8. 8. • Appox 21% develop arm lymphedema • Increase up to 24 months of time and beyond • Roughly, 1/5 women suffer from lymphedema • High rate of lymphedema roughly 4 times more with ALND than SLNB • Lymphedema risk, multi-factorial: – Axillary lymph node dissection and extent – BMI/ Co-morbidities – Axillary radiation
  9. 9. • 299 patients [63% stage I & II] • 67% Patients received Adjuvant RT and 79 % of them received axillary nodal irradiation • Level I-III dissection was done in all patients • Overall, clinically significant edema was 33.5% and severe edema was 17.2% • 13.4% with surgery alone and 42.4% if combined with radiotherapy
  10. 10. Lymphedema risk: Extent of Axillary dissection • A 50 year old lady with no h/o infusion of CT in I/L arm; No seroma within 6 months of surgery; no arm edema within 6 months of surgery. Predicted 5 year lymphedema probability [www.lymphedemarisk.com; Cleveland clinic] – Level I & II dissection without axillary RT: 10.8% – Level I, II & III dissection without axillary RT: 15.4%
  11. 11. Lymphedema: Axillary dissection or RT • Results from NSABP-B32: Intervention Clinical Lymphedema Bothersome Symptoms SLNB only 4.5% 4.8% SLNB+RT 7.4% 3.2% SLNB+ALND 16.7% 8.8% SLNB + ALND+ AxRT 12.4% 7.4%
  12. 12. Lymphedema: Axillary dissection or RT Study No. of patients Median follow up Outcome Comment Deutsch et al. IJROBP 2008; 70 (4): 1020-1024 NSABP-04 1665 Patients [RM, TM+RT, TM] No chemotherapy/ large tumor size 25 Years Arm edema: RM, TM+RT, TM; 58.1%, 38.2%, 39.1% respectively [p <0.001] cN0 patients, axillary failure was <4% (surgery or with RT vs. 19% in TM alone arm) No difference in OS Lymphedema: AMAROS
  13. 13. Intervention Relative Risk Axillary dissection compared with no axillary dissection RR = 3.47; 95% CI 2.34-5.15 Axillary dissection compared with sentinel node biopsy RR = 3.07; 95% CI 2.20-4.29 Radiation therapy RR = 1.92; 95% CI 1.61-2.28
  14. 14. Lymphedema: Axillary dissection or RT Shah C et al. IJROBP 2011; 81 (4): 907-914
  15. 15. Advancement in Radiation Technology
  16. 16. Conclusion I • Lymphedema and other morbidities are a significant deterrent for patients after treatment. • Though lymphedema is multi-factorial, axillary dissection has a prime role to play in causation • Axillary RT alone without dissection has minimal risk of axillary complications • In combination, however, has supra-additive effect (??) • Solutions: – Avoid axillary dissection – Avoid combination of dissection and radiotherapy
  17. 17. But Wait.. There is more to ALND than Lymphedema!!  Major prognostic determinant  Therapeutic value of ALND (??)  Planning adjuvant treatment (??)  Survival impact of ALND (??)
  18. 18. ALND: Present status • SLNB –ve 10% False negative • SLNB +ve  Further axillary lymph node dissection: – 1-3 lymph node: Supraclavicular Lymph node [Also would add to lymphedema*#] – ≥ 4 Node: Axillary + Supraclavicular Lymph node [Increased Lymphedema risk] * Kim M et al. IJROBP 2013; 86 (3):498-503 # Warren LE et al. IROBP 2014; 88 (3):565-71
  19. 19. ALND: Present status • Any further or no further Lymph node: Unlikely to change systemic therapy/Endocrine therapy [Except few patients] • Molecular profiling and primary tumor factors guide systemic adjuvant therapy: Oncotype DX etc. • 5.4% survival advantage [Orr RK; Ann Surg Oncol 1999; 6 (1):109-16] – No patient in included six RCTs received systemic chemotherapy – Present era: (??) Survival advantage of ALND
  20. 20. • The point now is: – SLNB to be preferred over ALND – What to do with SLNB+ ve patients? – Can patients with SLNB +ve be spared of ALND? – Can Axillary RT be an alternative to ALND in these cases?
  21. 21. Further nodal involvement in ALND specimens [AMAROS Trial] • SLNB was +ve in 647 patients (34%) – Macro-metastases : 409 (63%)41% – Micro-metastases: 161 (25%) 18% – Isolated tumor cells : 77 (12%) 18% Macro (n= 200) Micro (n=84) ITC (n=33) Combined (317) No further Involvement 117 69 27 213 1-3 nodes 65 10 5 80 (25%) 4-9 nodes 10 3 1 14 (5%) >9 nodes 8 2 0 10 (3%) 8% ≥ 4 nodes 33% ≥ 1 nodes
  22. 22. ASCO Guideline update on SLNB
  23. 23. Incidental dose to axilla • Standard tangents: cover around 50-60% of axillary level I & II • Mean dose to level I & II has been estimated to be around 40 Gray • Better coverage could be achieved with high tangents/modern techniques without increasing morbidities
  24. 24. Axillary dissection versus RT: Pre-SLNB era Study Design No. of patients Median follow up Outcome Comment Pejavar S et al. IJROBP 2006; 66 (5): 1320-1327 Retrospecti ve Stage I & II 1920; 1330 (ALND) & 590 (AXRT) 13 Years Nodal control rate 98% versus 97.9 % ALND not a significant factor for nodal recurrence Hafty BG et al. IJROBP 1990; 19:859-865 Retrospecti ve Stage I & II 187 (ALND) & 245 (AXRT) 7.5 Years Nodal control rate 96-97% - Wazer DE et al. Cancer 1994; 74 (3):878-83 Prospective Stage I & II, Age =>65 Years; 73 Years 8 Years Regional nodal control rate: 100% Tumor excision + Breast + Regional RT Galper S et al. IJROBP 2000; 48 (1):125-32 Retrospecti ve 418 patients; AXRT in absence of dissection 8 Years Regional nodal failure: 1.4% 126 had limited dissection (<= 5 Lymph node)
  25. 25. Axillary dissection vs. RT: Randomized trial Study No. of patients Median follow up Outcome Comment Deutsch et al. IJROBP 2008; 70 (4): 1020-1024 NSABP-04 1665 Patients [RM, TM+RT, TM] No chemotherapy/ large tumor size 25 Yrs cN0 patients, axillary failure was <4% (surgery or with RT vs. 19% in TM alone arm) Arm edema: RM, TM+RT, TM; 58.1%, 38.2%, 39.1% respectively [p <0.001] No difference in OS Sylvestre-LC et al. JCO 2004; 22 658 pts. [ALND vs. AxRT] 15 Years Isolated recurrence rates in ALND vs. RT group (1 vs. 3%; p=0.04 <10% had any form of systemic therapy OS [73.8% versus 75.5%] Veronesi U et al. Annals of Oncology 2005;16:383-88 435 patients [Age =>45 years; 1.2 cm; No Axillary t/t vs. AxRT] 5.5 Years Axillary failure rate: 1.5 % vs. 0.5% 5 Year DFS: 96%
  26. 26. • Multicentric trial; 4806 patients; 34 Centres; 2001-2010 • 1425 patients (30%) with +ve sentinel node: 744 to ALND and 681 to AxRT • T 1-2 primary, no palpable lymphadenopathy, unifocal (multifocal) • Axillary RT used if ≥ 4 nodes are involved • Lymphedema and shoulder mobility at 1,3,5,10 years measured • Primary endpoint: 5 year axillary recurrence • Secondary endpoint: Axillary recurrence free survival, DFS, OS, shoulder mobility, lymphedema, and QOL Landmark EORTC 10981-22023 AMAROS Trial
  27. 27. Results • Median follow up: 6.1 years • Median of 2 SLN removed in both arm • Median lymph nodes removed in ALND arm : 15 ALND Group Axillary RT Group 5-year axillary recurrence 0.43% 1.19% 5-year DFS 86.9% 82.7% 5-year OS 93.3% 92.5%
  28. 28. Lymphedema: AMAROS
  29. 29. Implications of these studies • Axillary dissection does not add to survival advantage. • Axillary dissection is not therapeutic and needs adjuvant radiotherapy • Combination treatment of surgery plus radiotherapy adds to increased morbidity • Axillary radiotherapy is effective, therapeutic and associated with minimal morbidity – In non-dissected axilla – In SLNB micro-metastatic – In SLNB Macro-metastatic
  30. 30. Where is the problem then? • No difference in QOL overall in AMAROSS: – QOL questionnaire not sensitive for lymphedema – Patient`s adaptation to their symptoms over time • Under powering of primary test hypothesis: – Fewer recurrences as expected (<2% at 5 years): Reflective of better systemic treatment & EBC – Similar issue with ACOSOG Z011 • Short term follow up: – Axillary recurrence early event (15-30 months)* *Fischer B et al. NSABP-B 04. N Engl J Med 2002; 347: 567–75 * Greco M et al. Ann Surg 2000; 232: 1–7.
  31. 31. Where is the problem then? • Not for all patients: Agreed [We need to select patients carefully] – ALND still remains the standard in Node +ve patients • What if we use APBI: Patients in the category we discuss, might fit in [What about tangential RT then??] – Not a problem right now, Cavity and or axilla can be easily treated with modern RT techniques • What if patients received NACT? – Well, please wait for ACOSOG Z1071
  32. 32. Conclusion • Axillary failure rates in early breast cancer (I & II) is very low • Clinically negative patients with SLNB+ ve can either safely receive: – No further dissection with tangential field RT/Axillary RT – Axillary RT and no further dissection
  33. 33. Axillary RT vs. dissection
  34. 34. Thanks !!!!

Management of axilla in breast cancer has evolved over period of time and in many instances now we can use RT with caution

Views

Total views

92

On Slideshare

0

From embeds

0

Number of embeds

1

Actions

Downloads

9

Shares

0

Comments

0

Likes

0

×