Indication for Postmastectomy Radiation Therapy (PMRT)

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The American Society of Clinical Oncology (ASCO) and American Society for Radiation Oncology (ASTRO):
    • Recommend PMRT for:
      • Tumor size greater than 5 cm with any number of involved axillary nodes
      • Smaller cancers with four or more involved
      • Locally advanced breast cancer
  • Locally advanced breast cancer:
    • Is defined as:
      • A tumor greater than 5 cm in size
      • Tumor extending to chest wall:
        • Not including pectoralis major muscle
      • Tumor extending to skin in the form of:
        • Nodules
        • Ulcerations
        • Edema
    • These patient populations have a risk of local recurrence greater than 20%:
      • After mastectomy, irradiation of the chest wall and regional lymph node basins improves local-regional control in these patient populations
  • PMTR in T1 to T2 tumors and 1 to 3 positive nodes:
    • Remains much more controversial
    • Many authors suggest that looking at the total number of risk factors in an individual patient:
      • Would be useful to determine if PMRT may be clinically beneficial
    • In addition to tumor size and the degree of nodal involvement, such factors include:
      • Ages less than 35 to 40
      • Lymphovascular invasion
      • High tumor grade
      • Close or positive surgical margins
      • Hormone receptor status
      • Lymph node ratio
      • Lack of receipt of systemic therapy
        • The data in the literature on these variables are conflicting however, and there is no consensus on how to integrate these factors.
  • ASCO, ASTRO, and SSO recently released an updated consensus statement regarding the role of PMRT in women with 1 to 3 positive lymph nodes:
    • The consensus panel unanimously agreed that PMRT in this subset of patients reduces local-regional failure, any recurrence, and breast cancer mortality:
      • In patients with T1 to T2 breast cancer with 1 to 3 positive lymph nodes
    • They agreed that the decision for PMRT should be made in a multidisciplinary setting and with the involvement of the patient after she is presented with all available data
    • The panel went on to acknowledge that in some subsets of patients, the risk of local-regional failure may be so low that the absolute benefit of PMRT is outweighed by its toxicities
    • Further, even if axillary lymph node dissection (ALND) is omitted in the setting of positive lymph nodes:
      • PMRT should only be used if there is already significant evidence justifying the benefit of PMRT without knowing the status of any additional axillary nodes
  • When given, PMRT should include:
    • The internal mammary, supraclavicular, and apical axillary nodes, and the chest wall or reconstructed breast
  • All patients with a positive axillary node after receipt of neoadjuvant chemotherapy should receive PMRT
  • References
    • Recht A, Comen EA, Fine RE, et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update. Ann Surg Oncol. 2017;24(1):38-51.
    • EBCTCG (Early Breast Cancer Trialists’ Collaborative Group), McGale P, Taylor C, et al. 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(9935):2127-2135.
    • Khan AJ, Haffty BG. Postmastectomy radiation therapy. In: Kuerer HM, ed. Kuerer’s Breast Surgical Oncology. New York, NY: McGraw-Hill; 2010:995-1008.
    • McBride A, Allen P, Woodward W, et al. Locoregional recurrence risk for patients with T1,2 breast cancer with 1-3 positive lymph nodes treated with mastectomy and systemic treatment. Int J Radiat Oncol Biol Phys. 2014;89(2):392-398.
    • Offersen BV, Brodersen HJ, Nielsen MM, Overgaard J, Overgaard M. Should postmastectomy radiotherapy to the chest wall and regional lymph nodes be standard for patients with 1-3 positive lymph nodes? Breast Care. 2011;6(5):347-351.
    • Sharma R, Bedrosian I, Lucci A, et al. Present-day locoregional control in patients with t1 or t2 breast cancer with 0 and 1 to 3 positive lymph nodes after mastectomy without radiotherapy. Ann Surg Oncol. 2010;17(11):2899-2908.
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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