REGIONAL NODAL MANAGEMENT AND PATTERNS OF FAILURE FOLLOWING CONSERVATIVE SURGERY AND RADIATION-THERAPY FOR STAGE-I AND STAGE-II BREAST-CANCER

Purpose: To determine the incidence, pattern of regional nodal failure , and treatment sequelae as determined by the extent of lymphatic irra diation. Methods and Materials: The records of 511 patients with 519 S tage I and II breast cancers treated with breast conserving surgery wi th or without axillary dissection and irradiation were reviewed. The e xtent of nodal irradiation was at the discretion of the attending radi ation oncologist and varied considerably over the years. Management of the axilla consisted of axillary dissection alone in 351, axillary di ssection and supplemental irradiation in 74, irradiation alone in 75, and simply observation in 21 patients. Results: Overall, axillary recu rrence was uncommon (1.2%), but was slightly more frequent after irrad iation alone (2.7%) than after surgery alone (03%), p = 0.14. There wa s no benefit for supplemental axillary irradiation after an axillary d issection yielding negative or 1 to 3 positive nodes. In the 21 patien ts in whom the axilla was observed, axillary recurrence was not observ ed. Supraclavicular failures were rare in women with negative or 1 to 3 positive axillary lymph nodes (0.5%), and not significantly affected by elective irradiation. Internal mammary node recurrence was seen in only one patient, and was not significantly influenced by elective in ternal mammary irradiation. Both arm and breast edema were significant ly more common in women having breast and nodal irradiation than after breast irradiation alone. These sequelae were not influenced signific antly by the number of lymph nodes obtained in the axillary dissection specimen. Radiation pneumonitis was seen with increased frequency wit h more extensive nodal radiotherapy. Pneumonitis was not found to be a ffected by the administration or sequencing of chemotherapy. Conclusio n: There is little justification for axillary or supraclavicular irrad iation following an axillary dissection which yields negative or minim ally involved (1 to 3 positive) lymph nodes. There were too few patien ts with extensive axillary node metastases (greater-than-or-equal-to 4 positive) in our series to draw conclusions about the optimal extent of nodal irradiation in this subset. Elective internal mammary lymph n ode irradiation increases technical complexity, does not appear to be advantageous, and when combined with supraclavicular irradiation place s the patient at highest risk for pneumonitis.