The importance of local-regional radiotherapy with conventional or high-dose chemotherapy in the management of breast cancer patients with >= 10 positive axillary nodes

Purpose: To assess the effect of local-regional radiotherapy (RT) on the ou tcome of breast cancer patients with greater than or equal to 10 positive a xillary lymph nodes who have received modern conventional or high-dose syst emic therapy. Methods and Materials: A total of 55 women with local-regionally confined b reast cancer involving 10 or more axillary nodes were treated between Octob er 1983 and January 1996, Local-regional therapy consisted of modified radi cal mastectomy in 39 and breast-conserving surgery in 16, Postoperative rad iotherapy was given to 44 of the 55 patients. Radiotherapy consisted of tan gential fields to the chest wall or intact breast to a median dose of 50.40 Gy, A total of 86% (38 of 44) received regional nodal irradiation as follo ws: 35 patients received RT to the supraclavicular (SC) region and axillary midplane to a median dose of 50.40 Gy and 46.20 Gy, respectively; 3 patien ts received RT to the SC region without inclusion of the axilla to a median dose of 50.40 GS, All patients received adjuvant standard-dose systemic ch emotherapy, 9 of whom received additional intensification chemotherapy foll owed by autologous bone-marrow transplant (ABMT) or peripheral blood stem-c ell transplant (PBSC), Twenty-five patients received adjuvant tamoxifen. Results: With a median follow-up of 30 months, the crude overall survival ( OS) and disease-free survival (DFS) for the entire group were 67% and 53%, respectively. On univariate analysis of various clinical, pathological, aci d therapy-related features, radiotherapy emerged as the most important fact or influencing the relapse rate, The addition of RT was significantly assoc iated with an improved DFS (p = 0.003), specifically by prolonging the time to disease progression. The median time to failure was 61 months and 12.5 months with and without RT, respectively, Patients receiving RT also appear ed to survive longer; however, the groups were not statistically different (p = 0.10). Analysis of the patterns of failure showed local-regional recur rence (LRR) as the first site of failure in 12 (22%) of 55 and distant fail ure in 20 (36%) of 55, Univariate results revealed both radiotherapy and ta moxifen to be significantly associated with decreased LRR rates (p = 0.0001 and p = 0.03, respectively); only RT remained independently significant on multivariate analysis. Conclusion: Local-regional radiotherapy is an essential component of the ma nagement of breast cancer patients with extensive nodal involvement, despit e the use of contemporary adjuvant chemotherapy including high-dose regimen s with autologous rescue. In addition to the expected improvement in LRR, r adiotherapy is also associated,vith significantly prolonged DFS and a trend for improvement in OS. (C) 1999 Elsevier Science Inc.