Selective avoidance of lymphatic radiotherapy in the conservative management of women with early breast cancer

Background and purpose: Until recently, elective treatment of the lymphatic pathways in women with early invasive breast cancer was assumed to impact on quality of life rather than on overall survival. In a multidisciplinary breast clinic these considerations underpinned a policy of observation of t he lymphatic pathways if axillary lymph nodes were not palpably enlarged an d if recommendations for adjuvant systemic therapy did not depend on knowle dge of pathological node status. This paper evaluates the long-term outcome of the observation policy in terms of lymphatic morbidity due to cancer re currence. Material and methods: Seven hundred and fifty-nine patients with operable b reast cancer and suitable for breast conserving surgery were seen between J anuary 1984 and December 1994. Of these, 291 (38.3%) were recommended a pol icy of observation to the lymphatic pathways. The case records of these pat ients were reviewed to record regional relapse patterns and morbidity. Results: At a median follow up of 60 months, 32/291 (11%) patients suffered ipsilateral lymphatic relapse at some stage prior to death or last follow up, representing a 22% actuarial 10-year risk of lymphatic relapse. Metasta ses coincided with, or preceded, lymphatic relapse in 8/ 32 (25%) patients. Eighteen out of 32 (56%) patients suffered symptoms of lymphatic relapse p rior to death or last follow up, despite subsequent surgery, radiotherapy a nd/or systemic therapies. The absolute risk of symptomatic ipsilateral lymp hatic relapse in the observation group was 18/291 (6.2%), representing an a ctuarial 10-year risk of 17%, Conclusion: A policy of observation on the axilla with deferred treatment o f lymphatic relapse has benefited 273/291 (94%) patients, but at the expens e of cancer-related regional morbidity in 18 (6%) patients. We conclude tha t the cancer-related morbidity suffered by a minority of patients and the s trengthening evidence of an overall survival benefit conferred by elective local-regional therapy favours a policy of elective treatment of the lympha tic pathways in the routine setting. (C) 1999 Elsevier Science Ireland Ltd. All rights reserved.