LONG-TERM FOLLOW-UP OF AXILLARY NODE-POSITIVE BREAST-CANCER PATIENTS RECEIVING ADJUVANT SYSTEMIC THERAPY ALONE - PATTERNS OF RECURRENCE

Purpose: Prognostic factors for locoregional failure have been poorly documented. The purpose of this retrospective review is to examine the patterns of failure of 320 patients with Stage II or III axillary nod e-positive breast cancer who received adjuvant chemotherapy without lo coregional radiation. Methods and Materials: The records of 735 patien ts who were referred to the London Regional Cancer Centre between 1980 and 1989 with a diagnosis of Stage II or III breast cancer were revie wed. Three hundred and twenty patients were identified who underwent s egmental mastectomy with axillary dissection or modified radical maste ctomy and adjuvant chemotherapy without adjuvant locoregional radiatio n. Seventy-one percent of these patients had undergone a modified radi cal mastectomy, 40% had T1 tumors, 49% T2, and 11% T3. Resection margi ns were positive in 13 patients. The median number of axillary nodes r emoved was 11. Fifty-four percent had one to three positive axillary n odes, 27% had four to seven positive nodes, and 19% had in excess of s even positive nodes. Results: Median follow-up for the 320 patients wa s 77 months. One hundred and fourteen patients developed a locoregiona l recurrence as the site of first relapse (31 in the intact breast, 29 on the chest wall, 21 in the axilla, 22 in the supraclavicular fossa, 1 in the internal mammary chain, and 10 in multiple sites). Thirty-th ree percent of segmental mastectomy patients and 13% of modified radic al mastectomy patients developed local recurrence. Seven percent of pa tients recurred in axillary or supraclavicular nodes each. Factors wit h regard to locoregional recurrence which on univariate analysis were significant included type of mastectomy (i.e., segmental vs. modified radical), size of primary tumor, positive resection margins, and perce ntage of ideal chemotherapy dose intensity (<66% vs. greater than or e qual to 66%). After multivariate analysis, only type of mastectomy, si ze of primary tumor, and percentage of ideal chemotherapy dose intensi ty retained significance. The number of positive axillary nodes was no t a significant factor. Number of positive axillary nodes plus the abo ve four clinical factors were analyzed in terms of regional recurrence specifically. By univariate and multivariate analysis, only size of p rimary tumor retained significance. Again, the number of positive axil lary nodes was not a relevant factor. Conclusion: Patients receiving a djuvant chemotherapy who are at high risk of locoregional recurrence i nclude those who undergo segmental mastectomy and those with larger tu mors (>5 cm in diameter). Breast or chest wall radiation is recommende d for these groups. Supraclavicular radiation is recommended for patie nts with tumors larger than 5 cm in diameter. Axillary recurrences wer e relatively infrequent in patients who had undergone an adequate Leve l I and II axillary dissection, and therefore, axillary radiation was not recommended. (C) 1997 Elsevier Science Inc.