Article

A positive margin is not always an indication for radiotherapy after mastectomy in early breast cancer.

Breast Cancer Outcomes Unit, British Columbia Cancer Agency-Vancouver Island Centre and the University of British Columbia, Victoria, BC, Canada.
International Journal of Radiation OncologyBiologyPhysics (impact factor: 4.11). 04/2004; 58(3):797-804. DOI:10.1016/S0360-3016(03)01626-2 pp.797-804
Source: PubMed

ABSTRACT Postoperative radiotherapy is frequently employed among breast cancer patients with positive surgical margins after mastectomy but there is little evidence to support this practice. This study examined relapse and survival among women with node-negative breast cancer and positive surgical margins after mastectomy.
Among 2570 women diagnosed between 1989 and 1998 and referred to the British Columbia Cancer Agency with pathologic (p)T1-2, pN0 invasive breast cancer treated with mastectomy, 94 had positive surgical margins and formed the study cohort. Women with more established indications for postmastectomy radiotherapy (PMRT) including T3-4 tumors or node-positive disease were excluded. Demographic, tumor, and treatment factors; relapse patterns; and Kaplan-Meier 8-year locoregional relapse-free, breast cancer-specific, and overall survival rates were compared between women who were treated with (n = 41) and without (n = 53) PMRT.
Median follow-up time was 7.7 years. The distributions of age, histologic grade, lymphovascular invasion (LVI), estrogen receptor status, and number of axillary nodes removed were similar between the two treatment groups. Six local chest wall recurrences (6.4%), 4 regional recurrences (4.3%), and 11 distant recurrences (11.7%) were identified. Local relapse rates were 2.4% vs. 9.4% (p = 0.23), and regional relapse rates were 2.4% vs. 5.7% (p = 0.63), with and without PMRT, respectively. Trends for higher cumulative locoregional relapse (LRR) rates without PMRT were identified in the presence of age <==50 years (LRR 20% without vs. 0% with PMRT), T2 tumor size (19.2% vs. 6.9%), grade III disease (23.1% vs. 6.7%), and LVI (16.7% vs. 9.1%). Statistical significance was not demonstrated in these differences (p > 0.10), possibly because of the small number of events. In patients with age >50 years, T1 tumors, grade I/II disease, and absence of LVI, no locoregional relapse occurred even with positive margins. PMRT did not improve distant relapse, 8-year breast cancer-specific and overall survival rates.
This study suggests that not all patients with node-negative breast cancer with positive margins after mastectomy require radiotherapy. Locoregional failure rates approximating 20% were observed in women with positive margins plus at least one of the following factors: age <==50 years, T2 tumor size, grade III histology, or LVI. The absolute and relative improvements in locoregional control with radiotherapy in these situations support the judicious, but not routine, use of PMRT for positive margins after mastectomy in patients with node-negative breast cancer.

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Keywords

breast cancer patients
 
British Columbia Cancer Agency
 
distant relapse
 
estrogen receptor status
 
following factors
 
grade I/II disease
 
grade III disease
 
higher cumulative locoregional relapse
 
histologic grade
 
Kaplan-Meier 8-year locoregional relapse-free
 
locoregional relapse
 
node-negative breast cancer
 
node-positive disease
 
pN0 invasive breast cancer
 
positive surgical margins
 
postmastectomy radiotherapy
 
Postoperative radiotherapy
 
study cohort
 
treatment factors
 
two treatment groups