N Engl J Med 2015 Jul 23
Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer.   
ABSTRACT
BACKGROUND
The effect of internal mammary and medial supraclavicular lymph-node irradiation (regional nodal irradiation) added to whole-breast or thoracic-wall irradiation after surgery on survival among women with early-stage breast cancer is unknown.
METHODS
We randomly assigned women who had a centrally or medially located primary tumor, irrespective of axillary involvement, or an externally located tumor with axillary involvement to undergo either whole-breast or thoracic-wall irradiation in addition to regional nodal irradiation (nodal-irradiation group) or whole-breast or thoracic-wall irradiation alone (control group). The primary end point was overall survival. Secondary end points were the rates of disease-free survival, survival free from distant disease, and death from breast cancer.
RESULTS
Between 1996 and 2004, a total of 4004 patients underwent randomization. The majority of patients (76.1%) underwent breast-conserving surgery. After mastectomy, 73.4% of the patients in both groups underwent chest-wall irradiation. Nearly all patients with node-positive disease (99.0%) and 66.3% of patients with node-negative disease received adjuvant systemic treatment. At a median follow-up of 10.9 years, 811 patients had died. At 10 years, overall survival was 82.3% in the nodal-irradiation group and 80.7% in the control group (hazard ratio for death with nodal irradiation, 0.87; 95% confidence interval [CI], 0.76 to 1.00; P=0.06). The rate of disease-free survival was 72.1% in the nodal-irradiation group and 69.1% in the control group (hazard ratio for disease progression or death, 0.89; 95% CI, 0.80 to 1.00; P=0.04), the rate of distant disease-free survival was 78.0% versus 75.0% (hazard ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02), and breast-cancer mortality was 12.5% versus 14.4% (hazard ratio, 0.82; 95% CI, 0.70 to 0.97; P=0.02). Acute side effects of regional nodal irradiation were modest.
CONCLUSIONS
In patients with early-stage breast cancer, irradiation of the regional nodes had a marginal effect on overall survival. Disease-free survival and distant disease-free survival were improved, and breast-cancer mortality was reduced. (Funded by Fonds Cancer; ClinicalTrials.gov number, NCT00002851.).

Related Questions

How much will you weigh the demonstrated disease-free survival, including distant disease-free survival, in your recommendations?

Assume patient had 15 nodes removed. What if 1 or 2 nodes were positive?

In other words, have the results of the MA.20 and EORTC trials changed your practice?

Or for that matter, offer PMRT on the basis of a patient having triple negative disease?

Did the EBCTCG meta-analysis change your practice?

After the publication of ACOSOG Z11 we are seeing these patients in increasing numbers.

Would it be acceptable to treat a patient with locally advanced breast cancer (ex pT2N2a) s/p lumpectomy with a short course 4 week treatment ins...

Is there a practical way to quanitfy risk of LRR in patients with T1-2 N0 with multiple high risk factors in such as multifocal disease, high grade, L...

Is it still acceptable to deliver hypofractionation for what was previously a Stage I TN breast cancer, now Stage IIIA? Should RNI be considered? Or e...