Adjuvant Radiation Trials for High-Risk Breast Cancer Patients:
Adequacy of Lymphadenectomy
Allan W. Silberman, MD, PhD, Gregory P. Sarna, MD, and Daphne Palmer, MD
Background: The recently published, widely publicized adjuvant radiation trials from Denmark
and Canada concluded that the addition of postoperative radiotherapy (XRT) to modified radical
mastectomy (MRM) and adjuvant chemotherapy reduces locoregional recurrences and prolongs
survival in high-risk premenopausal patients with breast cancer. Our thesis is that adequate
lymphadenectomies were not performed in either study. Consequently, the conclusion to these
studies is not applicable to those patients who have undergone adequate surgery.
Methods: To better assess adequate lymph node yield from an MRM, a retrospective review was
performed on 215 consecutive patients treated surgically for invasive breast cancer. Data from this
review were compared with the surgical data from the above-mentioned radiotherapy trials.
Results: In a group of 131 patients who had MRM, the average number of nodes removed was
26 (median, 25), and 75.5% of the specimens had 20 or more lymph nodes. In 73 patients who
underwent segmental mastectomy with axillary lymph node dissection, both the average and the
median number of lymph nodes removed were 24, and 68.9% had 20 or more nodes. These data
compare to the Danish radiation trial in which a median of 7 lymph nodes were removed (with 76%
of the patients having 9 or fewer lymph nodes in the specimen) and to the Canadian radiation trial
in which a median of 11 lymph nodes were removed. In addition, in our breast cancer patients with
positive nodes (84 of 204; 41.2%), 45.2.% (38 of 84) had more than three positive nodes compared
with 29.8% in the Danish study and 35% in the Canadian study.
Conclusions: Our surgical data are sufficiently different from those of the Danish and Canadian
studies to indicate that, in those studies, incomplete lymph node dissections were performed and that
residual disease was left behind in the axilla in some or all of the patients. The addition of XRT in
the setting of residual axillary disease may compensate for an inadequate operation and yield an
acceptable oncological result; however, these studies did not provide an adequate comparison with
a well-performed MRM without XRT. In the absence of documented benefit, XRT should not be
routinely added if a complete lymph node dissection has been performed.
Key Words: Breast cancer—Lymphadenectomy—Radiation trials.
Overgaard et al.,
from the Danish Breast Cancer
Cooperative Group, and Ragaz et al.,
recently concluded that the addition of postoperative
radiotherapy (XRT) to modified radical mastectomy
(MRM) and adjuvant chemotherapy (CMF; cyclophos-
phamide, methotrexate, 5-fluorouracil) reduces locore-
gional recurrences and prolongs survival in high-risk
premenopausal patients with invasive breast cancer.
The Danish study, started in 1982, randomly assigned
a total of 1708 women who had undergone MRM for
pathological stage II or III breast cancer to either eight
cycles of CMF plus irradiation of the chest wall and
regional lymph nodes (852 women) or nine cycles of
CMF alone (856 women). The frequency of locoregional
recurrence with or without distant metastases was 9% in
the group receiving XRT plus chemotherapy and 32% in
the group receiving chemotherapy alone. Overall sur-
vival at 10 years was 54% in the XRT ϩ CMF group and
45% in the CMF alone group. Multivariate analysis
demonstrated that XRT after MRM significantly im-
Received August 2, 1999; accepted November 18, 1999.
From the Divisions of Surgical Oncology (AWS), Medical Oncology
(GPS), and Radiation Oncology (DP), Cedars-Sinai Medical Center,
Los Angeles, California.
Address correspondence and reprint requests to: Allan W. Silber-
man, MD, PhD, Cedars-Sinai Comprehensive Cancer Center, 8700
Beverly Blvd., Los Angeles, CA 90048; Fax: 310-659-3928; E-mail:
Annals of Surgical Oncology, 7(5):357–360
Published by Lippincott Williams & Wilkins © 2000 The Society of Surgical Oncology, Inc.