EDITORIAL – BREAST ONCOLOGY
Is There a Role for Postmastectomy Radiation (PMRT) in Patients
with T1–2 Tumors and One to Three Positive Lymph Nodes
Treated in the Modern Era?
Nisha Ohri, MD and Bruce G. Haffty, MD
Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson and New Jersey
Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ
Postmastectomy radiation (PMRT) has been shown in
multiple randomized trials to reduce locoregional recur-
rence (LRR) rates and improve survival in women with
locally advanced breast cancer.
The role of PMRT in
patients with early-stage T1–2 disease with limited nodal
metastasis remains a subject of ongoing debate. Contro-
versy surrounding the optimal locoregional management of
the subset with one to three positive nodes stems from
conﬂicting data on the beneﬁts of PMRT in this population.
A 2014 update of the Early Breast Cancer Trialists’
Collaborative Group (EBCTCG) metaanalysis demon-
strated that patients with one to three positive lymph nodes
who underwent axillary dissection and received systemic
therapy had a signiﬁcant reduction in 10-year isolated LRR
(21.0 vs. 4.3%) and 20-year breast-cancer-speciﬁc mortal-
ity (49.4 vs. 41.5%) with PMRT. Similar beneﬁts were seen
among patients with only one positive node compared with
those with two or three positive nodes.
however, that it is difﬁcult to interpret these results in the
era of modern surgical techniques and enhanced systemic
therapy, as many of the trials included in the metaanalysis
were conducted in the 1970s and 1980s.
Two randomized studies from a more modern era were
published in 2015 and demonstrated a beneﬁt to compre-
hensive regional nodal irradiation (undissected axillary,
supraclavicular, and internal mammary lymph nodes) in
patients with early-stage breast cancer. The National
Cancer Institute of Canada Clinical Trials Group (NCIC
CTG) MA.20 trial included patients undergoing lumpec-
tomy, with 85% having N1 disease and 50% having only
one positive lymph node. The European Organization for
Research and Treatment of Cancer (EORTC) 22922 trial
included patients undergoing lumpectomy or mastectomy
(24%), with 43% having N1 disease and 44% having N0
disease. While an overall survival beneﬁt was not observed
in either trial, they both showed improved disease-free
survival (DFS) and distant DFS with regional nodal irra-
diation, with the EORTC 22922 trial additionally showing
improved breast cancer mortality.
Other retrospective series have shown that patients with
T1–2 tumors and one to three positive lymph nodes are at
low risk of locoregional recurrence without PMRT. A large
retrospective analysis from the MD Anderson Cancer
Center reported a 5-year LRR rate of \ 5% without PMRT
for patients treated between 2000 and 2007.
series from the Cleveland Clinic showed a 5-year LRR rate
of 8.9% without PMRT.
In a large single-institution ret-
rospective analysis of 1087 patients from the Memorial
Sloan Kettering Cancer Center, Moo et al. reported 5-year
LRR rates of 4.3% without PMRT and 3.2% with PMRT
(p = not signiﬁcant, NS).
In the present analysis, Wu and
colleagues report on long-term results from this cohort.
The present study adds signiﬁcantly to the debate sur-
rounding PMRT in patients with T1–2 breast cancer with
one to three positive lymph nodes. The majority of patients
(85%) did not receive PMRT. Nearly all patients under-
went axillary lymph node dissection (ALND), and the
median number of lymph nodes removed was 18. The
authors compared outcomes between patients who received
PMRT and those who did not. They found no signiﬁcant
difference in 10-year LRR rates (4 and 7%, respectively),
Ó Society of Surgical Oncology 2018
First Received: 23 March 2018;
Published Online: 26 April 2018
B. G. Haffty, MD
Ann Surg Oncol (2018) 25:1788–1790