Nodal treatment for Breast Cancer after pCR in Nodes

Red Journal:

An interesting article from France is published examining the potential value of lymph node irradiation (LNI) in patients achieving pCR after neoadjuvant chemotherapy, finding no differences in outcome if nodes were prophylactically covered. While this is an interesting observation, and useful data to have, one must note that the majority of patients in this retrospective study were cN0, and moreover that there was a predominance of cN0 patients in the no LNI cohort. And additional observation is that there were no cN2 patients in the no LNI cohort, nor were any patients with pathologic documentation of disease pre treatment. Even with a multivariate analysis, I am uncertain that these factors could be appropriately controlled for to come to a meaningful conclusion in cN1 but pN0 patients (a common clinical problem).

Link and Abstract:

Is Regional Lymph Node Irradiation Necessary in Stage II to III Breast Cancer Patients With Negative Pathologic Node Status After Neoadjuvant Chemotherapy?: "Purpose: Neoadjuvant chemotherapy (NAC) generally induces significant changes in the pathologic extent of disease. This potential down-staging challenges the standard indications of adjuvant radiation therapy. We assessed the utility of lymph node irradiation (LNI) in breast cancer (BC) patients with pathologic N0 status (pN0) after NAC and breast-conserving surgery (BCS).Methods and Materials: Among 1,054 BC patients treated with NAC in our institution between 1990 and 2004, 248 patients with clinical N0 or N1 to N2 lymph node status at diagnosis had pN0 status after NAC and BCS. Cox regression analysis was used to identify factors influencing locoregional recurrence–free survival (LRR-FS), disease-free survival (DFS), and overall survival (OS).Results: All 248 patients underwent breast irradiation, and 158 patients (63.7%) also received LNI. With a median follow-up of 88 months, the 5-year LRR-FS and OS rates were respectively 89.4% and 88.7% with LNI and 86.2% and 92% without LNI (no significant difference). Survival was poorer among patients who did not have a pathologic complete primary tumor response (hazard ratio, 3.05; 95% confidence interval, 1.17–7.99) and in patients with N1 to N2 clinical status at diagnosis (hazard ratio = 2.24; 95% confidence interval, 1.15–4.36). LNI did not significantly affect survival.Conclusions: Relative to combined breast and local lymph node irradiation, isolated breast irradiation does not appear to be associated with a higher risk of locoregional relapse or death among cN0 to cN2 breast cancer patients with pN0 status after NAC. These results need to be confirmed in a prospective study."