[en] Objective: To analyze the outcomes of breast cancer with ten or more positive axillary nodes, and investigate the role of post mastectomy radiotherapy. Methods: 146 patients were retrospectively analyzed. Survival rates and prognostic variables were calculated by Kaplan-Meier method and Cox Regression Model, and compared between different groups by Logrank test. Results: The median follow up was 49 (range, 7-90) months. Radiotherapy significantly improved the local regional recurrence-free survival (91.0% vs. 59.7%; χ²=29.89, P=0.000) and overall survival (71.9% vs. 35.1%; χ²=23.25, P=0.000). The ipsilateral chest wall and supraclavicular nodal radiation was associated with better chest wall recurrence-free survival (96.0% vs. 75.7%; χ²=18.55, P=0.000) and supraclavicular node recurrence-free survival (96.0% vs. 81.8%; χ²=11.83, P=0.000). However, the use of axillary nodal radiation had no impact on axillary node recurrence-free survival (100% vs. 93.3%; χ²=2.13, P=0.145). In multivariate analysis, use of radiotherapy (χ²=20.94, P=0.000), the number of positive axillary node (χ²=8.57, P=0.003), and progesterone receptor status (χ²=4.50, P=0.034) were independent prognostic factors for overall survival. Conclusions: Radiotherapy improves survival of breast cancer with ten or more positive axillary nodes. The chest wall and supraclavicular nodal region should be the radiation target. The number of positive axillary nodes and PR status are independent prognostic factors for overall survival. (authors)

[en] Objective: To investigate the value of post-mastectomy radiotherapy (PMRT) in patients with T₃N₀ breast cancer (BC) who were treated with modified radical mastectomy (MRM). Methods: A retrospective analysis was performed on the clinical data of BC patients treated with MRM from 1997 to 2014. The inclusion criteria were as follows: (1) female patients; (2) pathological diagnosis of invasive BC; (3) tumor volume greater than 5 cm without axillary lymph node metastasis; (4) the patients who received no neoadjuvant chemotherapy or endocrine therapy and had no distant metastasis or other second primary cancers. A total of 78 patients met the inclusion criteria. Forty patients (51%) received PMRT and sixty-seven patients (86%) received adjuvant chemotherapy. The Kaplan-Meier method was used to calculate overall survival (OS), disease-free survival (DFS) (DFS), and local-regional recurrence (LRR) rates, and survival differences between groups were analyzed by the log-rank test. Results: The median follow-up time was 79 months (6-232 months). For all patients,the 5-year OS, DFS, and LRR rates were 89%, 87%, and 2%, respectively. The 5-year DFS, OS and LRR rates for radiotherapy group were 84%, 84% and 0%, respectively, versus 91% (P = 0.641), 96% (P = 0.126), and 5% for non-radiotherapy group. Only estrogen receptor/progesterone receptor (ER/PR) status and molecular type had significant impacts on DFS (P = 0.002 and 0.031, respectively). One patient in non-radiotherapy group had chest wall recurrence. Conclusions: MRM is effective in reducing LRR in T₃N₀M₀ BC patients. Only ER/ PR status and molecular type significantly influence DFS. Effective systemic therapy may be helpful for some T₃N₀ patients to avoid chest wall and supraclavicular radiotherapy after MRM, but large-sample studies are needed to further confirm this conclusion. (authors)

[en] Radiotherapy is an essential part of postoperative adjuvant therapy for breast cancer. However, postoperative radiotherapy for breast cancer poses a potential risk of heart damage. This article summarizes the general information and diagnosis and assessment indices of radiation-induced heart damage and its risk factors, as well as the influencing factors for radiotherapy and effective protective measures. (authors)

[en] Objective: To analyze the outcomes and the role of radiotherapy in breast cancer patients with T₁-T₂ and one to three positive axillary nodes treated with modified radical mastectomy, and to investigate the prognostic factors for loco - regional recurrence in patients without radiotherapy . Methods: Three hundred and seventy breast cancer patients with T₁-T₂ and one to three positive axillary lymph nodes treated with mastectomy and axillary dissection were retrospectively analyzed. Kaplan-Meier method was used to calculate the overall survival (OS) and loco-regional recurrence-free survival (LRFS) rates. The Logrank test was used for the comparison of the survival curves of patients with or without radiotherapy. Univariate analyses of potential prognostic variables for LRFS were performed. Results: The 5-year OS and LRFS rates were 85.4% and 91%. Radiotherapy significantly improved the 5-year LRFS rate (100% vs. 89.5%; χ² = 5.17, P=0.023). However, there was no significant difference in overall survival rate between patients with and without radiotherapy. In univariate analyses, T stage, the number of positive axillary nodes, CerbB-2 and PR status were the significant predictive factors for LRFS. Conclusions: For breast cancer patients with T₁-T₂ and one to three positive axillary nodes, radiotherapy improves the LRFS, but not OS. T stage, the number of positive axillary nodes, CerbB-2 and PR status are predictive factors for loco-regional recurrence in patients without radiotherapy. (authors)

[en] Objective: To analyze the correlation between treatment time and radiotherapy plan of deep inspiration breath-hold (DIBH) technique for the whole breast irradiation (WBI) in the left breast cancer after breast-conserving surgery, verify the inter-fractional reproducibility of radiotherapy, observe the heart location and dosimetric changes and calculate the effect of DIBH upon the WBI setup error after the surgery. Methods: We prospectively enrolled 15 patients with left breast cancer undergoing WBI after breast-conserving surgery, who met the requirement of D1BH. Treatment time was recorded, its correlation with the number of field and monitor unit was analyzed. Inter-fractional setup errors and PTV delineation were calculated using cone beam CT (CBCT). The accuracy of the position and dose of the heart during radiotherapy was verified by the imaging fusion of CBCT and CT images. The variables among groups were analyzed by non-parametric Firedman test. Results: The average treatment time of DIBH radiotherapy was 4.6 minutes. The treatment time was correlated with the maximal and total number of sub-fields and total monitor units. During DIBH treatment, the mean cardiac displacement volume was 19.1 cm³ (3.8%). The mean cardiac dose difference between CBCT and planning CT was 5.1 cGy, and there was no significant difference in the heart V₅-V₃₀. The mean inter-fractional system setup error (Σ) and random setup error (σ) in the left-right (x), superior-inferior (y) and anterior-posterior (z) direction were Σ_x 1.9 mm, Σ_y 2.1 mm, Σ_z 2.0 mm, σ_x 1.3 mm, σ_y 1.3 mm, σ_z 1.4 mm, respectively. The corresponding minimal margins for setup error were 5.7 mm, 6.2 mm and 6.0 mm, respectively. Conclusion: DIBH for WBI after breast-conserving surgery does not significantly prolong the treatment time. Treatment time is related to treatment plan. DIBH yields high inter-fractional reproducibility and protects the heart. (authors)

[en] Objective: To evaluate the supraclavicular nodal failure (SCF) of the breast cancer patients with one to three positive axillary nodes treated with breast conserving surgery and to identify the risk factors for SCF. Methods: From Jan. 2001 to Mar. 2014, 256 breast cancer patients with one to three positive axillary nodes treated with breast conserving surgery and axillary dissection were analyzed. All patients received whole breast radiation to a total dose of 46-50 Gy (median 50 Gy) at 2 Gy/f or 43. 5 Gy at 2.9 Gy/f. Tumor bed was boosted to 50-70 Gy (median 60 Gy) at 2 Gy/f or 52. 2 Gy at 2.9 Gy/f. No patient received regional nodal radiation. 245(95.7%) patients received adjuvant chemotherapy. The SCF, LRR, DM and OS rates were calculated by Kaplan-Meier method and compare by the Logrank test. Results: The number of samples were 101 followed up at 5 years. The 5-year SCF, LRR, DM and OS rates were 2.1%, 2.1%, 5%, 98%, respectively. LVI and 2 to 3 positive axillary node and Luminal B were risk factors for SCF (P = 0.030, 0.010, 0.006). The 5-year SCF rate were 5.3% for patients with 2-3 positive axillary nodes and 2.8% for those with 1 positive nodes (P = 0.010); 5.3% and 1.8% for those LVI positive and negative (P = 0.030); 7.1%, 3.2%, 1.2% and 0% for Luminal B, Basal, Luminal A and Her-2 positive type (P = 0.006). Patients with 0, 1 and 2-3 risk factors had 5 year SCF rates of 0%, 3.0% and 10.6% (P = 0.000). Conclusions: The supraclavicular nodal recurrence rate is very low for breast cancer patients with one to three positive axillary nodes treated with breast conserving surgery without supraclavicular nodal radiation, indicating that prophylactive supraclavicular nodal is not necessary. Further research is needed to verify whether those patients with risk factors need SCF radiation or not. (authors)

[en] Objective: To evaluate the value of postmastectomy radiotherapy (PMRT) in locally advanced breast cancer patients treated with neoadjuvant chemotherapy (neoCT) and modified radical mastectomy, and to investigate the possibility of individualized radiotherapy according to the response to neoCT. Methods: We analyzed 523 patients with stage III_A and III_B breast cancer who received neoCT and modified radical mastectomy in our hospital from 1999 to 2013. Of all patients, 404 received PMRT, and 119 did not. The locoregional recurrence (LRR), disease-free survival (DFS), and overall survival (OS) rates were calculated using the Kaplan-Meier method, survival difference analysis and univariate prognostic-analysis were performed using the log-rank test,and multivariate prognostic analysis was performed using the Cox regression model. Results: Compared with those not treated with PMRT, the patients treated with PMRT had a significantly lower 5-year LRR rate (13.9% vs. 24.8%, P = 0.013), a significantly higher DFS rate (64.1% vs. 53.9%, P = 0.048), and an insignificantly higher OS rate (83.2% vs. 78.2%, P = 0.389). In the patients with ypT₃-T₄, ypN₂-N₃, or pathologic stage n disease, those treated with PMRT had a significantly reduced 5-year LRR rate (P < 0.05) and a significantly increased 5-year OS rate (P < 0.05), as compared with those not treated with PMRT. Among the 158 patients with ypN₀ disease, the 5-year LRR rate was significantly lower in those treated with PMRT than in those not treated with PMRT (P = 0.004). Of 41 patients who achieved a pathologic complete response, 2 patients, who did not receive PMRT, developed LRR. The multivariate prognostic analysis indicated that PMRT was an independent prognostic factor associated with reduced LRR in all patients and ypN₀ patients. Conclusions: In patients with stage III_A and III_B breast cancer treated with neoCT and modified radical mastectomy, PMRT can significantly reduce LRR for all patients and can reduce both recurrence and mortality for those with ypT₃-T₄, ypN₂-N₃, or pathologic stage III disease. There is no sufficient evidence that PMRT can be omitted safely for ypN₀ or pCR patients according to their response to neoCT. (authors)

[en] Objective: To observe the therapeutic effects, cosmetic results, and toxicities of central hypofractionated three-dimensional radiotherapy for patients with early-stage breast cancer after breast-conserving surgery. Methods: From February 2009 to February 2010, 45 patients with pT_is-2N_0-1M₀ breast cancer after breast-conserving surgery were enrolled in the trial. Three-dimensional conformal radiotherapy or simplified intensity-modulated radiotherapy was applied to each patient. The hypofractionated radiotherapy schedule was 43.5 Gy/15 fractions/3 weeks to the whole breast, with a boost of 8.7 Gy/3 fractions/3 days to the tumor bed. The dose was 2.9 Gy per fraction; the total course of treatment was 24 days. Thirty-three patients received chemotherapy, including neoadjuvant chemotherapy in 2 patients and postoperative adjuvant chemotherapy in 31 patients. Locoregional control and overall survival were calculated by Kaplan-Meier method. Results: The follow-up rate was 100%. The 2-year locoregional control and overall survival were both 100%, and one patient had a single bone metastasis. Of the patients, 1 developed grade 2 breast edema, 6 developed grade 2 breast fibrosis, 1 developed grade 2 upper extremity edema, 4 developed grade 2 radiation dermatitis, 5 developed grade 1 radiation pneumonitis, and 2 developed grade 2 radiation pneumonitis. Compared with the conventional fractionated radiotherapy for the patients with early-stage breast cancer after breast-conserving surgery, the hypofractionated three-dimensional radiotherapy had the number of fractions decreased from 30 to 18, course of treatment shortened from 40 days to 24 days, and the cost cut from ¥30450 to ¥19770. Conclusions: The central hypofractionated three-dimensional radiotherapy for the patients with early-stage breast cancer after breast-conserving surgery have good therapeutic effects and cosmetic results and acceptable toxicities, as well as significantly reduced time and cost of treatment. (authors)

[en] Objective: To quantify the setup errors measured with orthogonal megavoltage X-ray film in breast cancer patients immobilized in breast bracket. To probe into the margins from clinical target volume (CTV) to planning target volume (PTV) in 3 directions. Methods: Repeat orthogonal megavoltage X-ray films were acquired for routine of fine setup verification in 29 breast cancer patients after conserving surgery, 17 received whole breast radiation and 12 received both whole breast and supraclavicular node radiation. All patients were immobilized in the supine position with both arms raised over their heads, using a personalized a-cradle (breast bracket). Registrations of the bony anatomy for megavoltage X-ray films to digitally reconstructed-radiographs from the planning CT were compared. Systematic and random setup errors were quantified, and the differences between groups with and without supraclavicular node radiation were compared by independent two-sample t-test. Results: The mean set up deviation, systematic error and random error were (0.9 ± 3.1) mm, (0.7 ± 3.0) mm, (1.2 ± 2.1) mm and 3.1 mm, 3.0 mm, 2.1 mm and 2.7 mm, 3.3 mm, 3.5 mm in the mediolateral, superoinferior and anteroposterior dimensions. There is no difference of set up deviation between patients received supraclavicular node radiation and those did not (t = 0.02, 0.20, 0.20, P = 0.98, 0.85, 0.85). The margins from CTV to PTV were 9.6 mm, 9.8 mm, 7.7 mm in mediolateral, superoinferior and anteroposterior directions. Conclusion: For whole breast irradiation patients immobilized with breast bracket, the margins from CTV to PTV were recommended as 9.6 mm, 9.8 mm, 7.7 mm in mediolateral, superoinferior and anteroposterior directions. (authors)

[en] Objective: To study the effect of deep inspiration breath-hold (DIBH) technique on the heart dose in whole breast irradiation (WBI) for left breast cancer after breast-conserving surgery, and to investigate the anatomical factors for heart dose. Methods: Fifteen patients with left breast cancer who received WBI after breast-conserving surgery and met breathing control requirements were prospectively enrolled as subjects. Simulated CT scans were performed during free breathing (FB) and DIBH. The WBI plans were optimized based on DIBH images. The position, volume, and radiation doses to the heart and lung were compared between the status of FB and DIBH. Correlation of heart dose with various anatomical factors was analyzed in FB status. Between-group comparison of categorical data was made by nonparametric Wilcoxon rank test. A two-variable correlation analysis was made by the Pearson method. Results: There was no significant difference in heart volume between the status of FB and DIBH (P = 0.773). The volume of both lungs was significantly larger in DIBH status than in FB status (P = 0.001). The mean and maximum doses and V₅-V₄₀ for the heart, left anterior descending coronary artery, left ventricle, right ventricle, and left lung were significantly lower in DIBH status than in FB status (all P < 0.05). The greater DIBH increased the lung volume, the greater the mean heart dose decreased. In FB status, the left breast volume, heart-to-lung volume ratio, distance between the inferior margins of breast and heart, and maximum heart margin distance showed a linear correlation with heart dose. Particularly, the heart-to-lung volume ratio and maximum heart margin distance were independently correlated with heart dose. Conclusions: DIBH technique in WBI for left breast cancer after breast-conserving surgery significantly reduces heart and lung doses compared with FB. Changes in lung volume are the basis for improving the relative anatomical location of the heart. The heart-to-lung volume ratio and maximum heart margin distance may provide a reference for DIBH technique. (authors)