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Locoregional Recurrence Patterns After Mastectomy and Doxorubicin-Based Chemotherapy: Implications for Postoperative Irradiation

From the Departments of Radiation Oncology, Biomathematics, Medical Oncology, and Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX.

Address reprint requests to Eric A. Strom, MD, Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 97, Houston, TX 77030; email estrom{at}notes.mdacc.tmc.edu

PURPOSE: The objective of this study was to determine locoregional recurrence (LRR) patterns after mastectomy and doxorubicin-based chemotherapy to define subgroups of patients who might benefit from adjuvant irradiation.

PATIENTS AND METHODS: A total of 1,031 patients were treated with mastectomy and doxorubicin-based chemotherapy without irradiation on five prospective trials. Median follow-up time was 116 months. Rates of isolated and total LRR (± distant metastasis) were calculated by Kaplan-Meier analysis.

RESULTS: The 10-year actuarial rates of isolated LRR were 4%, 10%, 21%, and 22% for patients with zero, one to three, four to nine, or 10 involved nodes, respectively (P < .0001). Chest wall (68%) and supraclavicular nodes (41%) were the most common sites of LRR. T stage (P < .001), tumor size (P < .001), and 2-mm extranodal extension (P < .001) were also predictive of LRR. Separate analysis was performed for patients with T1 or T2 primary disease and one to three involved nodes (n = 404). Those with fewer than 10 nodes examined were at increased risk of LRR compared with those with 10 nodes examined (24% v 11%; P = .02). Patients with tumor size greater than 4.0 cm or extranodal extension 2 mm experienced rates of isolated LRR in excess of 20%. Each of these factors continued to significantly predict for LRR in multivariate analysis by Cox logistic regression.

CONCLUSION: Patients with tumors 4 cm or at least four involved nodes experience LRR rates in excess of 20% and should be offered adjuvant irradiation. Additionally, patients with one to three involved nodes and large tumors, extranodal extension 2 mm, or inadequate axillary dissections experience high rates of LRR and may benefit from postmastectomy irradiation.

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