53. Postmastectomy radiotherapy (PMRT)

Abstract

The role of PMRT in breast cancer patients has been controversial. The early clinical trials demonstrated improvement of local-regional control but failed to show an improvement in survival. Recently three randomized trials demonstrated significant improvement of overall survival with the use of PMRT in high risk breast cancer patients who were also treated with systemic adjuvant therapies. On the other hand in several studies and in meta-analysis an excess of non cancer, especially cardiovascular, deaths was documented. These deaths were probably related to high dose of radiation given to heart and great vessels with the use of outdated radiotherapy techniques. With the modern radiotherapy planning it is possible to reduce the dose to these structures. Duration of follow-up of patients treated with contemporary techniques is still limited however so far no increase of cardiovascular deaths was found. Great numbers of new technical solution in PMRT has Been recently published. According to the available evidence PMRT should be recommended to node positive breast cancer patients and combined with adjuvant systemic therapy. Chest wall and regional lymph nodes should be irradiated with the dose of SO Gy in 25 fractions and effort should be made to minimize dose to heart, great vessels and lung. The discussion on the optimal use of PMRT continues in the literature and most important issues include:

• 1)

  patients selection,

• 2)

  coordination of PMRT with systemic adjuvant therapies

• 3)

  technical aspects of radiotherapy like target volume definition, total dose, fractionation schedule and shielding of critical organs and tissues. Some of this questions are addressed by randomized studies that are presently underway.