A Questionnaire Survey of Current Practice in the Management of Internal Mammary Lymph Nodes in Breast Cancer

Smitha S. Rao; Nita S. Nair; Tabassum Wadasadawala; Smruti Mokal; Rima Pathak; Rajiv Sarin; Vani Parmar; Shalaka Joshi; Rajendra A. Badwe

doi:10.1055/s-0043-1763251

South Asian Journal of Cancer, Inhaltsverzeichnis

CC BY-NC-ND 4.0 · South Asian J Cancer 2024; 13(02): 085-089
DOI: 10.1055/s-0043-1763251

Original Article

Breast Cancer

A Questionnaire Survey of Current Practice in the Management of Internal Mammary Lymph Nodes in Breast Cancer

Smitha S. Rao

¹Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India

,

Nita S. Nair

¹Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India

,

Tabassum Wadasadawala

²Breast Disease Management Group, Department of Radiation Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India

,

Smruti Mokal

³Department of Biostatistics, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India

,

Rima Pathak

²Breast Disease Management Group, Department of Radiation Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India

,

Rajiv Sarin

⁴Cancer Genetics Unit, Breast Disease Management Group, Department of Radiation Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India

,

Vani Parmar

¹Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India

,

Shalaka Joshi

¹Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India

,

Rajendra A. Badwe

¹Breast Disease Management Group, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India

› Institutsangaben

Abstract

Nita S. Nair

Background Radiotherapy (RT) is an important modality in the management of breast cancers (BC). Large randomized trials have suggested that prophylactic regional nodal irradiation inclusive of internal mammary lymph nodes (IMLN) reduces BC-related mortality. However, the adoption of IMLN-RT has been variable due to relative benefits and toxicity concerns.

Methods A survey was emailed to radiation oncologists (ROs) across the country wherein they were asked about their practice regarding IMLN-RT in BC.

Results We received 128 responses, which included radiation oncologists across both private institutions (PIs) and government institutions (GIs). Fifty-six (43.8%) routinely offer prophylactic(p) IMLN-RT and an additional 15 (11.71%) suggested they would have offered it in the absence of logistic constraints. Almost all, 121 (94.5%) radiate the IMLN in case of radiologically positive lymph nodes (LNs).

Fifty-six ROs (43.8%) offered prophylactic IMLN-RT in node-negative disease. Among those who did not offer IMLN-RT, most (84.72%) felt the clinical evidence was equivocal. Of the 56 who offered pIMLN-RT, 34/56 (60.71%) offered to locally advanced tumors, 20/56 (35.71%) offered to all inner and central tumors (ICQT), 29/56 (51.78%) to > 4 axillary LN-positive and 9/56 (16.07%) to any axillary LN-positive. The majority, i.e., 36/56 (64.28%) radiated upper three intercostal spaces, 9 (16.07%) radiated upper five intercostal spaces, and 6 (10.9%) decided based on tumor location, while 5 (9%) irradiated one space below the involved space.

Overall, simulation-based planning was undertaken in 99% of PIs as opposed to 89% of GIs (p = 0.03). The majority of ROs, i.e., 92 (72.4%) preferred IMRT to IMLN-RT.

In addition, the surgical approach to IMLN was practiced by surgeons at 18 (14%) centers, of which 13 (72.22%) operated the IMLN when radiologically evident. The IMLN dissection was preferentially performed for second and third intercostal spaces as suggested in 10 (55.55%) responses, while 8 (44.44%) performed thoracoscopic dissection of the IMLN chain. The distribution of prophylactic, definitive IMLN-RT, and IMLN dissection did not differ significantly between GI and PI (p = NS).

Conclusion pIMLN-RT is still not the standard protocol in most centers citing equivocal evidence in the literature. Logistics, though different in GIs and PIs, did not impact the decision of pIMLN-RT. Further efforts would be required to standardize practice in IMLN across India.

Keywords

breast cancer - radiotherapy - internal mammary lymph nodes - survey - current practice

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