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Abstract
Introduction. Regional nodal irradiation in breast cancer carries a significant risk of adverse effects, including lymphedema, while overtreatment may lead to substantial morbidity without demonstrable improvement in oncologic outcomes. Although preliminary 5-year data from recent prospective trials suggest radiotherapy de-escalation maintains oncologic safety, conflicting evidence from other studies has prevented the establishment of international consensus on this therapeutic approach.
Aim. To identify breast cancer patient cohorts for whom radiotherapy de-escalation may represent an oncologically safe approach following neoadjuvant combination chemotherapy and achievement of pathological complete response (pCR) in regional lymph nodes.
Materials and Methods. We conducted a systematic analysis of both retrospective and prospective studies comparing outcomes between breast cancer patients who did or did not receive regional nodal irradiation following neoadjuvant chemotherapy with subsequent pCR in lymph nodes. The literature search was performed using PubMed database with the following keywords: breast cancer, regional lymph node irradiation, pathological complete response, and radiotherapy de-escalation.
Results. Our systematic review incorporated data from 28 published studies. The analysis demonstrated that improvements in overall survival and/or locoregional control were predominantly observed in patients with luminal subtypes. Notably, one study reported enhanced locoregional control specifically in patients with luminal subtype breast cancer, while another publication documented a significant overall survival benefit from regional nodal irradiation in cases demonstrating pCR in lymph nodes without concurrent pCR in the primary tumor. Preliminary findings from the prospective NSABP B-51 prospective study indicate no therapeutic benefit from regional nodal irradiation in patients who initially presented with limited nodal involvement and subsequently achieved nodal pCR.
Conclusion. Given the pending final results from the NSABP B-51 prospective study and the conflicting evidence from retrospective analyses, radiation therapy should currently be administered according to on the initial clinical stage and existing clinical practice guidelines.
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