tumorsMalignant tumoursMalignant tumours2224-50572587-6813Rosoncoweb10.18027/2224-5057-2017-2-62-66tumors-344Research ArticleОБЗОРЫ И АНАЛИТИКАREVIEWS AND ANALYSISНеоадъювантная химиотерапия и послеоперационное облучение: взаимосвязь и перспективыNeoadyavant chemotherapy and postoperative irradiation in breast cancer: interrelation and prospectsМитинТ. В.MitinT. V.

Отделение радиационной медицины

доктор, радиационный онколог

MD, PhD, radiation oncologist, Department of Radiation Medicine

mitin@ohsu.eduДеньгинаН. В.DenginaN. V.

к.м.н., заведующая радиологическим отделением

MD, PhD, head of radiotherapy department

indigo171201@yahoo.comОрегонский университет медицины и науки, Портленд, ОрегонСоединённые Штаты АмерикиOregon Health and Science UniversityUnited StatesГУЗ Областной клинический онкологический диспансер, УльяновскРоссияRegional Clinical Oncology Center, UlyanovskRussian Federation201720072017026266Copyright © Митин Т.В., Деньгина Н.В., 20172017Митин Т.В., Деньгина Н.В.Mitin T.V., Dengina N.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.malignanttumors.org/jour/article/view/344

Оксфордский мета-анализ 2005 года по результатам многих исследований не продемонстрировал преимуществ лучевой терапии после радикальной мастэктомии у больных с негативными лимфоузлами, однако показал снижение 5-летнего риска локальных рецидивов и 15-летнего риска смерти от рака молочной железы у пациенток с позитивными лимфоузлами, прошедших через адъювантное облучение. Тем не менее дебаты в отношении целесообразности проведения лучевой терапии после мастэктомии больным с ограниченным (от 1 до 3) поражением лимфоузлов до сих пор актуальны. Широко используемая в настоящее время неоадъювантная химиотерапия способна приводить к развитию клинического и патоморфологического ответа у части пациенток. Однако до сих пор было принято игнорировать информацию об ответе на неоадъювантное лечение и ориентироваться только на клинические данные до начала химиотерапии при назначении адъювантного облучения. Основная цель данной статьи – во-первых, представить очевидные данные применения лучевой терапии в более традиционной терапевтической последовательности, а во-вторых, продемонстрировать наиболее яркие сведения о том, как ответ на химиотерапию может повлиять на решение о необходимости назначения адъювантного облучения. 

In 2005 the Oxford meta-analysis of individual patient data from many trials showed no benefit to postmastectomy radiotherapy in node-negative breast cancer patients but reduced 5-year local recurrence and 15-year breast cancer mortality in patients with node-positive disease who underwent axillary lymphnode dissection. Despite these data, there is still some debate over the appropriateness of postmastectomy radiotherapy in patients with 1 to 3 involved lymph nodes. Neoadjuvant chemotherapy leads to clinical and pathological response in a certain proportion of patients. So far, the universal approach was to ignore the information on response to chemotherapy and recommend postmastectomy radiotherapy based on pre-chemo clinical disease status. The main goal of this article is first to summarize the evidence for the use of postmastectomy radiotherapy in a more traditional treatment sequence, and then show new evidence that highlights how information about the response to chemotherapy can be incorporated into the decision regarding the need and benefit of postmastectomy radiotherapy in the context of neoadjuvant chemotherapy. 

лучевая терапиярадикальная мастэктомиянеоадъювантная химиотерапияradiotherapyradical mastectomyneoadjuvant chemotherapyReferencesFisher B., Slack N.H., Cavanaugh P. J., Gardner B., Ravdin R.G., Cooperating Investigators: Postoperative radiotherapy in the treatment of breast cancer: Results of the NSABP clinical trial, Ann. Surg., 1970, No. 172, pp. 711–730.Fisher B., Slack N.H., Cavanaugh P. J., Gardner B., Ravdin R.G., Cooperating Investigators: Postoperative radiotherapy in the treatment of breast cancer: Results of the NSABP clinical trial, Ann. Surg., 1970, No. 172, pp. 711–730.Tapley N.D., Spanos W.J., Fletcher J.H., Montague E.D., Schell S., Oswald M.J. Results in patients with breast cancer treated by radical mastectomy and postoperative irradiation with no adjuvant chemotherapy, Cancer, 1982, Vol. 49, No. 6, pp. 1316–1319.Tapley N.D., Spanos W.J., Fletcher J.H., Montague E.D., Schell S., Oswald M.J. Results in patients with breast cancer treated by radical mastectomy and postoperative irradiation with no adjuvant chemotherapy, Cancer, 1982, Vol. 49, No. 6, pp. 1316–1319.Overgaard M., Hansen P.S., Overgaard J.C., Andersson M., Bach F., Kjaer M. et al., for the Danish Breast Cancer Cooperative Group 82b Trial. Postoperative Radiotherapy in High-Risk Premenopausal Women with Breast Cancer Who Receive Adjuvant Chemotherapy, N. Engl. J. Med., 1997, No. 337, pp. 949–955.Overgaard M., Hansen P.S., Overgaard J.C., Andersson M., Bach F., Kjaer M. et al., for the Danish Breast Cancer Cooperative Group 82b Trial. Postoperative Radiotherapy in High-Risk Premenopausal Women with Breast Cancer Who Receive Adjuvant Chemotherapy, N. Engl. J. Med., 1997, No. 337, pp. 949–955.Overgaard M., Jensen M.B., Overgaard J., Hansen P.S., Rose C., Andersson M. et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomized trial, Lancet, 1999, Vol. 353, No. 9165, pp. 1641–8.Overgaard M., Jensen M.B., Overgaard J., Hansen P.S., Rose C., Andersson M. et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomized trial, Lancet, 1999, Vol. 353, No. 9165, pp. 1641–8.Ragaz J., Olivotto I.A., Spinelli J. J., Phillips N., Jackson S.M., Wilson KS. et al. Locoregional radiation therapy in patients with highrisk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial, J. Natl. Cancer Inst., 2005, Vol. 97, No. 2, pp. 116–26.Ragaz J., Olivotto I.A., Spinelli J. J., Phillips N., Jackson S.M., Wilson KS. et al. Locoregional radiation therapy in patients with highrisk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial, J. Natl. Cancer Inst., 2005, Vol. 97, No. 2, pp. 116–26.Overgaard M., Nielsen H.M., Overgaard J. Is the benefit of postmastectomy irradiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DBCG 82 b&c randomized trials, Radiother. Oncol., 2007, No. 82, pp. 247–53.Overgaard M., Nielsen H.M., Overgaard J. Is the benefit of postmastectomy irradiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DBCG 82 b&c randomized trials, Radiother. Oncol., 2007, No. 82, pp. 247–53.Clarke M., Collins R., Darby S., Davies C., Elphinstone P., Evans V. et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomized trials, Lancet, 2005, Vol. 366, No. 9503, pp. 2087–106.Clarke M., Collins R., Darby S., Davies C., Elphinstone P., Evans V. et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomized trials, Lancet, 2005, Vol. 366, No. 9503, pp. 2087–106.EBCTCG (Early Breast Cancer Trialists” Collaborative Group). Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomized trials, Lancet, 2014, No. 383, pp. 2127–35.EBCTCG (Early Breast Cancer Trialists” Collaborative Group). Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomized trials, Lancet, 2014, No. 383, pp. 2127–35.Taghian A., Jeong J.H., Mamounas E., Anderson S., Bryan J., Deutsch M., Wolmark N. Patterns of locoregional failure in patients with operable breast cancer treated by mastectomy and adjuvant chemotherapy with or without tamoxifen and without radiotherapy: results from five national surgical adjuvant breast and bowel project randomized clinical trials, J. Clin. Oncol., 2004, No. 22, pp. 4247–4254.Taghian A., Jeong J.H., Mamounas E., Anderson S., Bryan J., Deutsch M., Wolmark N. Patterns of locoregional failure in patients with operable breast cancer treated by mastectomy and adjuvant chemotherapy with or without tamoxifen and without radiotherapy: results from five national surgical adjuvant breast and bowel project randomized clinical trials, J. Clin. Oncol., 2004, No. 22, pp. 4247–4254.Taghian A.G., Jeong J. J., Mamounas E.P., Parda D.S., Deutsch M., Costantino J.P., Wolmark N. Low locoregional recurrence rate among node-negative breast cancer patients with tumors 5 cm or larger treated by mastectomy, with or without adjuvant systemic therapy and without radiotherapy: results from five national surgical adjuvant breast and bowel project randomized clinical trials, J. Clin. Oncol., 2006, No. 24, pp. 3927–3932.Taghian A.G., Jeong J. J., Mamounas E.P., Parda D.S., Deutsch M., Costantino J.P., Wolmark N. Low locoregional recurrence rate among node-negative breast cancer patients with tumors 5 cm or larger treated by mastectomy, with or without adjuvant systemic therapy and without radiotherapy: results from five national surgical adjuvant breast and bowel project randomized clinical trials, J. Clin. Oncol., 2006, No. 24, pp. 3927–3932.Recht A., Comen E.A., Fine R.E. et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update, Practical Radiation Oncology, 2016 (article in press).Recht A., Comen E.A., Fine R.E. et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update, Practical Radiation Oncology, 2016 (article in press).Rastogi P., Anderson S. J., Bear H.D. et al. Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project protocols B-18 and B-27, J. Clin. Oncol., No. 26, pp. 778–785.Rastogi P., Anderson S. J., Bear H.D. et al. Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project protocols B-18 and B-27, J. Clin. Oncol., No. 26, pp. 778–785.Buchholz T.A., Tucker S. L., Masullo L. et al. Predictors of local-regional recurrence after neoadjuvant chemotherapy and mastectomy without radiation, J. Clinical Oncol., 2002, Vol. 20, No. 1, pp. 17–23.Buchholz T.A., Tucker S. L., Masullo L. et al. Predictors of local-regional recurrence after neoadjuvant chemotherapy and mastectomy without radiation, J. Clinical Oncol., 2002, Vol. 20, No. 1, pp. 17–23.Huang E.H., Tucker S. L., Strom E.A. et al. Postmastectomy radiation improves local-regional control and survival for selected patients with locally advanced breast cancer treated with neoadjuvant chemotherapy and mastectomy, J. Clin. Oncol., No. 22, pp. 4691–4699.Huang E.H., Tucker S. L., Strom E.A. et al. Postmastectomy radiation improves local-regional control and survival for selected patients with locally advanced breast cancer treated with neoadjuvant chemotherapy and mastectomy, J. Clin. Oncol., No. 22, pp. 4691–4699.McGuire S. E., Gonzalez-Angulo A.M., Huang E.H. et al. Postmastectomy radiation improves the outcome of patients with locally advanced breast cancer who achieve a pathologic complete response to neoadjuvant chemotherapy, Int. J. Radiat. Oncol. Biol. Phys., 2007, Vol. 68, No. 4, pp. 1004–9.McGuire S. E., Gonzalez-Angulo A.M., Huang E.H. et al. Postmastectomy radiation improves the outcome of patients with locally advanced breast cancer who achieve a pathologic complete response to neoadjuvant chemotherapy, Int. J. Radiat. Oncol. Biol. Phys., 2007, Vol. 68, No. 4, pp. 1004–9.Mamounas E.P., Anderson S.J., Dignam J.J. et al. Predictors of locoregional recurrence after neoadjuvant chemotherapy: results from combined analysis of National Surgical Adjuvant Breast and Bowel Project B-18 and B-27, J. Clin. Oncol., No. 30, pp. 3960–3966.Mamounas E.P., Anderson S.J., Dignam J.J. et al. Predictors of locoregional recurrence after neoadjuvant chemotherapy: results from combined analysis of National Surgical Adjuvant Breast and Bowel Project B-18 and B-27, J. Clin. Oncol., No. 30, pp. 3960–3966.Cortazar P., Zhang L., Untch M. et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis, Lancet, 2014, Vol. 384, No. 9938, pp. 164–172.Cortazar P., Zhang L., Untch M. et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis, Lancet, 2014, Vol. 384, No. 9938, pp. 164–172.Mamounas E.P., Cortazar P., Zhang L. et al. Locoregional recurrence (LRR) after neoadjuvant chemotherapy (NAC): Pooled-analysis results from the collaborative trials in neoadjuvant breast cancer (CTNeoBC), J. Clin. Oncol., 2014, Vol. 32 (suppl. 26, abstr. 61).Mamounas E.P., Cortazar P., Zhang L. et al. Locoregional recurrence (LRR) after neoadjuvant chemotherapy (NAC): Pooled-analysis results from the collaborative trials in neoadjuvant breast cancer (CTNeoBC), J. Clin. Oncol., 2014, Vol. 32 (suppl. 26, abstr. 61).

The authors declare that there are no conflicts of interest present.