| 1. Patients With Four or More Positive Axillary Lymph Nodes PMRT is recommended for
patients with four or more positive axillary lymph nodes. |
| 2. Patients With One to Three Positive Axillary Lymph Nodes There is insufficient
evidence to make recommendations or suggestions for the routine use of PMRT in patients
with T1/2 tumors with one to three positive nodes. |
| 3. Patients With T3 or Stage III Tumors PMRT is suggested for patients with T3 tumors
with positive axillary nodes and patients with operable stage III tumors. |
| 4. Patients Undergoing Preoperative Systemic Therapy There is insufficient evidence to
make recommendations or suggestions on whether all patients initially treated with
preoperative systemic therapy should be given PMRT. |
| 5. Modifications of These Guidelines for Special Patient Subgroups There is
insufficient evidence to make recommendations or suggestions for modifying guidelines
regarding the routine use of PMRT based on other tumor- related, patient-related, or
treatment-related factors. |
| 6. Chest Wall Irradiation In patients given PMRT, we suggest that adequately treating
the chest wall is mandatory. |
| 7. Details of Chest Wall Irradiation There is insufficient evidence for the Panel to
recommend or suggest such aspects of chest wall irradiation as total dose, fraction size,
the use of bolus, and the use of scar boosts. |
| 8. Axillary Nodal Irradiation We suggest that full axillary radiotherapy not be given
routinely to patients undergoing complete or level I/II axillary dissection. There is
insufficient evidence to make suggestions or recommendations as to whether some patient
subgroups might benefit from axillary irradiation. |
| 9. Supraclavicular Nodal Irradiation for Patients With Four or More Positive Axillary
Lymph Nodes The incidence of clinical supraclavicular failure is sufficiently great in
patients with four or more positive axillary nodes that we suggest a supraclavicular field
should be irradiated in all such patients. |
| 10. Supraclavicular Nodal Irradiation for Patients With One to Three Positive Axillary
Lymph Nodes There is insufficient evidence to state whether a supraclavicular field should
or should not be used for patients with one to three positive axillary nodes. |
| 11. Internal Mammary Nodal Irradiation There is insufficient evidence to make
suggestions or recommendations on whether deliberate internal mammary nodal irradiation
should or should not be used in any patient subgroup. |
| 12. Sequencing of PMRT and Systemic Therapy There is insufficient evidence to
recommend the optimal sequencing of chemotherapy, tamoxifen, and PMRT. The Panel does
suggest, based on the available evidence regarding toxicities, that doxorubicin not be
administered concurrently with PMRT. |
| 13. Integration of PMRT and Reconstructive Surgery There is insufficient evidence to
make recommendations or suggestions with regard to the integration of PMRT and
reconstructive surgery. |
| 14. Long-Term Toxicities The potential long-term risks of PMRT include lymphedema,
brachial plexopathy, radiation pneumonitis, rib fractures, cardiac toxicity, and
radiation- induced second neoplasms. Data would suggest that the incidence of many of
these toxicities will be lower when modern radiotherapy techniques are used, although
follow-up in patients treated with current radiotherapy is insufficient to rule out the
possibility of very late cardiac toxicities. In reviewing the available evidence with its
limitations, however, the Panel suggests that, in general, the risk of serious toxicity of
PMRT (when performed of toxicity using modern techniques) is low enough that such
considerations of toxicity should not limit its use in most circumstances when otherwise
indicated. |
15. Toxicity Considerations for Special Patient Subgroups There is insufficient
evidence to make recommendations or suggestions that PMRT should not be used for some
subgroups of patients because of increased rates of toxicity (such as radiation
carcinogenesis) compared with the rest of the population.
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