Locoregional PMRT is recommended for women with 4 or more positive axillary lymph nodes .
The role of PMRT in women with 1 to 3 positive axillary lymph nodes is unclear .
Locoregional PMRT is generally not recommended for women who have tumours that are less than 5 cm in diameter and who have negative axillary nodes .
OBJECTIVE To provide information and recommendations to assist women with breast cancer and their physicians in making decisions regarding the use of locoregional post-mastectomy radiotherapy ( PMRT ) .
OUTCOMES Locoregional control , disease-free survival , overall survival and treatment-related toxicities .
To reduce the risk of lymphedema , radiation of the entire axilla should not be used routinely after complete axillary dissection of level I and II lymph nodes .
The use of modern techniques in radiotherapy planning is recommended to minimize excessive normal tissue exposure , particularly to the cardiac and pulmonary structures .
Common short-term side effects of PMRT , including fatigue and skin erythema , are generally tolerable and not dose-limiting .
Severe long-term side effects , including lymphedema , cardiac and pulmonary toxicities , brachial plexopathy , rib fractures and secondary neoplasms , are relatively rare .
Long-term cardiac morbidity and mortality in a randomized trial of pre- and postoperative radiation therapy versus surgery alone in primary breast cancer.
BACKGROUND AND PURPOSE Some types of radiation therapy have been associated with an increased risk of cardiac mortality and morbidity in patients with early-stage breast cancer . A relationship has been observed between cardiac radiation dose-volume and the level of excess risk of cardiac mortality . However , relatively few data are available on the morbidity from myocardial infa rct ion associated with adjuvant radiotherapy . PATIENTS AND METHODS From 1971 to 1976 , a total of 960 patients with operable breast cancer were r and omly allocated to  preoperative radiation therapy , postoperative radiation therapy or to surgery alone . A previous analysis of the cardiac dose-volumes with the treatment techniques used in the trial indicated that the irradiated patients could roughly be divided into three groups . Information on the number of myocardial infa rct ions was obtained through computerized record linkage with a population -based registry of myocardial infa rct ions in Stockholm County . Information on cause-specific mortality was obtained from the Swedish Cause-of-Death Registry . The median follow-up was 20 years ( range 17 - 23 years ) . RESULTS A total of 58 patients developed an acute myocardial infa rct ion during the period of follow-up . The number of myocardial infa rct ion cases was not significantly different between the three treatment groups . When analyzed according to estimated cardiac radiation dose-volumes , patients in the highest dose-volume subgroup exhibited a hazard of myocardial infa rct ion of 1.3 ( 95 % CI 0.7 - 2.6 ) relative to that of the surgical controls , whereas the corresponding relative hazard for the intermediate and low dose-volume subgroups was below unity . Data on death due to cardiovascular disease showed that patients in the high dose-volume group exhibited a hazard of 2.0 ( 95 % CI 1.0 - 3.9 , P = 0.04 ) relative to that of the surgical controls . Concerning death due to ischemic heart disease , the relative hazard for the same subgroup was 2.5 ( 95 % CI 1.1 - 5.7 , P = 0.03 ) . The difference between the groups was established after 4 - 5 years . The cumulative incidence curves continued to diverge up to about 10 - 12 years . No further divergence appeared after 12 years , but the number of events was low . CONCLUSIONS This analysis confirms and extends previous results from the trial . Cardiac mortality was positively correlated with the cardiac dose-volume . Patients receiving high dose-volumes exhibited an increased mortality of ischemic heart disease , but not of myocardial infa rct ion , which implies another mechanism , e.g. radiation-induced microvascular damage to the heart
Locoregional PMRT is recommended for women with 4 or more positive axillary lymph nodes .
The role of PMRT in women with 1 to 3 positive axillary lymph nodes is unclear .
Locoregional PMRT is generally not recommended for women who have tumours that are less than 5 cm in diameter and who have negative axillary nodes .
OBJECTIVE To provide information and recommendations to assist women with breast cancer and their physicians in making decisions regarding the use of locoregional post-mastectomy radiotherapy ( PMRT ) .
OUTCOMES Locoregional control , disease-free survival , overall survival and treatment-related toxicities .
To reduce the risk of lymphedema , radiation of the entire axilla should not be used routinely after complete axillary dissection of level I and II lymph nodes .
The use of modern techniques in radiotherapy planning is recommended to minimize excessive normal tissue exposure , particularly to the cardiac and pulmonary structures .
Common short-term side effects of PMRT , including fatigue and skin erythema , are generally tolerable and not dose-limiting .
Severe long-term side effects , including lymphedema , cardiac and pulmonary toxicities , brachial plexopathy , rib fractures and secondary neoplasms , are relatively rare .