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Radiation Therapy Updates for Breast Cancer in the NCCN Guidelines

Surabhi Dangi-Garimella, PhD
On the second day of the 22nd Annual Conference of the National Comprehensive Cancer Network (NCCN), Kilian E. Salerno, MD, of the Roswell Park Cancer Institute, walked the audience through updates to the NCCN Guidelines, explaining clinical situations in which radiation is indicated, appropriate targets of radiation treatment, and optimal approaches for minimizing toxicity.

“Identifying an appropriate margin has been a topic of debate and the new Guideline provides direction,” said Salerno. “We must remember, though, that context matters.” The following 2 recommendations have been added to the Guideline:
  • 2 mm is considered an adequate margin in ductal carcinoma in situ treated with whole-breast irradiation.
  • For stage 1-II invasive disease treated with whole-breast irradiation, no tumor on ink is considered an adequate margin

Salerno then spoke about locoregional treatment of clinical stage I, IIA, or IIIB disease or node-positive disease. For negative axillary nodes the following treatment options have been recommended:
  • Radiation therapy to the whole breast, with or without boost to the tumor bed; preferably hypofractionation
  • Accelerated partial breast irradiation in some low-risk patients, following guidelines defined by the American Society of Radiation Oncology, which, Salerno said, will be updated in the coming year.

She then provided insight on post mastectomy radiation (PMRT), classic indications for which include 4 or more positive axillary lymph nodes, positive margins, and tumor size over 5 cm. However, patients with 1 to 3 lymph nodes, close margins and some high-risk features, such as age, extracapsular extension, and certain intrinsic subtypes, could also be considered for PMRT.

Regional node irradiation or RNI is recommended for those with 4 or more positive nodes, strongly considered for 1 to 3 positive nodes, and may be considered for some high-risk node negative patients.

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