Intent of therapy in metastatic breast cancer with isolated ipsilateral supraclavicular lymph node spread--a therapeutic dilemma

Abstract

Aims of the study: Isolated ipsilateral supraclavicular lymph nodal (IISCLN) metastasis was considered part of locally advanced breast cancer (LABC) previously but the recent staging system categorised this group to metastatic disease (stage IV). There is no clear consensus on intent of therapy in patients with IISCLN. A retrospective comparative analysis of IISCLN and LABC patients treated with a curative multimodality approach was performed to evolve guidelines on treatment approach in patients with IISCLN spread.

Methodology: A total number of 670 patients with breast cancer treated in the Department of Surgical Oncology, IRCH, AIIMS, during the period between January, 1993 to December, 2000 were studied retrospectively. Out of these 16 (2.4%) patients with cytology proven isolated metastasis to ipsilateral SCLN without any other distant disease and 299 LABC patients were analysed. All patients received neoadjuvant anthracycline based chemotherapy, surgery, postoperative radiotherapy (50 Gy) including supraclavicular fossa. The relapse patterns and survival in both the groups were compared.

Results: At a median follow up of 36 months (range 9-72 months) the total recurrence in the IISCLN group was 31% and in the LABC group was 26%, the systemic recurrence was equal at 25% in each group while the locoregional recurrence was 12% and 7% in the IISCLN and LABC groups respectively. The overall survival (OS) was 81% and 91% whereas the disease-free survival (DFS) was 12% and 7% in the IISCLN and LABC groups, respectively.

Conclusion: Intent of therapy in metastatic breast cancer is palliative. However, patients with IISCLN metastasis have a relatively less aggressive biologic behaviour as compared to patients with spread to other distant sites. Results of the current study shows that the relapse patterns and survival of IISCLN group and LABC are comparable. Hence, despite being staged as metastatic disease, patients with IISCLN spread should be treated with combined modality approach for prolonged survival.