The role of postmastectomy radiotherapy and regional nodal irradiation after radical mastectomy is defined in high-risk patients with locally advanced tumors, positive margins, and unfavorable biology. The benefit of postmastectomy radiotherapy in intermediate-risk patients (T3N0 tumors) remains a matter of controversy. It has been demonstrated that radiotherapy after breast-conserving surgery lowers the locoregional recurrence rate compared with surgery alone and improves the overall survival rate. In patients with four or more positive lymph nodes or extracapsular extension, regional lymph node irradiation is indicated regardless of the surgery type (breast-conserving surgery or mastectomy). Despite the consensus that patients with more than three positive lymph nodes should be treated with radiotherapy, there is controversy regarding the recommendations for patients with one to three involved lymph nodes. In patients with N0 disease with negative findings on axillary surgery, there is a trend to administer regional lymph node irradiation in patients with a high risk of recurrence. In patients treated with neoadjuvant systemic therapy and mastectomy, adjuvant radiotherapy should be administered in cases of clinical stage III and/or ≥ypN1. In patients treated with neoadjuvant systemic therapy and breast-conserving surgery, postoperative radiotherapy is indicated irrespective of pathological response.

Department of Oncology and Radiotherapy Faculty of Medicine in Hradec Králové University Hospital Hradec Králové Charles University 500 05 Hradec Králové Czech Republic

Department of Oncology Faculty of Medicine and Dentistry University Hospital Olomouc Palacky University 779 00 Olomouc Czech Republic

Department of Radiobiology Faculty of Military Health Sciences University of Defence 500 01 Hradec Králové Czech Republic

Faculty of Health Studies Pardubice University 532 10 Pardubice Czech Republic

Oncology Centre Multiscan 532 03 Pardubice Czech Republic

See more in PubMed

Clarke M., Collins R., Darby S., Davies C., Elphinstone P., Evans V., Godwin J., Gray R., Hicks C., James S., et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). 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;366:2087–2106. PubMed

Nielsen H.M., Overgaard M., Grau C., Jensen A.R., Overgaard J. Study of failure pattern among high-risk breast cancer patients with or without postmastectomy radiotherapy in addition to adjuvant systemic therapy: Long-term results from the Danish Breast Cancer Cooperative Group DBCG 82 b and c randomized studies. J. Clin. Oncol. 2006;24:2268–2275. doi: 10.1200/JCO.2005.02.8738. PubMed DOI

Taghian A. Adjuvant Radiation Therapy for Women with Newly Diagnosed, Non-Metastatic Breast Cancer. Introduction. In UpToDate, Post TW (Ed), UpToDate, Waltham, MA, USA. [(accessed on 22 March 2022)]. Available online: https://www.uptodate.com/contents/adjuvant-radiation-therapy-for-women-with-newly-diagnosed-non-metastatic-breast-cancer.

Harris J.R. Fifty years of progress in radiation therapy for breast cancer. Am. Soc. Clin. Oncol. Educ. Book. 2014;34:21–25. doi: 10.14694/EdBook_AM.2014.34.21. PubMed DOI

Haussmann J., Corradini S., Nestle-Kraemling C., Bölke E., Njanang F.J.D., Tamaskovics B., Orth K., Ruckhaeberle E., Fehm T., Mohrmann S., et al. Recent advances in radiotherapy of breast cancer. Radiat. Oncol. 2020;15:71. doi: 10.1186/s13014-020-01501-x. PubMed DOI PMC

Meattini I., Becherini C., Boersma L., Kaidar-Person O., Marta G.N., Montero A., Offersen B.V., Aznar M.C., Belka C., Brunt A.M., et al. European Society for Radiotherapy and Oncology Advisory Committee in Radiation Oncology Practice consensus recommendations on patient selection and dose and fractionation for external beam radiotherapy in early breast cancer. Lancet Oncol. 2022;23:e21–e31. doi: 10.1016/S1470-2045(21)00539-8. PubMed DOI

Remick J., Amin N.P. StatPearls. StatPearls Publishing; Treasure Island, FL, USA: [(accessed on 8 September 2023)]. Postmastectomy Breast Cancer Radiation Therapy. Available online: https://europepmc.org/article/NBK/nbk519034. PubMed

Taghian A.G., Jeong J.H., 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;24:3927–3932. PubMed

Floyd S.R., Buchholz T.A., Haffty B.G., Goldberg S., Niemierko A., Raad R.A., Oswald M.J., Sullivan T., Strom E.A., Powell S.N., et al. Low local recurrence rate without postmastectomy radiation in node-negative breast cancer patients with tumors 5 cm and larger. Int. J. Radiat. Oncol. Biol. Phys. 2006;66:358–364. doi: 10.1016/j.ijrobp.2006.05.001. PubMed DOI

Johnson M.E., Handorf E.A., Martin J.M., Hayes S.B. Postmastectomy radiation therapy for T3N0: A SEER analysis. Cancer. 2014;120:3569–3574. doi: 10.1002/cncr.28865. PubMed DOI PMC

EBCTCG (Early Breast Cancer Trialists’ Collaborative Group) McGale P., Taylor C., Correa C., Cutter D., Duane F., Ewertz M., Gray R., Mannu G., Peto R., et al. 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 randomised trials. Lancet. 2014;383:2127–2135. PubMed PMC

Hansen E., Roach M. III, editors. Handbook of Evidence-Based Radiation Oncology. Springer International Publishing; Berlin/Heidelberg, Germany: 2018.

Tendulkar R.D., Rehman S., Shukla M.E., Reddy C.A., Moore H., Budd G.T., Dietz J., Crowe J.P., Macklis R. Impact of postmastectomy radiation on locoregional recurrence in breast cancer patients with 1-3 positive lymph nodes treated with modern systemic therapy. Int. J. Radiat. Oncol. Biol. Phys. 2012;83:577–581. doi: 10.1016/j.ijrobp.2012.01.076. PubMed DOI

Holland R., Veling S.H., Mravunac M., Hendriks J.H. Histologic multifocality of Tis, T1-2 breast carcinomas. Implications for clinical trials of breast-conserving surgery. Cancer. 1985;56:979–990. doi: 10.1002/1097-0142(19850901)56:5<979::AID-CNCR2820560502>3.0.CO;2-N. PubMed DOI

Fisher B., Anderson S., Bryant J., Margolese R.G., Deutsch M., Fisher E.R., Jeong J.H., Wolmark N. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N. Engl. J. Med. 2002;347:1233–1241. doi: 10.1056/NEJMoa022152. PubMed DOI

Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) Darby S., McGale P., Correa C., Taylor C., Arriagada R., Clarke M., Cutter D., Davies C., Ewertz M., et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: Meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011;378:1707–1716. PubMed PMC

Tendulkar D., Shah C.H. Early breast cancer. In: Ward M.C., Tendulkar R.D., Videtic G.M.M., editors. Essentials of Clinical Radiation Oncology. 1st ed. Demos Medical; New York, NY, USA: 2018. p. 158.

de Boniface J., Szulkin R., Johansson A.L.V. Survival after Breast Conservation vs Mastectomy Adjusted for Comorbidity and Socioeconomic Status: A Swedish National 6-Year Follow-up of 48 986 Women. JAMA Surg. 2021;156:628–637. doi: 10.1001/jamasurg.2021.1438. PubMed DOI PMC

Correa C., Harris E.E., Leonardi M.C., Smith B.D., Taghian A.G., Thompson A.M., White J., Harris J.R. Accelerated Partial Breast Irradiation: Executive summary for the update of an ASTRO Evidence-Based Consensus Statement. Pract. Radiat. Oncol. 2017;7:73–79. doi: 10.1016/j.prro.2016.09.007. PubMed DOI

Swisher S.K., Vila J., Tucker S.L., Bedrosian I., Shaitelman S.F., Litton J.K., Smith B.D., Caudle A.S., Kuerer H.M., Mittendorf E.A. Locoregional Control According to Breast Cancer Subtype and Response to Neoadjuvant Chemotherapy in Breast Cancer Patients Undergoing Breast-conserving Therapy. Ann. Surg. Oncol. 2016;23:749–756. doi: 10.1245/s10434-015-4921-5. PubMed DOI

Werutsky G., Untch M., Hanusch C., Fasching P.A., Blohmer J.U., Seiler S., Denkert C., Tesch H., Jackisch C., Gerber B., et al. Locoregional recurrence risk after neoadjuvant chemotherapy: A pooled analysis of nine prospective neoadjuvant breast cancer trials. Eur. J. Cancer. 2020;130:92–101. doi: 10.1016/j.ejca.2020.02.015. PubMed DOI

Ditsch N., Rubio I.T., Gasparri M.L., de Boniface J., Kuehn T. Breast and axillary surgery in malignant breast disease: A review focused on literature of 2018 and 2019. Curr. Opin. Obstet. Gynecol. 2020;32:91–99. doi: 10.1097/GCO.0000000000000593. PubMed DOI

Polgár C., Kahán Z., Ivanov O., Chorváth M., Ligačová A., Csejtei A., Gábor G., Landherr L., Mangel L., Mayer Á., et al. Radiotherapy of Breast Cancer-Professional Guideline 1st Central-Eastern European Professional Consensus Statement on Breast Cancer. Pathol. Oncol. Res. 2022;28:1610378. doi: 10.3389/pore.2022.1610378. PubMed DOI PMC

Nikyar N., Tegnelius E., Valachis A. Adjuvant locoregional radiation therapy in breast cancer patients with pathologic complete response after neoadjuvant chemotherapy: A systematic review and meta-analysis. Clin. Transl. Radiat. Oncol. 2022;33:45–52. doi: 10.1016/j.ctro.2021.12.010. PubMed DOI PMC

Shah C., Al-Hilli Z., Vicini F. Advances in Breast Cancer Radiotherapy: Implications for Current and Future Practice. JCO Oncol Pract. 2021;17:697–706. doi: 10.1200/OP.21.00635. PubMed DOI

NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. Version 1. 2024. [(accessed on 6 February 2024)]. Available online: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.

Kaidar-Person O., Pfob A., Gentilini O.D., Borisch B., Bosch A., Cardoso M.J., Curigliano G., De Boniface J., Denkert C., Hauser N., et al. The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: A multidisciplinary expert consensus. EClinicalMedicine. 2023;61:102085. doi: 10.1016/j.eclinm.2023.102085. PubMed DOI PMC

Dodwell D., Taylor C., McGale P., Coles C., Duane F., Gray R., Kühn T., Hennequin C., Oliveros S., Wang Y., et al. Regional lymph node irradiation in early stage breast cancer: An EBCTCG meta-analysis of 13,000 women in 14 trials; Proceedings of the 2018 San Antonio Breast Cancer Symposium; San Antonio, TX, USA. 4–8 December 2018.

Poortmans P.M., Weltens C., Fortpied C., Kirkove C., Peignaux-Casasnovas K., Budach V., van der Leij F., Vonk E., Weidner N., Rivera S., et al. Internal mammary and medial supraclavicular lymph node chain irradiation in stage I-III breast cancer (EORTC 22922/10925): 15-year results of a randomised, phase 3 trial. Lancet Oncol. 2020;21:1602–1610. doi: 10.1016/S1470-2045(20)30472-1. PubMed DOI

Korzets Y., Levitas D., Grubstein A., Corn B.W., Amir E., Goldvaser H. Efficacy and Safety of the Addition of Internal Mammary Irradiation to Standard Adjuvant Radiation in Early-Stage Breast Cancer: A Systematic Review and Meta-Analysis. Curr. Oncol. 2022;29:6657–6673. doi: 10.3390/curroncol29090523. PubMed DOI PMC

Giuliano A.E., Hunt K.K., Ballman K.V., Beitsch P.D., Whitworth P.W., Blumencranz P.W., Leitch A.M., Saha S., McCall L.M., Morrow M. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: A randomized clinical trial. JAMA. 2011;305:569–575. doi: 10.1001/jama.2011.90. PubMed DOI PMC

Lucci A., McCall L.M., Beitsch P.D., Whitworth P.W., Reintgen D.S., Blumencranz P.W., Leitch A.M., Saha S., Hunt K.K., Giuliano A.E., et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J. Clin. Oncol. 2007;25:3657–3663. doi: 10.1200/JCO.2006.07.4062. PubMed DOI

Jagsi R., Chadha M., Moni J., Ballman K., Laurie F., Buchholz T.A., Giuliano A., Haffty B.G. Radiation field design in the ACOSOG Z0011 (Alliance) Trial. J. Clin. Oncol. 2014;32:3600–3606. doi: 10.1200/JCO.2014.56.5838. PubMed DOI PMC

Giuliano A.E., McCall L., Beitsch P., Whitworth P.W., Blumencranz P., Leitch A.M., Saha S., Hunt K.K., Morrow M., Ballman K. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: The American College of Surgeons Oncology Group Z0011 randomized trial. Ann. Surg. 2010;252:426–433. doi: 10.1097/SLA.0b013e3181f08f32. PubMed DOI PMC

Galimberti V., Cole B.F., Zurrida S., Viale G., Luini A., Veronesi P., Baratella P., Chifu C., Sargenti M., Intra M., et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): A phase 3 randomised controlled trial. Lancet Oncol. 2013;14:297–305. doi: 10.1016/S1470-2045(13)70035-4. PubMed DOI PMC

Bartels S.A.L., Donker M., Poncet C., Sauvé N., Straver M.E., van de Velde C.J.H., Mansel R.E., Blanken C., Orzalesi L., Klinkenbijl J.H.G., et al. Radiotherapy or Surgery of the Axilla After a Positive Sentinel Node in Breast Cancer: 10-Year Results of the Randomized Controlled EORTC 10981-22023 AMAROS Trial. J. Clin. Oncol. 2023;41:2159–2165. doi: 10.1200/JCO.22.01565. PubMed DOI

Whelan T.J., Olivotto I.A., Parulekar W.R., Ackerman I., Chua B.H., Nabid A., Vallis K.A., White J.R., Rousseau P., Fortin A., et al. MA.20 Study Investigators. Regional Nodal Irradiation in Early-Stage Breast Cancer. N. Engl. J. Med. 2015;373:307–316. doi: 10.1056/NEJMoa1415340. PubMed DOI PMC

Taghian A. Adjuvant Radiation Therapy for Women with Newly Diagnosed, Non-Metastatic Breast Cancer In: UpToDate, Post TW (Ed), Wolters Kluwer. [(accessed on 8 September 2023)]. Available online: https://www.uptodate.com.

Recht A., Comen E.A., Fine R.E., Fleming G.F., Hardenbergh P.H., Ho A.Y., Hudis C.A., Hwang E.S., Kirshner J.J., Morrow M., et al. Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update. Pract. Radiat. Oncol. 2016;6:e219–e234. doi: 10.1016/j.prro.2016.08.009. PubMed DOI

Sittenfeld S.M.C., Zabor E.C., Hamilton S.N., Kuerer H.M., El-Tamer M., Naoum G.E., Truong P.T., Nichol A., Smith B.D., Woodward W.A., et al. A multi-institutional prediction model to estimate the risk of recurrence and mortality after mastectomy for T1-2N1 breast cancer. Cancer. 2022;128:3057–3066. doi: 10.1002/cncr.34352. PubMed DOI PMC