1. Healthcare

Correspondence
only part of the axilla and the shoulder,4
and the full irradiation of level I–II nodes
can need modified tangential beams
including, at least in some patients,
an increased portion of shoulder
structures in the high dose volume.
We would be grateful if Donker
and colleagues could clarify any
modifications of standard irradiation
techniques applied in the trial, and
could clarify the dose delivered to
the shoulder structures by such
modifications.
Since
different
irradiation techniques5 might be
applied to spare the shoulder, we hope
that an analysis of the doses delivered
in the AMAROS trial and of the related
morbidity could be provided. Such
analysis might exclude any additional
shoulder morbidity due to axillary
radiotherapy, or vice versa, and it might
reveal an effect of axillary irradiation
and thus justify the investigation of
new irradiation techniques capable of
adequate shoulder sparing.
We declare no competing interests.
*Paolo Farace, Maria Assunta Deidda,
Maurizio Amichetti
[email protected]
Proton Therapy Unit, Azienda Provinciale per i
Servizi Sanitari, Trento, Italy (PF, MA); and
Radiotherapy Department, Regional Oncologic
Hospital, Cagliari, Italy (MAD)
1
2
3
4
e54
Donker M, van Tisenhoven G, Straver ME, et al.
Radiotherapy or surgery of the axilla after a
positive sentinel node in breast cancer
(EORTC 10981–22023 AMAROS): a
randomised, multicentre, open-label, phase 3
non-inferiority trial. Lancet Oncol 2014;
15: 1303–10.
Wernicke AG, Shamis M, Sidhu KK, et al.
Complication rates in patients with negative
axillary nodes 10 years after local breast
radiotherapy after either sentinel lymph node
dissection or axillary clearance. Am J Clin Oncol
2013; 36: 12–19.
Nesvold IL, Fosså SD, Holm I, et al.
Arm/shoulder problems in breast cancer
survivors are associated with reduced health
and poorer physical quality of life. Acta Oncol
2010; 49: 347–53.
Farace P, Deidda MA, Iamundo I, et al.
Bi-tangential hybrid IMRT for sparing the
shoulder in whole breast irradiation.
Strahlenther Onkol 2013; 189: 967–70.
5
MacDonald SM, Patel SA, Hickey S, et al.
Proton therapy for breast cancer after
mastectomy: early outcomes of a prospective
clinical trial. Int J Radiat Oncol Biol Phys 2013;
86: 484–90.
Authors’ reply
We appreciate Lorenzo Livi, Icro
Meattini, and Paolo Farace and
colleagues’ comments on our
AMAROS study1 which examined
whether axillary radiation therapy can
replace axillary lymph node dissection
(ALND) and whether axillary
structures could be better spared
using axillary radiotherapy.
We agree with Livi and Meattini that
there are patients in the AMAROS trial
for whom axillary treatment might
have been withheld completely.
However, although nomograms
might predict residual nodal disease in
patients with a positive sentinel node,
they do not predict recurrences or the
necessity of axillary treatment. The
AMAROS trial,1 the ACOSOG Z0011
trial,2 and the IBCSG-23 trial3 show
that decreasing axillary treatment
does not reduce axillary recurrences
or survival. Hence, there is an ongoing
trend towards less (toxic) treatment.
The AMAROS results show that
axillary radiotherapy instead of ALND
results in an equally low occurrence of
axillary recurrence, with substantially
less lymphoedema of the ipsilateral
arm.
We agree with Farace and colleagues
that axillary radiotherapy could induce
toxicity, particularly shoulder function
impairment. In the AMAROS trial,
we observed a temporary difference
in shoulder function impairment at
1-year follow-up in favour of patients
who underwent ALND, although
this difference was not significant.
However, in both groups, shoulder
function improved in the next 4 years
and there was no difference at 5-year
follow up.1 We intend to address the
toxicity of both ALND and axillary
radiotherapy in more detail soon.
Farace and colleagues are right:
irradiation of the shoulder muscles can
be diminished with modern axillary
radiotherapy techniques. Because the
AMAROS protocol was written and
initiated in the late 1990s, a modified
McWhirter technique was used to
irradiate the axilla, including the
periclavicular area. Nowadays, more
sophisticated techniques are generally
used whereby the axillary levels are
delineated and irradiated according
to planning target volume. We
expect that these and other axillary
radiotherapy techniques will further
diminish the already low incidence of
shoulder toxicity. The AMAROS trial
will be updated at 10-year follow-up.
We declare no competing interests.
*Mila Donker, Leen Slaets,
Emiel J Rutgers, Geertjan van Tienhoven
[email protected]
Department of Surgical Oncology, Netherlands
Cancer InsƟtute, Amsterdam, Netherlands (MD);
European Organisation for Research and Treatment
of Cancer, Brussels, Belgium (LS); Department of
Surgical Oncology, Netherlands Cancer Institute,
Amsterdam, the Netherlands (EJR), and Department
of Radiation Oncology, Academic Medical Centre,
Amsterdam, the Netherlands (GvT)
1
2
3
Donker M, van Tienhoven G, Straver ME, et al.
Radiotherapy or surgery of the axilla after a
positive sentinel node in breast cancer
(EORTC 10981-22023 AMAROS):
a randomised, multicentre, open-label, phase 3
non-inferiority trial. Lancet Oncol 2014;
15: 1303–10.
Giuliano AE, Hunt KK, Ballman KV, et al.
Axillary dissection versus no axillary dissection
in women with invasive breast cancer and
sentinel node metastasis: a randomized clinical
trial. JAMA 2011; 305: 569–75.
Galimberti V, Cole BF, Zurrida S, 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.
www.thelancet.com/oncology Vol 16 February 2015