There is a role for radiation therapy in the management of the axilla

The results of more recent randomized trials demonstrate that after mastectomy postoperative locoregional therapy improves survival in women with axillary node positive breast cancer who also received adjuvant systemic therapy. The EBCTCG metanalysis showed a significant reduction in the risk of breast cancer mortality also in the case of patients who received breast conserving surgery, both for disease-free and overall survival. Such results suggest that local-regional recurrence is a potential source of distant dissemination of disease leading to a reduction in survival and emphasize the importance of optimizing local-regional control. Based on these data, patients with 4 or more N+, > 20% involved axillary nodes, lymphovascular space invasion, gross extranodal extension are at increased risk failure and should receive radiation therapy to these regions in addition to the chest wall. With respects to toxicity, today special techniques, such as 3D-CRT and/or IMRT are considered a routine treatment in patients with breast cancer. The use of the CT simulation and new algorithms for 3D dose calculation and delivery has made possible to sculpt precisely the dose to the target volumes of almost any shape. In this view the quantitative dose volume information of heart and lungs becomes critical for the management of breast cancer. The heart volume can be delineated and totally spared, optimizing the beam angles, in nearly half of the left breast treatment and significantly reduced in the others. Also other topics should be faced, as the recent data on patients with 1 to 3 positive node and mammary chain risk. A very interesting topic is related to patients with axillary positive sentinel node biopsy. Recent data coming from the Amaros study have shown no difference in local failure at the axilla using radiation therapy alone or axillary dissection. Also very important was the decreased rate of lymphedema in patients treated with radiotherapy when compared with surgical dissection. These data open a possible new scenario in the modern era of breast cancer management and innovative and well designed studies are needed to update the future role of adjuvant locoregional irradiation