title: Radiation field design in the ACOSOG Z0011 (Alliance) Trial.
abstract: OBJECTIVE
  ACOSOG Z0011 established that axillary lymph node dissection (ALND) is unnecessary in patients with breast cancer with one to two positive sentinel lymph nodes (SLNs) who undergo lumpectomy, radiotherapy (RT), and systemic therapy. We sought to ascertain RT coverage of the regional nodes in that trial.
  
  
  METHODS
  We evaluated case report forms completed 18 months after enrollment. From 2012 to 2013, we collected all available detailed RT records for central review.
  
  
  RESULTS
  Among 605 patients with completed case report forms, 89% received whole-breast RT. Of these, 89 (15%) were recorded as also receiving treatment to the supraclavicular region. Detailed RT records were obtained for 228 patients, of whom 185 (81.1%) received tangent-only treatment. Among 142 with sufficient records to evaluate tangent height, high tangents (cranial tangent border ≤ 2 cm from humeral head) were used in 50% of patients (33 of 66) randomly assigned to ALND and 52.6% (40 of 76) randomly assigned to SLND. Of the 228 patients with records reviewed, 43 (18.9%) received directed regional nodal RT using ≥ three fields: 22 in the ALND arm and 21 in the SLND arm. Those receiving directed nodal RT had greater nodal involvement (P < .001) than those who did not. Overall, there was no significant difference between treatment arms in the use of protocol-prohibited nodal fields.
  
  
  CONCLUSIONS
  Most patients treated in Z0011 received tangential RT alone, and some received no RT at all. Some patients received directed nodal irradiation via a third field. Further research is necessary to determine the optimal RT approach in patients with low-volume axillary disease treated with SLND alone.
authors.affiliation: Reshma Jagsi, University of Michigan, Ann Arbor, MI; Manjeet Chadha, Beth Israel Medical Center, New York, NY; Janaki Moni, University of Massachusetts Medical School, Worcester, MA; Janaki Moni and Fran Laurie, Quality Assurance Review Center, Lincoln, RI; Karla Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Thomas A. Buchholz, MD Anderson Cancer Center, Houston, TX; Armando Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; and Bruce G. Haffty, Rutgers-Cancer Institute of New Jersey, New Brunswick, NJ. rjagsi@med.umich.edu.
authors.forename: Reshma
authors.initials: R
authors.lastname: Jagsi
authors.affiliation: Reshma Jagsi, University of Michigan, Ann Arbor, MI; Manjeet Chadha, Beth Israel Medical Center, New York, NY; Janaki Moni, University of Massachusetts Medical School, Worcester, MA; Janaki Moni and Fran Laurie, Quality Assurance Review Center, Lincoln, RI; Karla Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Thomas A. Buchholz, MD Anderson Cancer Center, Houston, TX; Armando Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; and Bruce G. Haffty, Rutgers-Cancer Institute of New Jersey, New Brunswick, NJ.
authors.forename: Manjeet
authors.initials: M
authors.lastname: Chadha
authors.affiliation: Reshma Jagsi, University of Michigan, Ann Arbor, MI; Manjeet Chadha, Beth Israel Medical Center, New York, NY; Janaki Moni, University of Massachusetts Medical School, Worcester, MA; Janaki Moni and Fran Laurie, Quality Assurance Review Center, Lincoln, RI; Karla Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Thomas A. Buchholz, MD Anderson Cancer Center, Houston, TX; Armando Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; and Bruce G. Haffty, Rutgers-Cancer Institute of New Jersey, New Brunswick, NJ.
authors.forename: Janaki
authors.initials: J
authors.lastname: Moni
authors.affiliation: Reshma Jagsi, University of Michigan, Ann Arbor, MI; Manjeet Chadha, Beth Israel Medical Center, New York, NY; Janaki Moni, University of Massachusetts Medical School, Worcester, MA; Janaki Moni and Fran Laurie, Quality Assurance Review Center, Lincoln, RI; Karla Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Thomas A. Buchholz, MD Anderson Cancer Center, Houston, TX; Armando Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; and Bruce G. Haffty, Rutgers-Cancer Institute of New Jersey, New Brunswick, NJ.
authors.forename: Karla
authors.initials: K
authors.lastname: Ballman
authors.affiliation: Reshma Jagsi, University of Michigan, Ann Arbor, MI; Manjeet Chadha, Beth Israel Medical Center, New York, NY; Janaki Moni, University of Massachusetts Medical School, Worcester, MA; Janaki Moni and Fran Laurie, Quality Assurance Review Center, Lincoln, RI; Karla Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Thomas A. Buchholz, MD Anderson Cancer Center, Houston, TX; Armando Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; and Bruce G. Haffty, Rutgers-Cancer Institute of New Jersey, New Brunswick, NJ.
authors.forename: Fran
authors.initials: F
authors.lastname: Laurie
authors.affiliation: Reshma Jagsi, University of Michigan, Ann Arbor, MI; Manjeet Chadha, Beth Israel Medical Center, New York, NY; Janaki Moni, University of Massachusetts Medical School, Worcester, MA; Janaki Moni and Fran Laurie, Quality Assurance Review Center, Lincoln, RI; Karla Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Thomas A. Buchholz, MD Anderson Cancer Center, Houston, TX; Armando Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; and Bruce G. Haffty, Rutgers-Cancer Institute of New Jersey, New Brunswick, NJ.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
authors.affiliation: Reshma Jagsi, University of Michigan, Ann Arbor, MI; Manjeet Chadha, Beth Israel Medical Center, New York, NY; Janaki Moni, University of Massachusetts Medical School, Worcester, MA; Janaki Moni and Fran Laurie, Quality Assurance Review Center, Lincoln, RI; Karla Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Thomas A. Buchholz, MD Anderson Cancer Center, Houston, TX; Armando Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; and Bruce G. Haffty, Rutgers-Cancer Institute of New Jersey, New Brunswick, NJ.
authors.forename: Armando
authors.initials: A
authors.lastname: Giuliano
authors.affiliation: Reshma Jagsi, University of Michigan, Ann Arbor, MI; Manjeet Chadha, Beth Israel Medical Center, New York, NY; Janaki Moni, University of Massachusetts Medical School, Worcester, MA; Janaki Moni and Fran Laurie, Quality Assurance Review Center, Lincoln, RI; Karla Ballman, Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN; Thomas A. Buchholz, MD Anderson Cancer Center, Houston, TX; Armando Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; and Bruce G. Haffty, Rutgers-Cancer Institute of New Jersey, New Brunswick, NJ.
authors.forename: Bruce G
authors.initials: BG
authors.lastname: Haffty
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001365:Axilla / Q000473:pathology; D001940:Breast / Q000473:pathology / Q000528:radiation effects*; D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000628:therapy; D005260:Female; D006801:Humans; D016015:Logistic Models; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D015412:Mastectomy, Segmental; D008875:Middle Aged; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care / Q000379:methods* / Q000706:statistics & numerical data; D011878:Radiotherapy / Q000379:methods* / Q000706:statistics & numerical data; D016032:Randomized Controlled Trials as Topic; D021701:Sentinel Lymph Node Biopsy; D055815:Young Adult