title: Patterns of practice of regional nodal irradiation in breast cancer: results of the European Organization for Research and Treatment of Cancer (EORTC) NOdal Radiotherapy (NORA) survey.
abstract: BACKGROUND
  Predicting outcome of breast cancer (BC) patients based on sentinel lymph node (SLN) status without axillary lymph node dissection (ALND) is an area of uncertainty. It influences the decision-making for regional nodal irradiation (RNI). The aim of the NORA (NOdal RAdiotherapy) survey was to examine the patterns of RNI.
  
  
  METHODS
  A web-questionnaire, including several clinical scenarios, was distributed to 88 EORTC-affiliated centers. Responses were received between July 2013 and January 2014.
  
  
  RESULTS
  A total of 84 responses were analyzed. While three-dimensional (3D) radiotherapy (RT) planning is carried out in 81 (96%) centers, nodal areas are delineated in only 51 (61%) centers. Only 14 (17%) centers routinely link internal mammary chain (IMC) and supraclavicular node (SCN) RT indications. In patients undergoing total mastectomy (TM) with ALND, SCN-RT is recommend by 5 (6%), 53 (63%) and 51 (61%) centers for patients with pN0(i+), pN(mi) and pN1, respectively. Extra-capsular extension (ECE) is the main factor influencing decision-making RNI after breast conserving surgery (BCS) and TM. After primary systemic therapy (PST), 49 (58%) centers take into account nodal fibrotic changes in ypN0 patients for RNI indications. In ypN0 patients with inner/central tumors, 23 (27%) centers indicate SCN-RT and IMC-RT. In ypN1 patients, SCN-RT is delivered by less than half of the centers in patients with ypN(i+) and ypN(mi). Twenty-one (25%) of the centers recommend ALN-RT in patients with ypN(mi) or 1-2N+ after ALND. Seventy-five (90%) centers state that age is not considered a limiting factor for RNI.
  
  
  CONCLUSIONS
  The NORA survey is unique in evaluating the impact of SLNB/ALND status on adjuvant RNI decision-making and volumes after BCS/TM with or without PST. ALN-RT is often indicated in pN1 patients, particularly in the case of ECE. Besides the ongoing NSABP-B51/RTOG and ALLIANCE trials, NORA could help to design future specific RNI trials in the SLNB era without ALND in patients receiving or not PST.
authors.affiliation: APHP, GH Henri Mondor Breast Center, Radiation Oncology Department, University Paris-East Creteil, France Association of Radiotherapy and Oncology of the Mediterranean Area (www.aromecancer.org) yazid.belkacemi@hmn.aphp.fr.
authors.forename: Y
authors.initials: Y
authors.lastname: Belkacemi
authors.affiliation: Association of Radiotherapy and Oncology of the Mediterranean Area (www.aromecancer.org) Department of Radiation Oncology, Rambam, Haifa, Israel.
authors.forename: O
authors.initials: O
authors.lastname: Kaidar-Person
authors.affiliation: Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
authors.forename: P
authors.initials: P
authors.lastname: Poortmans
authors.affiliation: Association of Radiotherapy and Oncology of the Mediterranean Area (www.aromecancer.org) Department of Radiation Oncology, CHUV, Lausanne.
authors.forename: M
authors.initials: M
authors.lastname: Ozsahin
authors.affiliation: Radiation Oncology Department, Oncology Institute of Southern Switzerland, Switzerland.
authors.forename: M-C
authors.initials: MC
authors.lastname: Valli
authors.affiliation: Department of Radiotherapy, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
authors.forename: N
authors.initials: N
authors.lastname: Russell
authors.affiliation: Edinburgh Cancer Centre, University of Edinburgh, Edinburgh, UK.
authors.forename: I
authors.initials: I
authors.lastname: Kunkler
authors.affiliation: EORTC Breast Working Party of the Radiation Oncology Group (ROG), EORTC, Brussels, Belgium.
authors.forename: J
authors.initials: J
authors.lastname: Hermans
authors.affiliation: Association of Radiotherapy and Oncology of the Mediterranean Area (www.aromecancer.org) Department of Radiation Oncology, Rambam, Haifa, Israel Italian Hospital, Haifa, Israel.
authors.forename: A
authors.initials: A
authors.lastname: Kuten
authors.affiliation: Department of Radiation Oncology, Academisch Medisch Centrum, Amsterdam.
authors.forename: G
authors.initials: G
authors.lastname: van Tienhoven
authors.affiliation: Institute for Radiation Oncology Arnhem (ARTI), Arnhem, The Netherlands.
authors.forename: H
authors.initials: H
authors.lastname: Westenberg
mesh_terms: D001943:Breast Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000532:radiotherapy*; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D015182:Lymphatic Irradiation / Q000379:methods / Q000592:standards*; D017410:Practice Guidelines as Topic / Q000592:standards*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
keywords: axillary dissection; breast cancer; internal mammary chain; radiotherapy; sentinel lymph node; supraclavicular node