title: Role of Internal Mammary Node Radiation as a Part of Modern Breast Cancer Radiation Therapy: A Systematic Review.
abstract: Despite data from multiple randomized trials, the role of internal mammary lymph node irradiation as a part of regional nodal irradiation (IMLN RT-RNI) remains unanswered. Recent noteworthy data and modern RT techniques might identify a subset of patients who will benefit from IMLN RT-RNI, lending insight into the balance between improved outcomes and acceptable toxicity. We evaluated the current role of IMLN RT-RNI by analyzing randomized, prospective, and retrospective data.
  
  
  
  In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a review of the published data was performed using PubMed to evaluate published studies from 1994 to 2015. The information evaluated included the number of patients, follow-up period, technical aspects of RT, and outcomes (clinical outcomes, complications/toxicity).
  
  
  
  We included 16 studies (4 randomized, 4 nonrandomized, 7 retrospective, and 1 meta-analysis). Although older randomized trials failed to show differences in clinical outcomes or toxicity with IMLN RT-RNI, recent randomized data suggest the potential for improved outcomes, including overall survival, with IMLN RT-RNI. Furthermore, nonrandomized data have suggested a potential benefit for central tumors with IMLN RT-RNI. Although recent data have suggested a potential increase in pulmonary complications with IMLN RT-RNI with the use of advanced radiation techniques, toxicity rates remain low with limited cardiac toxicity data available.
  
  
  
  Increasing data from recent randomized trials support the use of IMLN RT-RNI. IMLN RT can be considered based on the inclusion of IMLN RT as a part of RNI in recent trials and the inclusion criteria from IMLN RT-RNI trials and for patients with central or medial tumors and axillary disease.
authors.affiliation: Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska.
authors.forename: Vivek
authors.initials: V
authors.lastname: Verma
authors.affiliation: Michigan Healthcare Professionals/21st Century Oncology, Farmington Hills, Michigan.
authors.forename: Frank
authors.initials: F
authors.lastname: Vicini
authors.affiliation: Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Rahul D
authors.initials: RD
authors.lastname: Tendulkar
authors.affiliation: Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School and the Cancer Institute of New Jersey, New Brunswick, New Jersey.
authors.forename: Atif J
authors.initials: AJ
authors.lastname: Khan
authors.affiliation: Department of Radiation Oncology, Ohio State University, Columbus, Ohio.
authors.forename: Jessica
authors.initials: J
authors.lastname: Wobb
authors.affiliation: 21st Century Oncology, Myrtle Beach, South Carolina.
authors.forename: Sophia
authors.initials: S
authors.lastname: Edwards-Bennett
authors.affiliation: Department of Radiation Oncology, Summa Health System, Akron, Ohio.
authors.forename: Anand
authors.initials: A
authors.lastname: Desai
authors.affiliation: Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: csshah27@hotmail.com.
authors.forename: Chirag
authors.initials: C
authors.lastname: Shah
mesh_terms: D001943:Breast Neoplasms / Q000737:chemistry / Q000401:mortality / Q000532:radiotherapy*; D005260:Female; D006801:Humans; D008198:Lymph Nodes / Q000528:radiation effects*; D011446:Prospective Studies; D011879:Radiotherapy Dosage; D016032:Randomized Controlled Trials as Topic; D011960:Receptors, Estrogen / Q000032:analysis; D012189:Retrospective Studies
chemical_list: D011960:Receptors, Estrogen