| Objective: To analyze retrospectively the prognostic factors for T1-2 breast cancer patients with one to three positive nodes after modified radical postmastectomy.Methods: Between January 2001 and September 2006, there were 565 patients with T1-2 breast cancer and one to three positive nodes who had undergone modified radical mastectomy at the Fourth Hospital, Hebei Medical University, accounting for 17.82% (565/3170) for all breast cancer patients in the same period. The criteria for inclusion in this study were as follows: (1) female; (2) the number of dissected axillary lymph nodes was 10 or more; (3) the ratio of positive nodes was less 20%; (4) stage T1 or T2 in AJCC staging system with one to three positive nodes; (5) being treated with modified radical mastectomy and no neoadjuvant chemotherapy before modified radical mastectomy. There were 434 patients entered into this retrospective study. There were 84 patients with T1 disease and 350 patients with T2. There were 267, 128, and 39 patients with one, two and three positive nodes respectively. Of the 434 patients, 196 patients received postoperative radiotherapy and 238 patients didn't. The ipsilateral chest wall and supraclavicular fossa was irradiated with a dose of 46-50 Gy in 23-25 fractions. The 3- and 5-year overall survival rates (OS), local control rates (LC) and disease-free survival rates (DFS) were estimated, univariate and multivariate analysis were done for the prognostic factors.Results: (1) For all patients in this study, The median follow-up time was 44.8 months (range, 16.1-100.2). The median age was 48 years (range, 23-80). The median number of dissected nodes was 14 (range, 10-37). The 3- and 5-year OS, LC and DFS were 94.7% and 85.7%, 96.5% and 95.6%, 89.3% and 82.3% respectively. (2) The univariate analysis: OS: The 5-year OS in the patients with age younger than 35 years , between 36 years and 50 years , and older than 51 years were 81.5%, 91.4%, and 78.3%, respectively, P=0.008. For the patients who received postoperative radiotherapy (PMRT) or not, the 5-year OS were 82.4% and 89.2%, respectively, P=0.039. LC: The 5-year LC in the patients who received PMRT or not were 93.6% and 97.7%, respectively, P=0.041. DFS: The 5-year DFS in the patients with age younger than 35 years , between 36 years and 50 years , and older than 51 years were 73.3%, 89.0%, and 73.9%, respectively, P<0.001. The 5-year DFS in the patients with one, two, and three positive nodes were 86.6%, 76.2%, and 74.1%, respectively, P=0.037. The 5-year DFS in the patients who received PMRT or not were 78.5% and 86.1%, respectively, p=0.047. (3) In multivariate analysis, age(P=0.011) was an independent predictor for OS; postoperative radiotherapy (P=0.020)and the number of positive lymph nodes (P=0.040)were independent prognostic factors for LC; the number of positive lymph nodes (P=0.013), age (P=0.002)and postoperative radiotherapy(P=0.039)were prognostic factors of DFS. (4) Age younger than 35 years, non-postoperative radiotherapy and three positive nodes were associated with poor OS, LC and DFS. When a scoring system was established according to the three prognostic factors, we found out patients with different scores have different prognosis in LC and DFS. For patients with zero, one score, and two scores or more, the 5-year overall survival rates were 89.7% , 84.7%, and 82.2%( P=0.117). the 5-year local control rates were 98.4%, 95.1%, and 82.4% (P=0.013). The 5-year disease-free survival rates were 87.1%, 82.1%, and 53.5% (P=0.007). (5) Of the 434 patients, 17 developed LRR. In these 17 patients, 10 developed recurrence in the chest wall, 8 in the supraclavicular fossa, 1 had multiple sites of recurrence. There was no patient experienced recurrence in the axilla and internal mammary node. In the 434 patients, 51 developed distant metastases. The sites of distant metastases included the lung, bone, liver, brain, mediastinum, pleura, ovary, and abdominal cavity. Of these 51 patients, 28 (54.9%) occurred in the lung, 28 (54.9%) in the bone, 10 (19.6%) in the liver and 4 (7.8%) in the brain. (6) Seven patients developed recurrence in the chest wall and 7 patients in the supraclavicular fossa for the patients without radiotherapy. Three patients developed recurrence in the chest wall for the patients with radiotherapy. The LRR rates were 5.9% vs 1.5% , respectively, there was a significant difference between the two groups (P=0.020). There was none patient experienced recurrence in the axilla and internal mammary node for two groups. Thirty-one patients developed distant metastases for the patients without radiotherapy and twenty patients for the patients with radiotherapy. The distant metastases rates were 13.0% vs 10.2%, respectively (P=0.364).Conclusions: 1. Postoperative radiotherapy confers a better OS rate, LC rate and DFS rate in T1-2 breast cancer patients with one to three positive nodes after modified radical postmastectomy. 2. The prognosis of patients with age younger than 35 years and older than 51 years was similar, while the patients between 36 years and 50 years had better prognosis. 3. Age younger than 35 years, non-postoperative radiotherapy and three positive nodes were associated with poor prognosis. Patients with two risk factors or more had higher LRR and worse survival than patients with no or one risk factor. An optional treatment method is suggested to be selected for an individual patient according to its clinicopathologic characteristics. 4. Analysis of loco-regional failure after mastectomy has shown the chest wall and supraclavicular fossa to be the most common site of recurrence. Postmastectomy radiation volumes should include the chest wall and supraclavicular lymph nodes.
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