Effect of distribution of ipsilateral supraclavicular lymph node metastasis on target volume delineation in breast cancer:an analysis of 55 patients
Jing Hao*, Wang Shulian, LI Jing, Xue Mei, Xiong Zukun, Jin Jing, Wang Weihu, Song Yongwen, Liu Yueping, Ren Hua, Fang Hui, Liu Xinfan, Yu Zihao, Li Yexiong
*Department of Radiation Oncology, Department of Radiology, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
Abstract：Objective To retrospectively investigate the effect of the distribution of supraclavicular lymph node metastasis (LNM) on clinical target volume (CTV) delineation in radiotherapy for breast cancer. Methods Fifty-five patients with breast cancer who underwent helical computed tomography (CT) scan and were diagnosed with supraclavicular LNM were enrolled as subjects and their CT images were collected. The metastatic lymph nodes in 55 patients were recreated proportionally on the CT images of a standard patient with breast cancer with reference to normal anatomy in the supraclavicular area. The relationship between the distribution of supraclavicular LNM and the CTV recommended by the Radiation Therapy Oncology Group (RTOG) and other literature was analyzed. Results Sixty percent of LNM were pathologically confirmed and distant metastasis occurred in 64% of supraclavicular LNM. Ninety-one percent and eighty-two percent of patients had centers of LNM in the internal and external regions of the supraclavicular area, respectively. Sixty-six percent of patients had LNM located in the subclavian venous confluence. The CTV recommended by literature covered the centers of all LNM in only 20%-42% of patients, while the CTV recommended by the RTOG guide covered the centers of all LNM in only 26% of patients. Seventy-one percent and sixty-six percent of patients had the centers surpassing the lateral and posterior edges of the CTV, respectively. According to the distribution of LNM mentioned above, we expanded the CTV in the supraclavicular area by extending the lateral and posterior edges to the natural anatomical barriers and the new CTV covered the centers of all LNM in up to 82% of patients. Conclusions The locations of supraclavicular LNM surpass the range, particularly the lateral and posterior edges, of the CTV defined by the RTOG guide. Therefore, the CTV in the supraclavicular area needs to be extended to cover those regions mentioned above.
Jing Hao*,Wang Shulian,LI Jing et al. Effect of distribution of ipsilateral supraclavicular lymph node metastasis on target volume delineation in breast cancer:an analysis of 55 patients[J]. Chinese Journal of Radiation Oncology, 2015, 24(3): 256-261.
[1] Fisher B, Perera F, Cooke A, et al. Long-term follow-up of axillary node-positive breast cancer patients receiving adjuvant systemic therapy alone:Patterns of recurrence[J]. Int J Radiat Oncol Biol Phys,1997,38(3):541-550. [2] Yu JI, Park W, Huh SJ. Determining which patients require irradiation of the supraclavicular nodal area after surgery for N1 breast cancer[J]. Int J Radiat Oncol Biol Phys,2010,78(4):1135-1141.DOI:10.1016/j.ijrobp.2009.09.037. [3] Grills IS, Kestin LL, Goldstein N. Risk factors for regional nodal failure after breast conserving therapy:regional nodal irradiation reduces rate of axillary failure in patients with four or more positive lymph nodes[J]. Int J Radiat Oncol Biol Phys,2003,56(3):658-670. [4] Yu JI, Park W, Shin KH. Prophylactic supraclavicular radiotherapy after surgery in high-risk N1 breast cancer[J]. Oncology,2013,85(1):14-20.DOI:10.1159/000352002. [5] Atean I, Pointreau Y, Ouldamer L, et al. A simplified CT-based definition of the supraclavicular and infraclavicular nodal volumes in breast cancer[J]. Cancer Radiothérapie,2013,17(1):39-43.DOI:10.1016/j.canrad.2012.11.007. [6] Dijkema I, Hofman P, Raaijmakers C, et al. Loco-regional conformal radiotherapy of the breast:delineation of the regional lymph node clinical target volumes in treatment position[J]. Radiother Oncol,2004,71(3):287-295. [7] Madu C, Quint D, Normolle D, et al. Definition of the supraclavicular and infraclavicular nodes:implications for three-dimensional CT-based conformal radiation therapy[J]. Radiology,2001,221(2):333-339. [8] Breast cancer atlas for radiation therapy planning:consensus defin itions. Radiation therapy oncology group (RTOG) breast cancer contouring atlas[DB/OL][2014-07-29].http://www.rtog.org. [9] Sautter B, Sedlmayer F, Budach W, et al. DEGRO practical guidelines:Radiotherapy of breast cancer Ⅲ－radiotherapy of the lymphatic pathways[J]. Strahlenther Onkol,2014,190(4):342-351.DOI:10.1007/s00066-013-0543-7. [10] Ragaz J, Olivotto IA, Spinelli JJ, et al. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy:20-year results of the British Columbia randomized trial[J]. J Natl Cancer Inst,2005,97(2):116-126. [11] Nielsen HM, Overgaard J, Grau C, et al. Audit of the radiotherapy in the DBCG 82 b&c trials-a validation study of the 1538 patients randomized to postmastectomy radiotherapy[J]. Radiother Oncol,2005,76(3):285-292. [12] Caudrelier JM, Morgan SC, Montgomery L, et al. Helical tomotherapy for locoregional irradiation including the internal mammary chain in left-sided breast cancer:dosimetric evaluation[J]. Radiother Oncol,2009,90(1):99-105.DOI:10.1016/j.radonc.2008.09.028. [13] Perez C, Taylor M. Breast:stage tis, T1, and T2 tumors in principles and practice of radiation oncology[M].3rd ed. New York:Lippincott-Raven,1998. [14] Bentel GC, Marks LB, Hardenbergh PH, et al. Variability of the depth of supraclavicular and axillary lymph nodes in patients with breast cancer:is a posterior axillary boost field necessary?[J]. Int J Radiat Oncol Biol Phys,2000,47(3):755-758. [15] Klages HT, Szafinski F, Makoski HB. Variation in"supraclavicular" lymph node depth is partly determined by treatment position[J]. Strahlenther Onkol,2000,176(7):315-318. [16] Kirova YM, Servois V, Campana FO, et al. CT-scan based localization of the internal mammary chain and supraclavicular nodes for breast cancer radiation therapy planning[J].Radiother Oncol,2006,79(3):310-315. [17] Yang B, Wei XD, Yu TZ, et al. Dosimetric evaluation of integrated IMRT treatment of the chestwall and supraclavicular region for breast cancer after modified radical mastectomy[J].Med Dosim,2014,39(2):185-189.DOI:10.1016/j.meddos.2013.12.008. [18] Liengsawangwong R, Yu TK, Sun TL, et al. Treatment optimization using computed tomography-delineated targets should be used for supraclavicular irradiation for breast cancer[J]. Int J Radiat Oncol Biol Phys,2007,69(3):711-715. [19] Kirova YM, Pena PC, Dendale R, et al. Simplified rules for everyday delineation of lymph node areas for breast cancer radiotherapy[J]. Br J Radiol,2010,83(992):683-686.DOI:10.1259/bjr/28834220. [20] Reed VK, Cavalcanti JL, Strom EA, et al. Risk of subclinical micrometastatic disease in the supraclavicular nodal bed according to the anatomic distribution in patients with advanced breast cancer[J]. Int J Radiat Oncol Biol Phys,2008,71(2):435-440.DOI:10.1016/j.ijrobp.2007.10.025. [21] Chen J, Ma JL, Zhang SJ, et al. Distribution of involved regional lymph nodes in recurrent and locally advanced breast cancer and its impact on target definition[J]. Chin J Radiat Oncol,2011,20(2):123-127.DOI:10.3760/cma.j.issn.1004-4221.2011.02.012. [22] Wang J, Kudchadker R, Choi S, et al. Local recurrence map to guide target volume delineation after radical prostatectomy[J]. Prac Radiat Oncol,2014;46(6):239-246.DOI:10.1016/j.prro.2014.02.007. [23] Fan Y, Xu B, Liao Y, et al. A retrospective study of metachronous and synchronous ipsilateral supraclavicular lymph node metastases in breast cancer patients[J].Breast,2010,19(5):365-369.DOI:10.1016/j.breast.2010.03.022.
2015, Vol. 24 
