[an error occurred while processing this directive] | [an error occurred while processing this directive]
Standard whole breast tangential fields provide suboptimal axillary coverage and whole axilla radiation significantly increase lung dose in Chinese breast cancer patients treated with breast conservative surgery and sentinel node biopsy
Peng Ran, Wang Shulian, Ren Wenting, Wang Weihu, Fang Hui, Song Yongwen, Liu yueping, Zhang Ke, Miao Junjie, Li yexiong
Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College,Beijing 100021, China
Abstract Objective This study aimed to evaluate the coverage of the Level I and Ⅱ axilla with standard whole breast tangential fields (WBTF), and to what extent that whole axilla radiation could increase the dose to normal tissue with dosimetric study. Methods Fifteen consecutive left breast cancer patients treated with breast conservative surgery and sentinel node biopsy followed by whole breast radiation were studied. All had inverse IMRT plan using WBTF with prescription dose of 50 Gy to 95% of the planning target volume (PTV), defined as the whole breast. Level I and Ⅱ axilla was contoured according to the RTOG atlas. The dose distribution and coverage of Level I and Ⅱ axilla with WBTF was calculated. New plans delivering 50 Gy to 95% of the whole breast as well as Level I and Ⅱ axilla (WB+AX) were designed. The homogeneity index (HI=D5/D95) of the whole breast and conformal index (CI=VRI/TV, TV=target volume, VRI=Volume of the Reference Isodose) of the two plan, the dose to the heart, lung, left anterior descending coronary artery (LAD) and contralateral breast were compared between WBTF and WB+AX. Results The volume of Levels I and Ⅱ axilla was 71.7 and 26.5 cm2, respectively. With WBTF, the average dose to Levels I and Ⅱ axilla was 34.39 Gy and 21.90 Gy, respectively. The V50 and V40 were 22.57% and 49.86% for Level I axilla, 5.99% and 21.99% for Level Ⅱ axilla. WB+AX significantly increased the HI of the whole breast, and CI of the two plans and also significantly increased the dose to the ipsilateral lung and heart as compared with WBTF. There was no significant difference in mean dose to LAD between WBTF and WB+AX. Conclusions Standard whole breast tangential field doesn′t offer optimal coverage of Level I and Ⅱ axilla. Patients who had high-risk relapse of axilla should be planned to adequately cover the whole axilla if axilla dissection is not performed. Given the compromised dose homogeneity of the whole breast and the significantly increased lung dose with WB+AX plan, axilla dissection and axilla radiation should be weighted and discussed with patients for those who need axilla treatment.
Corresponding Authors:
Li Yexiong, Email:yexiong12@163.com;Wang Shulian,Email:wsl20040118@yahoo.com
Cite this article:
Peng Ran,Wang Shulian,Ren Wenting et al. Standard whole breast tangential fields provide suboptimal axillary coverage and whole axilla radiation significantly increase lung dose in Chinese breast cancer patients treated with breast conservative surgery and sentinel node biopsy[J]. Chinese Journal of Radiation Oncology, 2015, 24(2): 154-158.
Peng Ran,Wang Shulian,Ren Wenting et al. Standard whole breast tangential fields provide suboptimal axillary coverage and whole axilla radiation significantly increase lung dose in Chinese breast cancer patients treated with breast conservative surgery and sentinel node biopsy[J]. Chinese Journal of Radiation Oncology, 2015, 24(2): 154-158.
[1]Glechner A, Wockel A, Gartlehner G,et al. Sentinel lymph node dissection only versus complete axillary lymph node dissection in early invasive breast cancer:a systematic review and meta-analysis[J]. Eur J Cancer,2013,49(4):812-825.DOI:10.1016/j.ejca.2012.09.010. [2]Kell MR, Burke JP, Barry M, Morrow M. Outcome of axillary staging in early breast cancer:a meta-analysis[J]. Breast Cancer Res Treat,2010,120(2):441-447.DOI:10.1007/s10549-009-0705-6. [3]Giuliano AE, Hunt KK, Ballman KV,et al. Axillary dissection vs. no axillary dissection in women with invasive breast cancer and sentinel node metastasis:a randomized clinical trial[J].JAMA,2011,305(6):569-575.DOI:10.1001/jama.2011.90. [4]Louis-Sylvestre C, Clough K, Asselain B,et al. Axillary treatment in conservative management of operable breast cancer:dissection or radiotherapy Results of a randomized study with 15 years of follow-up[J]. J Clin Oncol,2004,22(1):97-101. [5]Hoebers FJ, Borger JH, Hart AA,et al. Primary axillary radiotherapy as axillary treatment in breast-conserving therapy for patients with breast carcinoma and clinically negative axillary lymph nodes[J]. Cancer,2000,88(7):1633-1642. [6]Donker M, van Tienhoven G, Straver ME,et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981－22023 AMAROS):a randomised, multicentre, open-label, phase 3 non-inferiority trial[J]. Lancet Oncol,2014,15(12):1303-1310.DOI:10.1016/S1470-2045(14)70460-7. [7]Schlembach PJ, Buchholz TA, Ross MI,et al. Relationship of sentinel and axillary level Ⅰ－Ⅱ lymph nodes to tangential fields used in breast irradiation[J]. Int J Radiat Oncol Biol Phys,2001,51(3):671-678. [8]Reznik J, Cicchetti MG, Degaspe B, Fitzgerald TJ. Analysis of axillary coverage during tangential radiation therapy to the breast[J]. Int J Radiat Oncol Biol Phys,2005,61(1):163-168. [9]Radiation therapy oncology group (RGOT). Breast cancer atlas for radiati on therapy planning:consensus definitions[DB/OL][2014-12-10]. http://wwwrtogorg/CoreLab/ ContouringAtlases/BreastCancerAtlasaspx. [10]Krasin M, McCall A, King S,et al. Evaluation of a standard breast tangent technique:a dose-volume analysis of tangential irradiation using three-dimensional tools[J]. Int J Radiat Oncol Biol Phys,2000,47(2):327-333. [11]Kataria T, Bisht SS, Gupta D,et al. Incidental radiation to axilla in early breast cancer treated with intensity modulated tangents and comparison with conventional and 3D conformal tangents[J]. Breast,2013,22(6):1125-1129.DOI:10.1016/j.breast.2013.07.054. [12]Nagar H, Zhou L, Biritz B,et al. Is there a tradeoff in using modified high tangent field radiation for treating an undissected node-positive axilla?[J].Clin Breast Cancer,2014,14(2):109-113.DOI:10.1016/j.clbc.2013.10.004. [13]Aristei C, Chionne F, Marsella AR,et al. Evaluation of level I and Ⅱ axillary nodes included in the standard breast tangential fields and calculation of the administered dose:results of a prospective study[J]. Int J Radiat Oncol Biol Phys,2001,51(1):69-73. [14]Ohashi T, Takeda A, Shigematsu N,et al. Dose distribution analysis of axillary lymph nodes for three-dimensional conformal radiotherapy with a field-in-field technique for breast cancer[J]. Int J Radiat Oncol Biol Phys,2009,73(1):80-87.DOI:10.1016/j.ijrobp.2008.04.003. [15]Reed DR, Lindsley SK, Mann GN,et al. Axillary lymph node dose with tangential breast irradiation[J]. Int J Radiat Oncol Biol Phys,2005,61(2):358-364. [16]Alco G, Igdem SI, Ercan T,et al. Coverage of axillary lymph nodes with high tangential fields in breast radiotherapy[J].Br J Radiol,2010,83(996):1072-1076.DOI:10.1259/bjr/25788274. [17]Orecchia R, Huscher A, Leonardi MC,et al. Irradiation with standard tangential breast fields in patients treated with conservative surgery and sentinel node biopsy:using a three-dimensional tool to evaluate the first level coverage of the axillary nodes[J]. Br J Radiol,2005,78(925):51-54. [18]Oetzel D, Schraube P, Hensley F,et al. Estimation of pneumonitis risk in three-dimensional treatment planning using dose-volume histogram analysis[J]. Int J Radiat Oncol Biol Phys,1995,33(2):455-460. [19]Graham MV, Purdy JA, Emami B,et al. Clinical dose-volume histogram analysis for pneumonitis after 3D treatment for non-small cell lung cancer (NSCLC)[J]. Int J Radiat Oncol Biol Phys,1999,45(2):323-329. [20]Dunst J. Cardiac risks associated with adjuvant radiotherapy for breast cancer[J]. Strahlenther Onkol,2013,189(7):590-591.DOI:10.1007/s00066-013-0363-9. [21]Hieken TJ, Boughey JC. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases:commentary on the IBCSG 23－01 Trial[J]. Gland Surg,2013,2(3):128-132.DOI:10.3978/j.issn.2227－684X.2013.07.04. [22]Jagsi R, Chadha M, Moni J,et al. Radiation field design in the ACOSOG Z0011(Alliance) trial[J]. J Clin Oncol,2014,32(32):3600-3606.DOI:10.1200/JCO.2014.56.5838. [23]Early breast cancer trialists′ collaborative group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival:an overview of the randomised trials[J]. Lancet,2005,365(9472):1687-1717.
2015, Vol. 24 
