Prone positioning for whole-breast irradiation (WBI) reduces dose to organs at risk, but reduces set-up speed, precision, and comfort. We aimed to improve these problems by placing patients in prone crawl position on a newly developed crawl couch (CrC). A group of 10 right-sided breast cancer patients requiring WBI were randomized in this cross-over trial, comparing the CrC to a standard prone breastboard (BB). Laterolateral (LL), craniocaudal (CC) and anterioposterior (AP) set-up errors were evaluated with cone beam CT. Comfort, preference and set-up time (SUT) were assessed. Forty left and right-sided breast cancer patients served as a validation group. For BB versus CrC, AP, LL and CC mean patient shifts were − 0.8 ± 2.8, 0.2 ± 11.7 and − 0.6 ± 4.4 versus − 0.2 ± 3.3, − 0.8 ± 2.5 and − 1.9 ± 5.7 mm. LL shift spread was reduced significantly. Nine out of 10 patients preferred the CrC. SUT did not differ significantly. The validation group had mean patient shifts of 1.7 ± 2.9 (AP), 0.2 ± 3.6 (LL) and − 0.2 ± 3.3 (CC) mm. Mean SUT in the validation group was 1 min longer (P < 0.05) than the comparative group. Median SUT was 3 min in all groups. The CrC improved precision and comfort compared to BB. Set-up errors compare favourably to other prone-WBI trials and rival supine positioning.

This review intends to rekindle efforts to map the lymphatic system by using a more modern approach, based on medical imaging. The structure, function, and pathologies associated with the lymphatic system are first discussed to highlight the need for more accurately mapping the lymphatic system. Next, the need for an interdisciplinary approach, with a central role for the anatomist, to come up with better maps of the lymphatic system is emphasized. The current approaches on lymphatic system research involving medical imaging will be discussed and suggestions will be made for an all‐encompassing effort to thoroughly map the entire lymphatic system. A first‐hand account of our integration as anatomists in the radiotherapy department is given as an example of interdisciplinary collaboration. From this account, it will become clear that the interdisciplinary collaboration of anatomists in the clinical disciplines involved in lymphatic system research/treatment still holds great promise in terms of improving clinical regimens that are currently being employed. As such, we hope that our fellow anatomists will join us in an interdisciplinary effort to map the lymphatic system, because this could, in a relatively short timeframe, provide improved treatment options for patients with cancer or lymphatic pathologies all over the world. Anat Rec, 302:1681–1695, 2019. © 2019 American Association for Anatomy

Breast cancer is one of the most important causes of premature mortality among women and it is one of the most frequently diagnosed tumours worldwide. For this reason, routine screening for prevention and early diagnosis is important for the quality of life of patients. Breast cancer cells can enter blood and lymphatic capillaries, then metastasizing to the regional lymph nodes in the axilla and to both visceral and non-visceral sites. Rather than at the primary site, they seem to enter the systemic circulation mainly through the sentinel lymph node and the biopsy of this indicator can influence the axillary dissection during the surgical approach to the pathology. Furthermore, secondary lymphoedema is another important issue for women following breast cancer surgical treatment or radiotherapy. Considering these fundamental aspects, the present article aims to describe new methodological approaches to assess the anatomy of the lymphatic network in the axillary region, as well as the molecular and physiological control of lymphatic vessel function, in order to understand how the lymphatic system contributes to breast cancer disease. Due to their clinical implications, the understanding of the molecular mechanisms governing lymph node metastasis in breast cancer are also examined. Beyond the investigation of breast lymphatic networks and lymphatic molecular mechanisms, the discovery of new effective anti-lymphangiogenic drugs for future clinical settings appears essential to support any future development in the treatment of breast cancer.

In order to provide an alternative for fresh frozen specimens to map the lymphatic system, the possibility of using Thiel embalmed specimens for this purpose was explored. The thoracic duct was used to investigate if retrograde injection of contrast agent was possible in Thiel embalmed specimens and to verify up to which diameter lymphatic vessels could be reconstructed and rendered in 3D, after CT scanning. 3D renderings were used for digital diameter measurement, to determine the smallest lymphatic diameter that could still be visualized on CT. Finally, the contrast agent concentration was adapted based on the findings during image reconstruction and 3D rendering. All Thiel embalmed specimens proved suitable for retrograde injection of contrast agent into the thoracic duct and all 3D renderings perfectly overlapped with the dissection pictures. The smallest diameter of contrast filled lymphatics that could be reconstructed and rendered in 3D was 0.23 mm. Increasing the concentration of barium sulfate from 10 to 50% reduced the postprocessing time needed to render a “clean” 3D structure, following automatic segmentation based on grey values, by 95%. The authors would recommend the use of Thiel embalmed specimens for mapping the lymphatic system, as these specimens do not show the rapid putrefaction that occurs in fresh frozen specimens, thus greatly facilitating experimental planning.

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