<p>Postmastectomy radiotherapy using three different techniques: a retrospective evaluation of the incidental dose distribution in the internal mammary nodes</p>

Abstract

ObjectiveTo evaluate the incidental coverage dose to the internal mammary nodes (IMN) in patients treated with postmastectomy radiotherapy (PMRT) and its relationship with the treatment plan.Patients and methodsWe retrospectively analyzed 138 patients undergoing PMRT and divided them into three groups: three-dimensional conformal radiotherapy (3D-CRT), field-in-field forward intensity-modulated radiotherapy (F-IMRT), and inverse intensity-modulated radiotherapy (I-IMRT). The IMN were contoured according to the Radiation Therapy Oncology Group consensus and not included in the planning target volume. We analyzed incidental IMN dose coverage and its relationship with the lung and heart.ResultsThe mean dose (Dmean) to the IMN was 32.85 Gy for all patients, and the dose delivered to the IMN showed no differences in 3D-CRT, F-IMRT, and I-IMRT (33.80, 29.65, and 32.95 Gy, respectively). In addition, 10.42%, 2.04%, and 9.76% of patients achieved ≥45 Gy with 3D-CRT, F-IMRT, and I-IMRT, respectively. No differences were evident among the three treatment plans regarding IMN dose in the first three intercostal spaces (ICS1–3). The Dmean, V20, V30, V40, and V50 of ICS2 and ICS3 were superior to those of ICS1 for all three plans. For 3D-CRT, a moderate positive correlation was evident between the Dmean to the IMN and the Dmean to the heart. For F-IMRT and I-IMRT, positive correlations were evident between the Dmean of the IMN and the Dmean and V20 of the lung.ConclusionThe mean incidental dose to the IMN for IMRT (F-IMRT and I-IMRT) and 3D-CRT after modified radical mastectomy was insufficient to treat subclinical disease. A substantial dose was delivered to the IMN in some patients. Higher incidental doses to the IMN were associated with a higher heart mean dose for 3D-CRT and a higher dose to the lung for IMRT. Future prospective studies should further explore subgroups that do not require IMN irradiation.

Excluding Lung Tissue from the PTV during Internal Mammary Irradiation. A Safe Technique for OAR-Sparing?

“…Geometrical variations and inaccuracies during RNI are mostly related to patients positioning during radiotherapy and anatomical changes during the course of treatment. The suggested CTV to PTV margins for RNI in breast cancer vary between 5 mm and 10 mm [ 17 , 21 , 26 , 27 ]. However, the current literature lacks data and analyses regarding the PTV margins for modern treatment modalities such as VMAT or SIB irradiation.…”

Factors Influencing the Incidental Dose Distribution in Internal Mammary Nodes: A Comparative Study

“…IMNI has been shown to have a significant impact on locoregional control, breast cancer mortality, and OS (5-7), but controversies concerning IMNI still exist, mainly because of radiotherapy-induced longterm lung and heart toxicity (8,24,25). Though the incidental dose to the IMNs not achieve clinically significant therapeutic levels (26,27), recent studies have demonstrated that accepting adequate doses during incidental irradiation can result in a clinical benefit (6,10). By determining the variability in the IIMNI dose coverage with standard chest wall tangential fields (28,29).…”

Internal mammary lymph node metastasis in breast cancer patients based on anatomical imaging and functional imaging

“…For patients with breast cancer (stage I, II, or III), observed IMLN recurrence rate was < 1.5% after primary breast cancer treatment, even when the internal mammary chain (IMC) not excised or irradiated [11][12][13]. Patients most likely benefit from systemic therapies and incidental regional node irradiation [14][15][16][17][18]. But according to extended radical mastectomy data, 9.2% of patients with no positive axillary nodes (ALN) present IMLN metastasis [19].…”