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Situ J, Buissink P, Mu A, Chung DKV, Finnegan R, Gamage TPB, Jayathungage Don TD, Walker C, Reynolds HM. An interactive 3D atlas of sentinel lymph nodes in breast cancer developed using SPECT/CT. Cancer Imaging 2024; 24:97. [PMID: 39080795 PMCID: PMC11289966 DOI: 10.1186/s40644-024-00738-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 07/05/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND The identification and assessment of sentinel lymph nodes (SLNs) in breast cancer is important for optimised patient management. The aim of this study was to develop an interactive 3D breast SLN atlas and to perform statistical analyses of lymphatic drainage patterns and tumour prevalence. METHODS A total of 861 early-stage breast cancer patients who underwent preoperative lymphoscintigraphy and SPECT/CT were included. Lymphatic drainage and tumour prevalence statistics were computed using Bayesian inference, non-parametric bootstrapping, and regression techniques. Image registration of SPECT/CT to a reference patient CT was carried out on 350 patients, and SLN positions transformed relative to the reference CT. The reference CT was segmented to visualise bones and muscles, and SLN distributions compared with the European Society for Therapeutic Radiology and Oncology (ESTRO) clinical target volumes (CTVs). The SLN atlas and statistical analyses were integrated into a graphical user interface (GUI). RESULTS Direct lymphatic drainage to the axilla level I (anterior) node field was most common (77.2%), followed by the internal mammary node field (30.4%). Tumour prevalence was highest in the upper outer breast quadrant (22.9%) followed by the retroareolar region (12.8%). The 3D atlas had 765 SLNs from 335 patients, with 33.3-66.7% of axillary SLNs and 25.4% of internal mammary SLNs covered by ESTRO CTVs. CONCLUSION The interactive 3D atlas effectively displays breast SLN distribution and statistics for a large patient cohort. The atlas is freely available to download and is a valuable educational resource that could be used in future to guide treatment.
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Affiliation(s)
- Josephine Situ
- Department of Engineering Science, The University of Auckland, Auckland, New Zealand
| | - Poppy Buissink
- Department of Engineering Science, The University of Auckland, Auckland, New Zealand
| | - Annie Mu
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - David K V Chung
- Alfred Nuclear Medicine and Ultrasound, Newtown, NSW, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Camperdown, NSW, Australia
| | - Rob Finnegan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
- Institute of Medical Physics, School of Physics, The University of Sydney, Camperdown, NSW, Australia
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | | | | | - Cameron Walker
- Department of Engineering Science, The University of Auckland, Auckland, New Zealand
| | - Hayley M Reynolds
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.
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Jayathungage Don TD, Safaei S, Maso Talou GD, Russell PS, Phillips ARJ, Reynolds HM. Computational fluid dynamic modeling of the lymphatic system: a review of existing models and future directions. Biomech Model Mechanobiol 2024; 23:3-22. [PMID: 37902894 PMCID: PMC10901951 DOI: 10.1007/s10237-023-01780-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/02/2023] [Indexed: 11/01/2023]
Abstract
Historically, research into the lymphatic system has been overlooked due to both a lack of knowledge and limited recognition of its importance. In the last decade however, lymphatic research has gained substantial momentum and has included the development of a variety of computational models to aid understanding of this complex system. This article reviews existing computational fluid dynamic models of the lymphatics covering each structural component including the initial lymphatics, pre-collecting and collecting vessels, and lymph nodes. This is followed by a summary of limitations and gaps in existing computational models and reasons that development in this field has been hindered to date. Over the next decade, efforts to further characterize lymphatic anatomy and physiology are anticipated to provide key data to further inform and validate lymphatic fluid dynamic models. Development of more comprehensive multiscale- and multi-physics computational models has the potential to significantly enhance the understanding of lymphatic function in both health and disease.
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Affiliation(s)
| | - Soroush Safaei
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Gonzalo D Maso Talou
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Peter S Russell
- School of Biological Sciences, The University of Auckland, Auckland, New Zealand
- Surgical and Translational Research Centre, Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Anthony R J Phillips
- School of Biological Sciences, The University of Auckland, Auckland, New Zealand
- Surgical and Translational Research Centre, Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Hayley M Reynolds
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.
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Naoum GE, Taghian AG. Regional Lymph Node Radiation Is Not the Main Risk Factor for Breast Cancer Related Lymphedema: Stop Chasing Radiation Doses, Fractionation or Techniques-Focus on Axillary Surgery De-escalation or Prevention. Int J Radiat Oncol Biol Phys 2023; 117:461-464. [PMID: 37652608 DOI: 10.1016/j.ijrobp.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 09/02/2023]
Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Northwestern University Memorial Hospital, Chicago, Illinois.
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Prasun P, Kharade V, Pal V, Gupta M, Das S, Pasricha R. Dosimetric Comparison of Hypofractionated Regimen in Breast Cancer Using Two Different Techniques: Intensity-Modulated Radiation Therapy (IMRT) and Volumetric-Modulated Arc Therapy (VMAT). Cureus 2023; 15:e38045. [PMID: 37228558 PMCID: PMC10206676 DOI: 10.7759/cureus.38045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Breast cancer treated with adjuvant hypofractionation radiotherapy with two different techniques, i.e., volumetric-modulated arc therapy (VMAT) and intensity-modulated radiation therapy (IMRT) and their effects in terms of loco-regional control and adverse effects in terms of cutaneous, pulmonary, and cardiac outcomes are compared. MATERIALS AND METHODS This is a prospective non-randomized observational study. VMAT and IMRT plan for 30 breast cancer patients who were supposed to receive adjuvant radiotherapy were prepared using a hypofractionation schedule. The plans were dosimetrically evaluated. OBJECTIVE Dosimetric comparative analysis of IMRT and VMAT in hypofractionated radiotherapy in breast cancer is done and tested whether VMAT has a dosimetric advantage over IMRT. These patients were recruited for a clinical assessment of toxicities. They were followed up for at least three months. RESULT On dosimetric analysis, planning target volume (PTV) coverage (PTV_ V95) of both VMAT (96.41 ± 1.31) and IMRT (96.63 ± 1.56) were similar with significantly lower monitor units required with VMAT plans (1,084.36 ± 270.82 vs 1,181.55 ± 244.50, p = 0.043). Clinically, all patients tolerated hypofractionation through VMAT (n = 8) and IMRT (n = 8) satisfactorily in the short term. No cardiotoxicity or appreciable falls in pulmonary function test parameters were observed. Acute radiation dermatitis poses challenges similar to standard fractionation or any other delivery technique. CONCLUSION PVT dose, homogeneity, and conformity indices were similar in both VMAT and IMRT groups. In VMAT, there was high-dose sparing of some critical organs like the heart and lungs at the cost of the low-dose baths to these organs. Increased risk of secondary cancer will require a decade-long follow-up study to indict the VMAT technique. As we move toward precision in oncology, "one-size-fits-all" can never be an acceptable dictum. Each patient is unique and therefore we must offer, and the patient must "choose wisely."
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Affiliation(s)
- Pallav Prasun
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Vipin Kharade
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Vikas Pal
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Manish Gupta
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Saikat Das
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Rajesh Pasricha
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
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Jing H, Tang Y, Wang ZZ, Wei R, Jin JY, Li J, Zhao LY, Jin J, Liu YP, Song YW, Fang H, Chen B, Qi SN, Lu NN, Tang Y, Li N, Zhai YR, Zhang WW, Wang SL, Li YX. Individualized Clinical Target Volume for Irradiation of the Supraclavicular Region in Breast Cancer Based on Mapping of the Involved Ipsilateral Supraclavicular Lymph Nodes. Int J Radiat Oncol Biol Phys 2023; 115:922-932. [PMID: 36368434 DOI: 10.1016/j.ijrobp.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/12/2022] [Accepted: 10/26/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE To map supraclavicular fossa-involved lymph nodes (SCF-LNs) in patients with nonmetastatic breast cancer, evaluate the coverage of widely adopted atlases, and propose modified borders for individualized regional irradiation. METHODS AND MATERIALS M0 patients with biopsy-proven SCF-LNs who were SCF treatment-naïve were included. The SCF was spatially divided into subregions, with each node mapped on the original images. The geographic misses after the borders of multiple atlases were evaluated and factors affecting SCF-LNs' spread pattern were analyzed. RESULTS From 1998 to 2022, 209 patients with 1242 SCF-LNs were eligible. Patients had a median of 4 nodes. At least 537 nodes (43.2%) in 147 patients (70.3%) were lateral to the sternocleidomastoid muscle (SCM), and 403 nodes (32.4%) in 127 patients (60.8%) were dorsal to the anterior scalene muscle (ASM). In the 88 patients with ≤3 SCF-LNs, at least 66 nodes (39.1%) in 40 patients (45.5%) were lateral to the SCM, and 34 nodes (20.1%) in 29 patients (33.0%) were dorsal to the ASM. These nodes were not covered by the Radiation Therapy Oncology Group (RTOG) atlas and partly within the Radiotherapy Comparative Effectiveness atlas. One hundred four patients (49.8%) had 432 SCF-LNs (34.8%) beyond the upper border of the European Society for Radiotherapy and Oncology (ESTRO) atlas. In multivariate regression, nodal sizes were associated with wider spread in the primary group. Being triple-negative (TN) subtype was associated with less spread in the recurrent group. Situation-based clinical target volumes (CTVs) were theorized, in which for a sequential spread, the posterior border could be the posterior scalene muscle or even be more constringent; otherwise, it should touch the anterior trapezius surface. CONCLUSIONS SCF-LNs tend to spread laterally and dorsally beyond the RTOG borders, even in M0 stages with ≤3 SCF-LNs. The ESTRO upper border does not guarantee coverage with multiple SCF-LNs. Nodal burden and non-TN types are predictive of wider dissemination. A situation-based CTV is possibly feasible. Deciphering the SCF-LN spread route is needed.
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Affiliation(s)
- Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zong-Zhan Wang
- Department of Radiation Oncology, Qingdao Central Hospital, Qing Dao, Shan Dong, China
| | - Ran Wei
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing-Yi Jin
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Li
- Department of Radiation Oncology, Beijng Hospital, Beijing, China
| | - Li-Yun Zhao
- Department of Radiation Oncology, Beijng Hospital, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Rui Zhai
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-Wen Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Risk-Adapted Target Delineation for Breast Cancer: Controversies and Considerations. Pract Radiat Oncol 2023; 13:e115-e120. [PMID: 36748210 DOI: 10.1016/j.prro.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 12/13/2022]
Abstract
The advent of computed tomography-based planning coupled with modern tools for target delineation and hypofractionated treatment schedules has increased efficiency and throughput for patients with breast cancer. While the benefit of adjuvant radiation therapy (RT) in reducing locoregional recurrences is established, disentangling local versus regional recurrence risks with modern treatment protocols has become an area of active research to de-escalate treatment. Delineation guidelines for nodal regions either attempt to replicate results of conventional RT techniques by translating bony landmarks to clinical target volumes or use landmarks based on the fact that lymphatic channels run along the vasculature. Because direct comparisons of both approaches are implausible, mapping studies of nodal recurrences have reported on the proportion of nodes included in these delineation guidelines, and larger, bony, landmark-based guidelines appear intuitively appealing for patients with unfavorable risk factors. A pooled analysis of these studies is reported here, along with literature supporting the exclusion of the true chest wall from postmastectomy/breast-conserving surgery clinical target volumes and the selective (versus routine) use of bolus during postmastectomy RT. The risk-adapted approach suggested here accounts for the risk of recurrence as well as toxicity and endorses nuanced target volume delineation rather than a one-size-fits-all approach.
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Marks LB, Pierce LJ, Buchholz TA, Haffty BG. Nailing the Clavicular Head: Assuring Adequate Coverage of the Medial/Inferior Aspect of the Supraclavicular Space in Patients Receiving Regional Nodal Radiation Therapy for Breast Cancer. Pract Radiat Oncol 2023; 13:e121-e125. [PMID: 36748209 DOI: 10.1016/j.prro.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/29/2022] [Accepted: 10/01/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Lori J Pierce
- Rogel Cancer Center, University of Michigan School of Medicine, Ann Arbor, Michigan
| | | | - Bruce G Haffty
- Deptartment Radiation Oncology, Rutgers Robert Wood Johnson and New Jersey Medical Schools, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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Zhang M, Cao L, Chen J, Li B, Huang X, Cai G, Xu C. Mapping of PET/CT-based regional nodes distribution of recurrent/advanced breast cancer and comparison with current delineation atlas. Br J Radiol 2022; 95:20220382. [PMID: 35731844 PMCID: PMC10996945 DOI: 10.1259/bjr.20220382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/29/2022] [Accepted: 06/14/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To localize the distribution of regional nodes in recurrent/advanced breast cancer patients based on 18-fludeoxyglucose (FDG) positron emission tomography/CT (PET/CT) images and validate the coverage of clinical target volumes (CTVs) for regional nodes with current contouring guidelines. METHODS We enrolled 154 recurrent/advanced breast cancer patients with FDG-avid regional nodes who underwent PET/CT between January 2018 and June 2020. Involvement of lymph node regions including axillary lymph node level I-III (ALN-I, ALN-II, ALN-III), Rotter's nodes (RN), medial supraclavicular (SC-M), lateral supraclavicular (SC-L) and internal mammary nodes (IMN) was recorded respectively. Coverage of the CTVs in different atlases and the locations of out-of-field were evaluated. RESULTS A total of 348 lymph node regions containing disease were identified, including ALN-I 109, ALN-II 46, ALN-III 36, RN 17, SC-M 68, SC-L 36 and IMN 36. Recurrent ALNs mainly located cranially and ventrally to the axillary vein (AV). Ipsilateral cervical nodes were simultaneously affected in 33/76 SC positive patients. RADCOMP (306/348) and RUIJIN (291/348) guidelines had higher coverage compared with RTOG (205/348) and ESTRO (202/348) guidelines (p < 0.001, respectively). In primary non-metastastic and recurrent patients, major missings located in SC-L (7/7, 17/17) and IMN (7/10, 15/19) for RTOG guideline while SC-L (7/7, 17/17) for ESTRO guideline (p < 0.001, respectively). Among recurrent patients, SC-M (22/31) was another major missing area for ESTRO guideline (p < 0.001). CONCLUSION The current guidelines effectively cover most regional nodes in postoperative breast cancer patients. SC-L and IMN were the major missing regions. Recurrent ALNs were most often seen in cranial and ventral to the AV. The CTV of patients with clinically positive SC was recommended to extend up to the hyoid level. The CTVs should be adjusted based on risks of recurrence individually. ADVANCES IN KNOWLEDGE The difference of regional nodes delineation between current guidelines mainly located in SC and IMN regions. High axilla including subclavicular nodes and the RN above AV for recurrent patients and the region between cricoid and hyoid for positive SC patients should be meticulously contoured.
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Affiliation(s)
- Maochen Zhang
- Department of Radiation Oncology, Ruijin Hospital, Shanghai
Jiao Tong University, School of Medicine,
Shanghai, China
| | - Lu Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai
Jiao Tong University, School of Medicine,
Shanghai, China
| | - Jiayi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai
Jiao Tong University, School of Medicine,
Shanghai, China
| | - Biao Li
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao
Tong University, School of Medicine,
Shanghai, China
| | - Xinyun Huang
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao
Tong University, School of Medicine,
Shanghai, China
| | - Gang Cai
- Department of Radiation Oncology, Ruijin Hospital, Shanghai
Jiao Tong University, School of Medicine,
Shanghai, China
| | - Cheng Xu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai
Jiao Tong University, School of Medicine,
Shanghai, China
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Bazan JG, Khan AJ. Target Volume Delineation and Patterns of Recurrence in the Modern Era. Semin Radiat Oncol 2022; 32:254-269. [DOI: 10.1016/j.semradonc.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Iacob R, Manolescu DL, Stoicescu ER, Fabian A, Malita D, Oancea C. Breast Cancer—How Can Imaging Help? Healthcare (Basel) 2022; 10:healthcare10071159. [PMID: 35885686 PMCID: PMC9323053 DOI: 10.3390/healthcare10071159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Breast cancer is the most common malignant disease among women, causing death and suffering worldwide. It is known that, for the improvement of the survival rate and the psychological impact it has on patients, early detection is crucial. For this to happen, the imaging techniques should be used at their full potential. We selected and examined 44 articles that had as subject the use of a specific imaging method in breast cancer management (mammography, ultrasound, MRI, ultrasound-guided biopsy, PET-CT). After analyzing their data, we summarized and concluded which are the best ways to use each one of the mentioned techniques for a good outcome. We created a simplified algorithm with easy steps that can be followed by radiologists when facing this type of neoplasia.
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Affiliation(s)
- Roxana Iacob
- Department of Radiology and Medical Imaging, ‘Victor Babes’ University of Medicine and Pharmacy Timisoara, 300041 Timișoara, Romania; (R.I.); (E.R.S.); (A.F.); (D.M.)
| | - Diana Luminita Manolescu
- Department of Radiology and Medical Imaging, ‘Victor Babes’ University of Medicine and Pharmacy Timisoara, 300041 Timișoara, Romania; (R.I.); (E.R.S.); (A.F.); (D.M.)
- Center for Research and Innovation in Precision Medicine of Respiratory Diseases (CRIPMRD), ‘Victor Babeș’ University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Correspondence:
| | - Emil Robert Stoicescu
- Department of Radiology and Medical Imaging, ‘Victor Babes’ University of Medicine and Pharmacy Timisoara, 300041 Timișoara, Romania; (R.I.); (E.R.S.); (A.F.); (D.M.)
- Research Center for Pharmaco-Toxicological Evaluations, ‘Victor Babes’ University of Medicine and Pharmacy Timisoara, 300041 Timișoara, Romania
| | - Antonio Fabian
- Department of Radiology and Medical Imaging, ‘Victor Babes’ University of Medicine and Pharmacy Timisoara, 300041 Timișoara, Romania; (R.I.); (E.R.S.); (A.F.); (D.M.)
| | - Daniel Malita
- Department of Radiology and Medical Imaging, ‘Victor Babes’ University of Medicine and Pharmacy Timisoara, 300041 Timișoara, Romania; (R.I.); (E.R.S.); (A.F.); (D.M.)
| | - Cristian Oancea
- Center for Research and Innovation in Precision Medicine of Respiratory Diseases (CRIPMRD), ‘Victor Babeș’ University of Medicine and Pharmacy, 300041 Timișoara, Romania;
- Department of Pulmonology, ‘Victor Babes’ University of Medicine and Pharmacy, 300041 Timișoara, Romania
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Mapping of Level I Axillary Lymph Nodes in Patients with Newly Diagnosed Breast Cancer: Optimal Target Delineation and Treatment Techniques for Breast and Level I Axilla irradiation. Pract Radiat Oncol 2022; 12:487-495. [PMID: 35247622 DOI: 10.1016/j.prro.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/03/2021] [Accepted: 02/14/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE To map the locations of level I axilla (Ax-L1) lymph nodes (LNs), evaluate the clinical target volume (CTV) coverage defined by the Radiation Therapy Oncology Group (RTOG) breast cancer atlas, and assess the optimal techniques for whole-breast and Ax-L1 irradiation (WBI + Ax-L1). MATERIALS AND METHODS We identified 76 newly diagnosed breast cancer patients with 1-4 positive LNs confirmed by axillary dissection. The locations of 116 involved Ax-L1 LNs on diagnostic computed tomography (CT) were mapped onto simulated CT images of a standard patient. Ax-L1 LN coverage by the RTOG atlas was evaluated, and a modified Ax-L1 CTV with better coverage was proposed. Treatment plans were designed for WBI + Ax-L1 with high tangential simplified intensity-modulated radiation therapy (HT-sIMRT) and volumetric modulated arc therapy (VMAT), and for WBI + RTOG Ax-L1 with VMAT with a prescription dose of 50 Gy in 25 fractions, respectively. The differences in dosimetric parameters were compared. RESULTS The RTOG atlas missed 29.3% of LNs. Modification by extending 1 cm caudal and 0.5 cm anterior to the RTOG-defined CTV borders allowed the modified Ax-L1 CTV to encompass 90.5% of LNs. All plans met the required prescription dose to WBI and Ax-L1. The mean dose and V20 and V5 of the ipsilateral lung were 11.7Gy, 23.0%, 38.1% for HT-sIMRT WBI + Ax-L1, and 8.9 Gy, 16.4%, 32.5% for VMAT WBI + Ax-L1 plans, respectively. The mean heart doses in the left-sided plans were 3.2Gy and 3.0Gy, respectively. The V30 of the humeral head and minimum dose to the axillary-lateral thoracic vessel junction were 2.0% vs 1.8%, and 45.5Gy vs 45.7Gy for VMAT WBI + Ax-L1 and VMAT WBI + RTOG Ax-L1 plans, respectively. CONCLUSIONS A modified Ax-L1 CTV with expansion of the caudal and anterior borders might provide better coverage. Compared with HT-sIMRT WBI + Ax-L1, VMAT WBI+ Ax-L1 provided an adequate dose to Ax-L1 with decreasing the doses to most normal tissues. Coverage of modified Ax-L1 did not increase the dose to organs-at-risk compared with coverage of RTOG Ax-L1.
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Hsieh MT, Aherne NJ, Ross W, Salindera S, Westhuyzen J, Winkley L, Shakespeare TP. Evaluation of apical clips placed during axillary dissection demonstrates potential under-coverage of axillary radiation therapy target volumes during breast cancer regional nodal irradiation. J Med Imaging Radiat Oncol 2021; 66:158-164. [PMID: 34821471 DOI: 10.1111/1754-9485.13349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Evidence-based Australian guidelines (eviQ) recommend adjuvant supraclavicular fossa irradiation after axillary lymph node dissection (ALND) in node-positive breast cancer patients. Disparity between surgically determined versus computed tomography (CT) determined nodal volumes may result in discontiguous nodal volumes and untreated nodal tissue. We examine the extent of untreated nodal tissue in women with breast cancer post-level II or III ALND and adjuvant radiation therapy (RT) using ESTRO contouring guidelines. METHODS Female breast cancer patients who underwent level II and III ALND with apical clip placement from 2016 to 2020 and CT simulated in supine position were included. CT-defined axillary level II-IV volumes were contoured using ESTRO guidelines. The distance between the apical clip and RT nodal volumes was measured to indicate extent of untreated tissue. RESULTS Of 34 eligible patients treated by 7 surgeons, 76% had level II ALND and 24% level III ALND. Only 5.9% of clips entirely encompassed the corresponding RT nodal volumes. 55.9% of clips fell within and 44.1% fell inferolaterally outside the corresponding RT nodal volumes. A median 3.6 cm (range 0-7.5 cm) of undissected nodal tissue would not be included within standard RT target volumes following eviQ recommendations. CONCLUSION There is a disparity between surgically determined versus CT determined axillary nodal volumes, leading to discontiguous nodal volumes and untreated axillary nodal tissue, despite following standard radiation contouring guidelines. Intraoperatively placed apical axillary clips may assist radiation oncologists to accurately delineate undissected nodal tissues at risk.
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Affiliation(s)
- Michael Ti Hsieh
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Noel J Aherne
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia.,School of Health and Human Sciences, Southern Cross University, Coffs Harbour, New South Wales, Australia.,RCS Faculty of Medicine, University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - William Ross
- RCS Faculty of Medicine, University of New South Wales, Coffs Harbour, New South Wales, Australia.,Department of Surgery, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Shehnarz Salindera
- Department of Surgery, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Justin Westhuyzen
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Lauren Winkley
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Thomas P Shakespeare
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia.,RCS Faculty of Medicine, University of New South Wales, Coffs Harbour, New South Wales, Australia
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Kaidar-Person O, Offersen BV, Boersma L, Meattini I, Dodwell D, Wyld L, Aznar M, Major T, Kuehn T, Strnad V, Palmu M, Hol S, Poortmans P. Tricks and tips for target volume definition and delineation in breast cancer: Lessons learned from ESTRO breast courses. Radiother Oncol 2021; 162:185-194. [PMID: 34302915 DOI: 10.1016/j.radonc.2021.07.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
Delineation of target and 'organ at risk' volumes is a critical part of modern radiation therapy planning, the next essential step after deciding the indication, patient discussion and image acquisition. Adoption of volume-based treatment planning for non-metastatic breast cancer has increased greatly along with the use of improved planning techniques, essential for modern therapy. However, identifying the volumes on a planning CT is no easy task. The current paper is written by ESTRO's breast course faculty, providing tricks and tips for target volume definition and delineation for optimal postoperative breast cancer irradiation.
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Affiliation(s)
- Orit Kaidar-Person
- Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Israel.
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Liesbeth Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, The Netherlands
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, UK
| | - Marianne Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary & Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Thorsten Kuehn
- Department of Gynaecology and Obstetrics, Interdisciplinary Breast Center, Klinikum Esslingen, Germany
| | - Vratislav Strnad
- Dept. of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Miika Palmu
- European SocieTy for Radiotherapy and Oncology, UK
| | - Sandra Hol
- Instituut Verbeeten, Tilburg, The Netherlands
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