Do We Overtreat or Undertreat the Axillary Region in Lymph Node-positive Breast Cancer Patients? (original) (raw)

Supine MRI for regional breast radiotherapy: imaging axillary lymph nodes before and after sentinel-node biopsy

Physics in medicine and biology, 2017

Regional radiotherapy (RT) is increasingly used in breast-cancer treatment. Conventionally, computed tomography (CT) is performed for RT planning. Lymph node (LN) target levels are delineated according to anatomical boundaries. MRI could enable individual LN delineation. The purpose was to evaluate applicability of MRI for LN detection in supine treatment position, before and after sentinel-node biopsy (SNB). 23 female breast-cancer patients (cTis-3N0M0) underwent 1.5T MRI, before and after SNB, additional to CT. Endurance for MRI was monitored. Axillary levels were delineated. LNs were identified and delineated on MRI from before and after SNB, and on CT, and compared by Wilcoxon signed-rank tests. LN locations and LN-based volumes were related to axillary delineations and associated volumes. Although postoperative effects were visible, LN numbers on postoperative MRI (median 26 LNs) were highly reproducible compared to preoperative MRI when adding excised sentinel nodes, and highe...

Coverage of axillary lymph nodes with high tangential fields in breast radiotherapy

British Journal of Radiology, 2010

The aim of this study is to evaluate the coverage of axillary nodal volumes with high tangent fields (HTF) in breast radiotherapy and to determine the utility of customised blocking. The treatment plans of 30 consecutive patients with early breast cancer were evaluated. The prescription dose was 50 Gy to the whole breast. Axillary level I-II lymph node volumes were delineated and the cranial border of the tangential fields was set just below the humeral head to create HTF. Dose-volume histograms (DVH) were used to calculate the doses received by axillary nodal volumes. In a second planning set, HTF were modified with multileaf collimators (MLC-HTF) to obtain an adequate dose coverage of axillary nodes. The mean doses of the axillary nodes, the ipsilateral lung and heart were compared between the two plans (HTF vs MLC-HTF) using a paired sample t-test. The doses received by 95% of the breast volumes were not significantly different for the two plans. The doses received by 95% of the level I and II axillary volumes were 16.79 Gy and 11.59 Gy, respectively, for HTF, increasing to 47.2 Gy and 45.03 Gy, respectively, for MLC-HTF. Mean lung doses and per cent volume of the ipsilateral lung receiving 20 Gy (V20) were also increased from 6.47 Gy and 10.47%, respectively, for HTF, to 9.56 Gy and 16.77%, respectively, for MLC-HTF. Our results suggest that HTF do not adequately cover the level I and II axillary lymph node regions. Modification of HTF with MLC is necessary to obtain an adequate coverage of axillary levels without compromising healthy tissue in the majority of the patients.

Ex vivo MRI of axillary lymph nodes in breast cancer

European Journal of Radiology, 2009

To provide a strategy for precise co-localization of lymph nodes on axillary lymph-node dissection (ALND) specimens both on pathology and MR. To identify nodal features suggestive of metastatic involvement on a node-to-node basis. Materials and methods: National Institutional review-board approved this prospective study of 18 patients with breast cancer referred for ALND. Ex vivo T1 and inversion recovery (IR) T2 WI of ALND specimens tightly positioned within scaled plastic cranes was performed immediately after surgery. The correspondence of MR-based or pathologically based nodes location was assessed. The MR size and morphological presentation of metastatic and normal nodes were compared (Student's t-test or Mann-Whitney test). Quantitative variables were compared using Pearson coefficient. Results: 207 nodes were retrieved on pathology and 165 on MR. MR-pathological correlation of nodes location was high regarding MR-identified nodes (r = 0.755). An MR short axis threshold of 4 mm yielded the best predictive value for metastatic nodal involvement (Se = 78.6%; Sp = 62.3%). Irregular contours (Se = 35.7%; Sp = 96.7%), central nodal hyper-intensity on IR T2 WI (Se = 57.1%; Sp = 91.4%), and a cortical thickness above 3 mm (Se = 63.6%; Sp = 83.2%) were significantly associated with metastatic involvement. Conclusion: Ex vivo MR allows node-to-node correlation with pathology. Morphological MR criteria can suggest metastatic involvement.

Axillary lymph node dose with tangential breast irradiation

International Journal of Radiation Oncology*Biology*Physics, 2005

Purpose: The advent of sentinel lymph node mapping and biopsy in the staging of breast cancer has resulted in a significant decrease in the extent of axillary nodal surgery. As the extent of axillary surgery decreases, the radiation dose and distribution within the axilla becomes increasingly important for current therapy planning and future analysis of results. This analysis examined the radiation dose distribution delivered to the anatomically defined axillary level I and II lymph node volume and surgically placed axillary clips with conventional tangential breast fields and CT-based three-dimensional (3D) planning. Methods and Materials: Fifty consecutive patients with early-stage breast cancer undergoing breast conservation therapy were evaluated. All patients underwent 3D CT-based planning with conventional breast tangential fields designed to encompass the entire breast parenchyma. Using CT-based 3D planning, the dose distribution of the standard tangential breast irradiation fields was examined in relationship to the axillary level I and II lymph node volumes. Axillary level I and II lymph node anatomic volumes were defined by CT and surgical clips placed during complete level I-II lymph node dissection. Axillary level I-II lymph node volume doses were examined on the basis of the prescribed breast radiation dose and 3D dose distribution. Results: All defined breast volumes received >95% of the prescribed dose. By contrast, the 95% isodose line encompassed only an average of 55% (range, 23-87%) of the axillary level I-II lymph node anatomic volume. No patient had complete coverage of the axillary level I-II lymph node region by the 95% isodose line. The mean anatomic axillary level I-II volume was 146.3 cm 3 (range, 83.1-313.0 cm 3 ). The mean anatomic axillary level I-II volume encompassed by the 95% isodose line was 84.9 cm 3 (range, 25.1-219.0 cm 3 ). The mean 95% isodose coverage of the surgical clip volume was 80%, and the median value was 81% (range, 58 -98%). The mean volume deficit between the axillary level I-II volume and the surgical clip volume was 41.7 cm 3 (median, 30.0 cc). Conclusion: In this study, standard tangential breast radiation fields failed to deliver a therapeutic dose adequately to the axillary level I-II lymph node anatomic volume. No patient received complete coverage of the axillary level I-II lymph node volume. Surgically placed axillary clips also failed to delineate the level I-II axilla adequately. Definitive irradiation of the level I and II axillary lymph node region requires significant modification of standard tangential fields, best accomplished with 3D treatment planning, with specific targeting of anatomically defined axillary lymph node volumes as described, in addition to the breast parenchymal volumes.

Assessment of Dose Delivery to Supraclavicular and Axillary Lymph Nodes in Adjuvant Breast Cancer Radiotherapy, with or without Posterior Axillary Boost in Relation to BMI

2016

Background: The axillary and supraclavicular nodal volume treatment results in improvement of local control and survival after breast conserving surgery (BCS) or modified radical mastectomy (MRM). Studies on the depth of these nodes have questioned the consistent use of standard fields for all patients. This study was done to assess the dose delivery to these lymph nodes with conventional treatment techniques according to body mass index (BMI).Methods: Twenty six patients with breast cancer undergoing breast surgery were included and computed tomography (CT) simulation was done. Their axillary and supraclavicular nodal volumes were contoured for planning target volume (PTV). Supraclavicular and posterior axillary fields were generated for each patient with digital reconstruction radiography (DRR) technique. Then the dose distribution of the two conventional methods - anterior-posterior field (AP), and anterior field with posterior boost (AP+PA boost) - for total dose of 5000 cGy, wa...

Regional lymph node radiotherapy in breast cancer: single anterior supraclavicular field vs. two anterior and posterior opposed supraclavicular fields

Electronic physician

The treatment of lymph nodes engaged in breast cancer with radiotherapy leads to improved locoregional control and enhanced survival rates in patients after surgery. The aim of this study was to compare two treatment techniques, namely single anterior posterior (AP) supraclavicular field with plan depth and two anterior and posterior opposed (AP/PA) supraclavicular fields. In the study, we also examined the relationships between the depth of supraclavicular lymph nodes (SCLNs) and the diameter of the wall of the chest and body mass index (BMI). Forty patients with breast cancer were analyzed using computed tomography (CT) scans. In planning target volume (PTV), the SCLNs and axillary lymph nodes (AXLNs) were contoured, and, with the attention to PTV, supraclavicular (SC) depth was measured. The dosage that reached the aforementioned lymph nodes and the level of hot spots were investigated using two treatment methods, i.e., 1) AP/PA and 2) AP with three-dimensional (3D) planning. Eac...

PET-CT and MR Imaging in the Management of Axillary Nodes in Early Stage Breast Cancer

Journal of the College of Physicians and Surgeons Pakistan, 2020

Methodology: Sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) was carried out on 102 patients, who had locally advanced cases and had not previously received neoadjuvant therapy. Axillary lymph nodes pathology results were evaluated and compared with PET-CT and MRI findings. Results: PET-CT specificity was 93.18%, MRI specificity was 93.75%, and combined PET-CT and MRI specificity was 97.67%. PET-CT sensitivity was 81.03%, MRI sensitivity was 68.57%, and combined PET-CT and MRI sensitivity was 83.05%. For detecting the presence of axillary lymph node metastasis, there was a good correlation between histopathological results and the combined evaluation with PET-CT and MRI (kappa: 0.785, p <0.001). In combined PET-CT and MRI, short diamater mean values of lymph nodes in 10 patients, which could not detect lymph node metastases, were determined to be 5.2 ±0.9 mm. Conclusion: Combining PET-CT and MRI is superior to PET-CT or MRI imaging alone in distinguishing benign and malignant axillary lymph node; and contributes to deciding the approach to axillary lymph node surgery. Lymph node size is also important for this imaging method to determine benign and malignant nodes correctly.

Impact of Breast MRI on Surgical Treatment, Axillary Approach, and Systemic Therapy for Breast Cancer

Breast Diseases: A Year Book Quarterly, 2009

The purpose of this study is to determine how often breast magnetic resonance imaging (MRI) brings additional information that influences management of patients with breast cancer concerning surgical treatment, axillary lymph node approach, and systemic therapy. From July 2004 to July 2005, 99 patients recently diagnosed with breast cancer in clinical stages 0, I, and II were prospectively evaluated about their therapeutic plans, at first based on usual protocol (physical examination, mammography and ultrasound) and next going through bilateral breast MR. Examinations were carried out at 1.5 T on five sequences of FSPGR 3D for 90 seconds (four post-gadolinium diethylenetriaminepenta acetic acid 0.16 mM ⁄ Kg). Parameters analyzed on MRI were extension of primary lesion; detection of multifocality, multicentricity, or contra lateral lesion; muscular or skin involvement; and presence of lymph node involvement. Pathologic confirmation of additional lesions was achieved by core or excisional biopsy. MRI made 69 additional findings in 53 patients. Fifty-one findings were true-positives (51 ⁄ 69 = 73.9%) including 16 larger single lesions; 18 cases of multifocality; 7 cases of multicentricity; 3 cases of contra lateral lesion; 5 cases of lymph node involvement (one of them involved medial thoracic chain); 1 with muscular involvement; 1 with skin involvement. MRI has changed previous management plans in 44.4% of 99 patients. We observed increase in mastectomies (26.8%) on axillary lymph node dissection (25%) and changes on systemic therapy (20.2%), all because of additional MRI true-positive findings. Breast MRI alters significantly the rate of mastectomy, the approach of axillary chain for staging, and the use of systemic therapy because of its accuracy in evaluating breast cancer local extent. n

Axillary nodal irradiation practice in the sentinel lymph node biopsy era: Comparison of the contemporary available 3D and IMRT techniques

The British Journal of Radiology

Objective: Our study aimed to compare regional node coverage and doses to the organ at risk (OAR) using conventional technique (CT) vs “AMAROS” (AT) vs intensity-modulated radiation therapy (IMRT) techniques in patients receiving regional nodal irradiation (RNI) for breast cancer (BC). Methods: We included 30 consecutive patients with BC who received RNI including axillary nodes. Two independent and blinded dosimetric RNI plans were generated for all patients. For target volume coverage, we analyzed the V95%, the D95%, the mean and the minimal dose within the nodal station. For hotspots within nodal target volume, we used the V105%, the V108% and the maximal doses. For OAR, lung V20, mean lung and heart doses, the maximal dose to the brachial plexus and the axillary-lateral thoracic vessel junction region were compared between the three techniques. Results: Target volume coverage and hotspots: Mean V95% in stations I, II, III and IV were 35.8% and 75% respectively with CV, 22.59 and...