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Tangential vs. defined radiotherapy in early breast cancer treatment without axillary lymph node dissection

A comparative study

Tangentiale vs. definierte Strahlentherapie bei der frühen Brustkrebsbehandlung ohne Lymphknotendissektion

Eine Vergleichsstudie

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Abstract

Purpose

Recent studies have demonstrated low regional recurrence rates in early-stage breast cancer omitting axillary lymph node dissection (ALND) in patients who have positive nodes in sentinel lymph node dissection (SLND). This finding has triggered an active discussion about the effect of radiotherapy within this approach. The purpose of this study was to analyze the dose distribution in the axilla in standard tangential radiotherapy (SRT) for breast cancer and the effects on normal tissue exposure when anatomic level I–III axillary lymph node areas are included in the tangential radiotherapy field configuration.

Patients and methods

We prospectively analyzed the dosimetric treatment plans from 51 consecutive women with early-stage breast cancer undergoing radiotherapy. We compared and analyzed the SRT and the defined radiotherapy (DRT) methods for each patient. The clinical target volume (CTV) of SRT included the breast tissue without specific contouring of lymph node areas, whereas the CTV of DRT included the level I–III lymph node areas.

Results

We evaluated the dose given in SRT covering the axillary lymph node areas of level I–III as contoured in DRT. The mean VD95 % of the entire level I–III lymph node area in SRT was 50.28 % (range, 37.31–63.24 %), VD45 Gy was 70.1 % (54.8–85.4 %), and VD40 Gy was 83.5 % (72.3–94.8 %). A significant difference was observed between lung dose and heart toxicity in SRT vs. DRT. The V20 Gy and V30 Gy of the right and the left lung in DRT were significantly higher in DRT than in SRT (p < 0.001). The mean heart dose in SRT was significantly lower (3.93 vs. 4.72 Gy, p = 0.005).

Conclusion

We demonstrated a relevant dose exposure of the axilla in SRT that should substantially reduce local recurrences. Furthermore, we demonstrated a significant increase in lung and heart exposure when including the axillary lymph nodes regions in the tangential radiotherapy field set-up.

Zusammenfassung

Ziel

Aktuelle Studien zeigen niedrige regionäre Rezidive beim frühen Mammakarzinom, wenn trotz positiver Biopsie des Wächerlymphknotens („sentinel lymph node dissection“, SLND) keine Axilladissektion („axillary lymph node dissection“, ALND) angeschlossen wird. Diese Ergebnisse führten zu einer Diskussion über die Wertigkeit der adjuvanten tangentialen Strahlentherapie („standard tangential radiotherapy“, SRT) innerhalb dieses neuen Therapiekonzepts. Ziel der Studie ist es, die Dosisverteilung in der Axilla bei der SRT zu analysieren und den Effekt auf das umgebende Normalgewebe darzustellen, wenn der gesamte axilläre Lymphabfluß innerhalb einer definierten Radiotherapie (DRT) gezielt miterfasst wird.

Patienten und Methoden

Wir analysierten prospektiv 51 Therapiepläne von Patientinnen mit frühem Mammakarzinom, die eine Strahlentherapie erhielten. Bei jeder einzelnen Patientin wurden SRT und DRT verglichen und analysierten.

Ergebnisse

Wir evaluierten die Dosis im Bereich der axillären Lymphknotenregionen Level I–III bei SRT im Vergleich zu DRT. Das durchschnittliche VD95 % des gesamten Level I–III bei SRT betrug 50,28 % (Bereich 37,31–63,24 %), das VD45 Gy 70,1 % (Bereich 54,8–85,4 %) und das VD40 Gy 83,5 % (Bereich 72,3–94,8 %). V20 Gy und V30 Gy der rechten und linken Lunge bei DRT waren signifikant höher als bei SRT (p < 0,001) und die mittlere Herzbelastung bei SRT war signifikant niedriger (3,93 vs. 4,72 Gy, p = 0,005).

Schlussfolgerung

Wir zeigten eine relevante Dosis in der Axilla bei SRT, welche substantiell zur Senkung der regionären Rezidive beitragen sollte. Weiterhin fanden wir einen signifikanten Anstieg der Herz- und Lungenbelastung, wenn der gesamte axilläre Lymphabfluß im SRT-Setup gezielt miterfasst wird, auch wenn diese Befunde klinisch wenig relevant sind.

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Conflict of interest

M. Nitsche, N. Temme, M. Förster, M. Reible, and R. M. Hermann state that there are no conflicts of interest.

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Authors and Affiliations

  1. Zentrum für Strahlentherapie und Radioonkologie, Bremen, Germany

    Mirko Nitsche M.D., Nils Temme M.Sc., Manuela Förster, Michael Reible M.D. & Robert Michael Hermann M.D.

  2. Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Kiel, Germany

    Mirko Nitsche M.D.

  3. Abteilung Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Hannover, Germany

    Robert Michael Hermann M.D.

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  1. Mirko Nitsche M.D.
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Nitsche, M., Temme, N., Förster, M. et al. Tangential vs. defined radiotherapy in early breast cancer treatment without axillary lymph node dissection. Strahlenther Onkol 190, 715–721 (2014). https://doi.org/10.1007/s00066-014-0681-6

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