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Dose variability in different lymph node levels during locoregional breast cancer irradiation: the impact of deep-inspiration breath hold

Dosisvariabilität verschiedener Lymphknotenstationen während der lokoregionalen Bestrahlung bei Mammakarzinom: Einfluss des Luftanhaltens in tiefer Inspiration

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Abstract

Purpose

Aim of the present analysis was to evaluate the movement and dose variability of the different lymph node levels of node-positive breast cancer patients during adjuvant radiotherapy (RT) with regional nodal irradiation (RNI) in deep-inspiration breath hold (DIBH).

Methods

Thirty-five consecutive node-positive breast cancer patients treated from October 2016 to February 2018 receiving postoperative RT of the breast or chest wall including RNI of the supra-/infraclavicular lymph node levels (corresponding to levels IV, III, Rotter LN (interpectoral), and some parts of level II) were analyzed. To evaluate the lymph node level movement, a center of volume (COV) was obtained for each lymph node level for free-breathing (FB) and DIBH plans. Geometric shifts and dose differences between FB and DIBH were analyzed.

Results

A significant movement of the COV in anterior (y) and cranial (z) dimensions was observed for lymph node levels I–II and Rotter lymph nodes (p < 0.001) due to DIBH. Only minor changes in the lateral dimension (x axis) were observed, without reaching significance for levels III, IV, and internal mammary. There was a significant difference in the mean dose of level I (DIBH vs. FB: 38.2 Gy/41.3 Gy, p < 0.001) and level II (DIBH vs. FB: 45.9 Gy/47.2 Gy, p < 0.001), while there was no significant difference in level III (p = 0.298), level IV (p = 0.476), or internal mammary nodes (p = 0.471).

Conclusion

A significant movement of the axillary lymph node levels was observed during DIBH in anterior and cranial directions for node-positive breast cancer patients in comparison to FB. The movement leads to a significant dose reduction in level I and level II.

Zusammenfassung

Fragestellung

Ziel der vorliegenden Analyse war es, die Bewegungs- und Dosisvariabilität der verschiedenen Lymphknotenstationen nodalpositiver Brustkrebspatientinnen während der adjuvanten Bestrahlung inklusive regionaler Lymphabflussbestrahlung (RNI) in tiefer Inspiration („deep inspiration breath hold“, DIBH) zu bewerten.

Methoden

Von Oktober 2016 bis Februar 2018 wurden 35 nodalpositive Brustkrebspatientinnen mit postoperativer RT der Brust oder Brustwand einschließlich RNI der supra-/infraklavikulären Lymphknotenregionen (entsprechend Level IV, III, Rotter-Lymphknoten interpektoral und Anteile von Level II) untersucht. Zur Beurteilung der Bewegung der Lymphknotenstationen wurde für jedes Lymphknotenlevel der geometrische Volumenmittelpunkt („center of volume“, COV) in freier Atmung („free breathing“, FB) und DIBH ermittelt. Die räumlichen Bewegungen und Dosisunterschiede zwischen FB und DIBH wurden analysiert.

Ergebnisse

Eine signifikante Bewegung des COV in anteriorer (y) und kranialer (z) Richtung wurde für die Lymphknotenlevel I–II sowie für die Rotter-Lymphknoten (p < 0,001) in DIBH beobachtet. Es wurden nur geringe Veränderungen im Bereich der lateralen Dimension (x-Achse) beobachtet, welche für die Level III, IV und die Mammaria-interna-Lymphknoten nicht signifikant waren. Es zeigten sich außerdem signifikante Dosisunterschiede für das Lymphknotenlevel I (DIBH vs. FB: 38,2 Gy/41,3 Gy; p < 0,001) und II (DIBH vs. FB: 45,9 Gy/47,2 Gy; p < 0,001), während es keinen signifikanten Unterschied für das Level III (p = 0,298), IV (p = 0,476) und Mammaria interna (p = 0,471) gab.

Schlussfolgerungen

Eine signifikante Bewegung der axillären Lymphknotenstationen während DIBH wurde vorwiegend in anteriorer und kranialer Richtung im Vergleich zu FB beobachtet. Die Bewegung führte zu einer signifikanten Dosisreduktion innerhalb der Lymphknotenlevel I und II.

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Authors and Affiliations

  1. Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany

    Montserrat Pazos, Aurélie Gaasch, Stephan Schönecker, Daniel Reitz, Christian Heinz, Maximilian Niyazi, Claus Belka &  Stefanie Corradini

  2. Department of Radiation Oncology, Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy

    Alba Fiorentino & Filippo Alongi

  3. Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Ismaningerstr. 22, 81675, Munich, Germany

    Marciana-Nona Duma

  4. University of Brescia, Brescia, Italy

    Filippo Alongi

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  1. Montserrat Pazos
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  2. Alba Fiorentino
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  6. Christian Heinz
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  10. Claus Belka
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  11. Stefanie Corradini
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Corresponding author

Correspondence to Stefanie Corradini.

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Conflict of interest

M. Pazos, A. Fiorentino, A. Gaasch, S. Schönecker, D. Reitz, C. Heinz, M. Niyazi, M.-N. Duma, F. Alongi, C. Belka, and S. Corradini declare that they have no competing interests.

Additional information

Montserrat Pazos and Alba Fiorentino contributed equally.

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Pazos, M., Fiorentino, A., Gaasch, A. et al. Dose variability in different lymph node levels during locoregional breast cancer irradiation: the impact of deep-inspiration breath hold. Strahlenther Onkol 195, 13–20 (2019). https://doi.org/10.1007/s00066-018-1350-y

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