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

Authors Wang W, Zhang Y, Xu M, Shao Q, Sun T, Yu T, Liu X, Li J

Received 16 October 2018

Accepted for publication 27 December 2018

Published 30 January 2019 Volume 2019:11 Pages 1097—1106


Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 2

Editor who approved publication: Dr Antonella D'Anneo

Wei Wang,1 Yingjie Zhang,1 Min Xu,1 Qian Shao,1 Tao Sun,2 Ting Yu,1,3 Xijun Liu,1 Jianbin Li1

1Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Jinan, Shandong 250117, China; 2Department of Medical Physics, Shandong Cancer Hospital affiliated with Shandong University, Jinan, Shandong 250117, China; 3School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250117, China

Objective: To 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 methods: We 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.
Results: The 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.
Conclusion: The 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.

Keywords: postmastectomy radiotherapy, internal mammary chain incidental irradiation dose, three-dimensional conformal radiotherapy, field-in-field forward intensity-modulated radiotherapy, inverse IMRT

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