breast cancer atlas rtog

7/22/2019 Breast Cancer Atlas Rtog

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Breast Cancer Atlas for RadiationTherapy Planning:

Consensus Definitions


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Collaborators

Julia White1, An Tai1, Douglas Arthur2, Thomas Buchholz3,

Shannon MacDonald4, Lawrence Marks5, Lori Pierce6,Abraham Recht7, Rachel Rabinovitch8, Alphonse Taghian4,

Frank Vicini9, Wendy Woodward3, X. Allen Li1

1Medical College of Wisconsin, 2Virginia Commonwealth University, 3M.D.Anderson Cancer Center, 4Massachusetts General Hospital, 5University of North

Carolina, 6University of Michigan, 7Beth Israel Deaconess Medical Center

Hospital, 8University of Colorado, 9 William Beaumont Hospital


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Content

Overlying principles: slides 4 - 6

Consensus definitions of anatomical boundaries:

slides 7 - 12 Illustrative cases:

A: Stage I intact post-lumpectomy left breast(slides 13 - 30)

B: Stage III post-mastectomy left breast

(slides 32 - 51)

C: Stage III intact post-lumpectomy right

breast (slides 54 - 71)3


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Overlying principles: Breast Contour

Breast CTV:

Considers referenced clinical breast at time of

CT Includes the apparent CT glandular breast

tissue Incorporates consensus definitions ofanatomical borders (see table)

Includes the lumpectomy CTV

Lumpectomy GTV: Includes seroma and surgical

clips when present4


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Overlying principles: Chestwall Contour

Chestwall CTV: Considers referenced clinical chestwall at time

of CT

Incorporates consensus definitions of

anatomical borders (see table)

Includes the mastectomy scar(may not be feasiblefor occasional cases where the scar extends beyond the typical

borders of the chestwall)

5


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Overlying principles:Nodal volumesRegional nodal CTV:

Nodal volumes contoured for targeting willdepend on the specific clinical case

Considers consensus definitions of anatomical

borders (see table)

The three levels of the axilla can overlap

caudal to cranial Axillary apex was considered level III

of the axilla

6


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Breast and Chestwall Contour: Anatomical Boundaries

Cranial Caudal Anterior Posterior Lateral Medial

Breast1

Clinical

Reference

+ Secondrib

insertiona

Clinical

reference +

loss of CTapparent

breast

Skin

Excludespectoralis

muscles,chestwall

muscles, ribs

Clinical

Reference +

mid axillary

line typically,

excludeslatissimus

(Lat.) dorsi m.b

Sternal-

ribjunction c

Breast +

Chestwall2Same Same Same

Includespectoralis

muscles,

chestwall

muscles, ribs

Same Same

Chestwall3

Caudal

border of

the

claviclehead

Clinical

reference+

loss of CT

apparent

contralateral

breast

Skin

Rib-pleural

interface.(Includes

pectoralis

muscles,chestwall

muscles, ribs)

Clinical

Reference/

mid axillary

line typically,

excludeslattismus dorsi

m a

Sternal-

rib

junctionb

7


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Contouring Comments:

Breast and Chestwall1. Breast: After appropriate lumpectomy for breast onlytreatment

a. Cranialborder is highly variable depending on breast

size and patient position. The lateral aspect can be

more cranial then the medial aspect depending on

breast shape and patient position.

b. Lateralborder is highly variable depending on breast

size and amount of ptosis.c. Medialborder is highly variable depending on breast

size and amount of ptosis. Clinical reference needs to

be taken into account. Should not cross midline.8


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Breast and Chestwall2. Breast-Chestwall: CTV after appropriate lumpectomy for morelocally advanced cases includes those:

With clinical stage IIb, III who receive neoadjuvantchemotherapy and lumpectomy

Who have sufficient risk disease to require post-mastectomy

radiation had mastectomy done3. Chestwall: CTV after appropriate mastectomy:

a. Lateralborder meant to estimate the lateral border of the previous

breast. Typically extends beyond the lateral edge of thepectoralis muscles but excluded the latissimus dorsi muscle

b. Clinical reference marks need to be taken into account. The

chestwall typically should not cross midline. Medial extent ofmastectomy scar should typically be included 9

R i l N d l C A i l B d i


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Regional Nodal Contours: Anatomical BoundariesCranial Caudal Anterior Posterior Lateral Medial

Supra-

clavicular

Caudal to

the cricoid

cartilage

Junction ofbrachioceph.-

axillary vns./

caudal edge

clavicle heada

Sternocleidomastoid

(SCM)

muscle (m.)

Anterior aspect

of the scalene

m.

Cranial: lateral

edge of SCMm.

Caudal:

junction 1st rib-

clavicle

Excludes

thyroid and

trachea

Axilla-

Level I

Axillary

vessels cross

lateral edge of

Pec. Minor m.

Pectoralis

(Pec.) major

muscle insert

into ribsb

Plane defined

by: anterior

surface of Pec.

Maj. m. and

Lat. Dorsi m.

Anterior

surface of

subscapularis

m.

Medial

border of lat.

dorsi m.

Lateral

border of

Pec. minor

m.

Axilla-

level II

Axillary

vessels cross

medial edge

of Pec. Minor

m.

Axillary vessels

cross lateral

edge of Pec.

Minor m.c

Anterior

surface Pec.

Minor m.

Ribs and

intercostal

muscles

Lateral

border of

Pec. Minor

m.

Medial

border of

Pec. Minor

m.

Axilla-

level III

Pec. Minor

m. insert on

cricoid

Axillary vessels

cross medial

edge of Pec.

Minor m. d.

Posterior

surface Pec.

Major m.

Ribs and

intercostal

muscles

Medial

border of

Pec. Minor

m.

Thoracic

inlet

Internal

mammary

Superior

aspect of the

medial 1st rib.

Cranial aspect

of the 4th rib- e. - e. - e. - e.


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Regional Nodal Volumesa. Supraclavicular caudal bordermeant to approximate the

superior aspect of the breast/ chestwall field border

b. Axillary level I caudal borderis clinically at the base ofthe anterior axillary line

c. Axillary level II caudal borderis the same as the cranial

border of level 1

d. Axillary level III caudal borderis the same as the

cranial border of level IIe. Internal Mammary lymph nodes: encompass the

internal mammary/ thoracic vessels

11


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Case A- Intact post lumpectomy breast Stage I ( T1c, N0, M0) Left breast cancer

Surgery: Lumpectomy and sentinel node biopsy

Radiation: Breast

Six surgical clips placed at lumpectomy site

External markers placed at time of CT: BB at AP set-up point

4 wire markers for clinical estimate of cranial, caudal,

medial, and lateral extent of anticipated tangents Wire extending from 9-3 oclock around the infra-

mammary fold

Wire over the lumpectomy scar12


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Stage IIIB (T-3, N-3, M-0) left breast cancer, tumor size

7 cm, 11/15 nodes positive

Surgery: total mastectomy and axillary done dissection Radiation: chestwall +

Case B: Post-mastectomy, Stage III

regional lymph nodes

External wires present on CT:

Wire on mastectomy scar

BB on AP set-point at clinically estimated level of the

match for the supraclavicular + axilla with thechestwall + IMC fields

Wires at lateral and inferior clinically estimated extent

of the chestwall 31


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Case C: Stage III- Intact breast

l


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post lumpectomy

Stage IIIA (T-2, N-2, M-0) right breast cancer, tumor size 3 cm,

4/18 nodes positive

Surgery: Lumpectomy and axillary node dissection

Radiation: Breast, chestwall + regional lymph nodes

External wires present on CT:

Wire on lumpectomy scar BB on AP set-point at clinically estimated level of the match for

the supraclavicular + axilla with the chestwall + IMC fields

Wire extending from 9-3 oclock around the infra-mammary fold Wires at lateral and inferior clinically estimated extent of the

chestwall

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