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Sentinel Node Lymphoscintigraphy and Internal Mammary Nodal Drainage Assessment in Breast Cancer Patients
Proceedings of the 47th Annual ASTRO Meeting
Conclusions: MR imaging could be a valuable tool in better defining tumor bed for partial breast irradiation, young patients, if the delay from surgery is long, and for centrally located tumors.
2004
Sentinel Node Lymphoscintigraphy and Internal Mammary Nodal Drainage Assessment in Breast Cancer Patients
M. Yao,1 D. Byrd,2 E. Schubert,3 L. Dunnwald,3 B. Anderson,2 R. Moe,2 R. Yeung,2 G. Mann,2 J. Eary,3 D. Mankoff3 Radiation Oncology, University of Washington, Seattle, WA, 2Surgery, University of Washington, Seattle, WA, 3Nuclear Medicine, University of Washington, Seattle, WA 1
Purpose/Objective: The internal mammary nodes (IMNs) are a clinically important, but difficult to assess, site of lymphatic drainage from the breast. Elective coverage of this region in the setting of adjuvant radiation in breast cancer patients has been controversial, and a consensus on appropriate patient selection criteria for such treatment are lacking. The objectives of this study are to 1) delineate predictors of IMN drainage and 2) describe specific sites of IMN drainage in a large series of breast cancer patients who underwent lymphoscintigraphic sentinel node mapping as part of their surgical staging. Materials/Methods: The records of 855 consecutive patients in our institution who underwent pre-operative peri-tumoral injection of 0.22 micron filtered Tc-99m sulfur radiocolloid and lymphoscintigraphy prior to sentinel lymph node biopsy for breast malignancies were reviewed. Patient, tumor, and technical variables were analyzed for value in predicting IMN drainage in the 729 of these patients in whom sentinel nodes were identified at the time of lymphoscintigraphy, including 194 patients who were found to have positive axillary nodes. Results: Of the 729 patients in whom sentinel nodes were identified at the time of lymphoscintigraphy, 120 (16.5%) had drainage to the IMN chain, including 11 (1.5%) in whom the IMN were the only site of drainage. Lesion location was the strongest predictor of IMN drainage (p⬍0.0001). Pre-menopausal (Pre-) patients were more likely than post-menopausal (Post-) patients to have IMN drainage (20.1% vs. 14.0%, p ⫽ .03). The frequencies of IMN drainage in the whole population (All) and Pre- and Post- subgroups, are summarized on the left side of the table below. Neither tumor size, grade, histology, axillary nodal positivity, presence of angiolymphatic space invasion, hormone receptor status, HER-2/neu or p53 overexpression, nor tumor proliferative rate were predictive of IMN drainage. Detailed description of drainage locations, including intercostal (IC) space, were available for 54 of the 120 patients who mapped to the IMNs, with results summarized in the right side of the table. Conclusions: Pre-operative lymphoscintigraphy following peri-tumoral injection successfully identified at least one sentinel node in 85% of 855 patients (94% of pre-menopausal and 81% of post-menopausal). In patients in whom any sentinel node was seen, the presence of IMN drainage pathways was predicted by tumor location within the breast and menopausal status, with values ranging from 8% to 42% within subgroups divided on the basis of these two variables. Detailed mapping of 54 patients who had drainage to the IMN chain showed that these sentinel nodes mapped to the 1st through 7th IC spaces. While the majority of the nodes fell within the first 3 IC spaces, a surprising 46% of these patients had nodes that may have been outside of empirically delineated elective IMN radiation portals. These findings suggest that lymphoscintigraphy using peri-tumoral injection may be a valuable tool in refining the patient selection process and individualizing the field design for IMN irradiation. Further study, including pathology correlation and clinical endpoints, is warranted. Supported in part by NIH Grant CA90771.
2005
The Effect of Location and Size of Planning Target Volume (PTV) on the Dose-Volume Histogram (DVH) of the Ipsilateral Breast in 3D Conformal, External Beam Partial Breast Radiotherapy (PBRT)
A.Y. Kee, R. Choo, B. Debra, I. Petersen, P. Schomberg, D. Schickell, T. Pisansky, Y. Garces Radiation Oncology, Mayo Clinic, Rochester, MN Purpose/Objective: One of the goals of PBRT is to minimize dose to the unaffected breast tissue while delivering an intended, high dose to the target area. The purpose of this study is to examine the effect of location and size of PTV on DVH of the breast in external beam PBRT. Materials/Methods: A normal, unaffected, left breast of a breast cancer patient was selected for this study. CT images of the breast were obtained with 2.5 mm thickness per slice. The breast volume (BV) was calculated, using the following boundaries (medial: mid-sternum; lateral: mid-axilla; superior: sternal notch; inferior: 2 cm below the infra-mammary crease; anterior: skin;
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Conclusions: MR imaging could be a valuable tool in better defining tumor bed for partial breast irradiation, young patients, if the delay from surgery is long, and for centrally located tumors.
2004
Sentinel Node Lymphoscintigraphy and Internal Mammary Nodal Drainage Assessment in Breast Cancer Patients
M. Yao,1 D. Byrd,2 E. Schubert,3 L. Dunnwald,3 B. Anderson,2 R. Moe,2 R. Yeung,2 G. Mann,2 J. Eary,3 D. Mankoff3 Radiation Oncology, University of Washington, Seattle, WA, 2Surgery, University of Washington, Seattle, WA, 3Nuclear Medicine, University of Washington, Seattle, WA 1
Purpose/Objective: The internal mammary nodes (IMNs) are a clinically important, but difficult to assess, site of lymphatic drainage from the breast. Elective coverage of this region in the setting of adjuvant radiation in breast cancer patients has been controversial, and a consensus on appropriate patient selection criteria for such treatment are lacking. The objectives of this study are to 1) delineate predictors of IMN drainage and 2) describe specific sites of IMN drainage in a large series of breast cancer patients who underwent lymphoscintigraphic sentinel node mapping as part of their surgical staging. Materials/Methods: The records of 855 consecutive patients in our institution who underwent pre-operative peri-tumoral injection of 0.22 micron filtered Tc-99m sulfur radiocolloid and lymphoscintigraphy prior to sentinel lymph node biopsy for breast malignancies were reviewed. Patient, tumor, and technical variables were analyzed for value in predicting IMN drainage in the 729 of these patients in whom sentinel nodes were identified at the time of lymphoscintigraphy, including 194 patients who were found to have positive axillary nodes. Results: Of the 729 patients in whom sentinel nodes were identified at the time of lymphoscintigraphy, 120 (16.5%) had drainage to the IMN chain, including 11 (1.5%) in whom the IMN were the only site of drainage. Lesion location was the strongest predictor of IMN drainage (p⬍0.0001). Pre-menopausal (Pre-) patients were more likely than post-menopausal (Post-) patients to have IMN drainage (20.1% vs. 14.0%, p ⫽ .03). The frequencies of IMN drainage in the whole population (All) and Pre- and Post- subgroups, are summarized on the left side of the table below. Neither tumor size, grade, histology, axillary nodal positivity, presence of angiolymphatic space invasion, hormone receptor status, HER-2/neu or p53 overexpression, nor tumor proliferative rate were predictive of IMN drainage. Detailed description of drainage locations, including intercostal (IC) space, were available for 54 of the 120 patients who mapped to the IMNs, with results summarized in the right side of the table. Conclusions: Pre-operative lymphoscintigraphy following peri-tumoral injection successfully identified at least one sentinel node in 85% of 855 patients (94% of pre-menopausal and 81% of post-menopausal). In patients in whom any sentinel node was seen, the presence of IMN drainage pathways was predicted by tumor location within the breast and menopausal status, with values ranging from 8% to 42% within subgroups divided on the basis of these two variables. Detailed mapping of 54 patients who had drainage to the IMN chain showed that these sentinel nodes mapped to the 1st through 7th IC spaces. While the majority of the nodes fell within the first 3 IC spaces, a surprising 46% of these patients had nodes that may have been outside of empirically delineated elective IMN radiation portals. These findings suggest that lymphoscintigraphy using peri-tumoral injection may be a valuable tool in refining the patient selection process and individualizing the field design for IMN irradiation. Further study, including pathology correlation and clinical endpoints, is warranted. Supported in part by NIH Grant CA90771.
2005
The Effect of Location and Size of Planning Target Volume (PTV) on the Dose-Volume Histogram (DVH) of the Ipsilateral Breast in 3D Conformal, External Beam Partial Breast Radiotherapy (PBRT)
A.Y. Kee, R. Choo, B. Debra, I. Petersen, P. Schomberg, D. Schickell, T. Pisansky, Y. Garces Radiation Oncology, Mayo Clinic, Rochester, MN Purpose/Objective: One of the goals of PBRT is to minimize dose to the unaffected breast tissue while delivering an intended, high dose to the target area. The purpose of this study is to examine the effect of location and size of PTV on DVH of the breast in external beam PBRT. Materials/Methods: A normal, unaffected, left breast of a breast cancer patient was selected for this study. CT images of the breast were obtained with 2.5 mm thickness per slice. The breast volume (BV) was calculated, using the following boundaries (medial: mid-sternum; lateral: mid-axilla; superior: sternal notch; inferior: 2 cm below the infra-mammary crease; anterior: skin;
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