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19 Breast Cancer Breast Cancer 485 19 Breast Cancer Sabin B. Motwani, Eric A. Strom, Marsha D. McNeese, and Thomas A. Buchholz CONTENTS 19.15 Regional Nodal Failure 501 19.15.1 Internal Mammary Chain Radiation – 19.1 Introduction 485 General Concepts 502 19.2 Epidemiology 486 19.16 Postoperative Chest Wall Tangential 19.3 Anatomy 486 Photon Fields 503 19.3.1 Lymphatics 486 19.16.1 Field Borders 503 19.3.2 Lymphatic Drainage 486 19.16.2 Dosimetry 503 19.4 Patterns of Spread 488 19.17 Electron Beam Chest Wall Fields 504 19.4.1 Locoregional 488 19.17.1 Field Borders 504 19.4.2 Systemically 488 19.17.1.1 Dosimetry 505 19.5 Work-Up 489 19.17.1.2 Energy 505 19.5.1 History and Physical Examination 489 19.18 Partly-Deep Tangential Pair Fields 505 19.5.2 Mammography 489 19.18.1 General Concepts 505 19.5.3 Biopsy 489 19.18.1.1 Treatment Planning 505 19.6 Staging 490 19.18.1.2 Dosimetry 505 19.6.1 Axillary Lymph Node Dissection and 19.18.1.3 Energy 505 Sentinel Biopsy 491 19.19 Anterior Supraclavicular–Axillary 19.6.2 Other Studies 492 Photon Field 505 19.6.3 Surgery 492 19.19.1 Field Borders 505 19.7 Radiation Therapy – General Concepts 492 19.19.2 Dosimetry 506 19.7.1 Boost Treatment – General Concepts 493 19.20 Supraclavicular and Axillary Apex Field 19.8 Breast Conservation Radiation Therapy 493 (Electron Beam Technique) 507 19.8.1 Indications 493 19.21 Internal Mammary Chain Radiation 507 19.8.2 Treatment to Breast Only 493 19.21.1 Field Borders 507 19.8.3 Simulation: The University of Texas M. D. Anderson 19.21.2 IM Dosimetry 508 Cancer Center Method, Supine Breast 494 19.22 Axillary Irradiation 508 19.8.4 Virtual Simulation 495 19.22.1 Indications 508 19.8.5 Dosimetry 495 19.23 Posterior Axillary Field 508 19.9 Regional Nodes 495 19.24 Postmastectomy Boost 509 19.10 Boost to Primary Site 495 19.24.1 General Concepts 509 19.11 Supraclavicular Nodal Irradiation 497 19.24.2 Dosimetry 509 19.12 Prone Position Breast Conservation References 509 Radiation Therapy 499 19.12.1 General Concepts 499 19.1 19.12.2 Dosimetry 499 19.12.3 Set-Up 499 Introduction 19.13 Partial Breast Irradiation 500 19.13.1 General Concepts 500 Radiation oncologists may be called on to treat all 19.13.2 Standard Brachytherapy 500 or some of the following in breast cancer patients: 19.13.3 Multiplane, Multineedle Implant 500 19.13.4 MammoSite™ 501 the breast or postmastectomy chest wall, axilla, 19.13.5 Conformal External Beam 501 ipsilateral internal mammary (IM) lymph nodes, 19.14 Postmastectomy Irradiation 501 and the supraclavicular lymph nodes depending 19.14.1 Indications 501 on the clinicopathological features of an individual patient’s disease. This chapter will begin with a brief review of epidemiology, breast anatomy and lym- S. B. Motwani, MD; E. A. Strom, MD; M. D. McNeese, MD; T. A. Buchholz, MD phatic drainage patterns, patterns of spread, work- Department of Radiation Oncology, The University of Texas, up and staging of breast cancer, and will focus on the M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit technical aspects of irradiation to the intact breast 1202, Houston,TX 77030, USA and in the postmastectomy setting. 486 S. B. Motwani et al. 19.2 Epidemiology Breast cancer is the most common cancer of women, with 211,240 estimated new cases reported (2005) annually in the U.S. and 40,410 estimated deaths (Jemal et al. 2005). It is estimated that a woman has a one in eight chance of developing breast cancer sometime in their lifetime (Feuer et al. 1993). The risk of breast cancer is associated with increas- ing age, particularly in women 55 years or older (Devesa et al. 1995). Additionally, genetic, endo- crine and reproductive factors, and family histories all contribute to assessing an individual’s risk for developing breast cancer. It is interesting that there is up to a tenfold difference in breast cancer inci- dence depending on geography and socioeconomic background (Parkin and Muir 1992). Fig. 19.1. Distribution of lymphatic trunks draining breast and chest wall musculature. Intercostal lymphatics are probably 19.3 also directing route of spread. (Reprinted with permission Anatomy from Haagensen 1986) A thin layer of mammary or breast tissue extends portion of the supraclavicular area. There are three from the edge of the sternum medially to the latis- trunks of primary importance: the subclavian trunk simus dorsi muscle laterally, up to the inferior edge from the axilla, the jugular trunk from the neck and of the clavicle superiorly. The breast mound usually supraclavicular area, and the bronchomediastinal extends from the anterior 2nd rib to anterior 6th or trunks. All the trunks combine in a variety of ways 7th rib, depending on the size. This protuberance to empty on the right side into a short common is from near midline to the anterior axillary line, trunk, the right lymphatic trunk, and on the left although the largest volume of tissue is located in the side into the internal jugular vein, subclavian vein, upper-outer quadrant. Often times the breast has or the thoracic duct. a thick portion of tissue extending into the axilla, The axillary lymph nodes are separated into three known as the axillary tail of Spence. A common site anatomically continuous levels using the pectora- for primary tumors, this area can become so promi- lis minor muscle as a point of reference as shown nent that it can form an apparent axillary mass or in Figure 19.2. This muscle has its origin from the give the appearance of a secondary breast mound. third, fourth, and fifth ribs inserting onto the cora- coid process of the scapula. The three levels are: • Level I (proximal) – nodes located inferior (lat- 19.3.1 eral) to the pectoralis minor muscle Lymphatics • Level II (middle) – nodes directly beneath the muscle There is a well-developed lymphatic system within • Level III (distal) – nodes superior (medial) to the the breast with primary drainage to the axilla, supra- muscle clavicular, infraclavicular, and IM lymph nodes as shown in Fig. 19.1. Generally, this drainage moves superiorly and laterally toward the axillary lymph 19.3.2 nodes. These then drain into the confluence of the Lymphatic Drainage internal jugular and subclavian veins in the base of the neck under the insertion of the sternocleido- The primary drainage of the breast tissue is to the mastoid muscle to the head of the clavicle. The lym- ipsilateral lower axilla. Analysis of the degree of phatic trunks are therefore located in the medial axillary lymphatic involvement by the tumor pro- Breast Cancer 487 3 2 B III 4 10 C 5 A 9 II D 11 6 12 1 7 E I 8 F 13 G Fig. 19.2. Anatomy of axilla (pectoralis major and minor muscles partially removed to demonstrate anatomic levels of lymph nodes). Internal mammary artery and vein (1), substernal cross drainage to contralateral internal mammary lymphatic chain (2); subclavian muscle and Halsted’s ligament (3); lateral pectoral nerve (from lateral cord) (4); pectoral branch from thora- coacromial vein (5); pectoralis minor muscle (6); pectoralis major muscle (7); lateral thoracic vein (8); medial pectoral nerve (from medial cord) (9); pectoralis minor muscle (10); median nerve (11); subcapsular vein (12); thoracodorsal vein (13); internal mammary lymph nodes (A); apical lymph nodes (B); interpectoral (Rotter’s) lymph nodes (C); axillary vein lymph nodes (D); central lymph nodes (E); scapular lymph nodes (F); external mammary lymph nodes (G). Level I lymph nodes lateral to lateral border of pectoralis minor muscle; level II lymph nodes behind pectoralis minor muscle; level III lymph nodes medial to medial border of pectoralis minor muscle. (Reprinted with permission from Osborne 1987) vides the most important single prognostic factor Table 19.1. Distribution of 839 cases according to metastatic for breast carcinoma. In general, axillary lymphatic involvement by level involvement occurs in an orderly fashion. It is more Levels involved Number of common to see level-I and -II involvement than I cases (%) and III or III alone. Generally, only level-I and -II I 455 (54.2) nodes are routinely dissected for staging purposes. I+II 187 (22.3) Veronesi I+II+III and I+III 186 (22.2) In a series of 1446 patients, et al. (1990) Total number of cases with regular distribution 828 (98.7) showed that the incidence of skip metastases is quite II 010 (1.2) rare, with only 1.2% showing invasion in level II III 001 (0.1) Total number of cases with ‘skip’ distribution 011 (1.3) without involvement at level I. Conversely, when the nodes at level I were positive, approximately 40% Total 839 (100.0) of higher level nodes were also involved. The dis- tribution of nodal metastases by level is shown in Table 19.1. The other major route of lymphatic spread is of the costal cartilage. They are primarily found in via the ipsilateral internal mammary chain (IMC). the first three intercostal spaces with fewer lymph These nodes are small, 2–5 mm in diameter, and can nodes identified in the fourth and fifth interspaces. be structural nodes or poorly organized collections Ultrasound and lymphoscintigraphy can be used to of lymphocytes in areolar tissue. These nodes are determine the location of these structures, and ultra- grouped around and travel with the IM artery and sound can detect small volume metastases based on vein and generally within a few centimeters of the architectural changes.
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