Elisabeth Kildegaard Madsen, E.K.M.

Martin Berg, M.B.

Pupovici, G.

Elsevier - Publisher Connector 

2nd ESTRO Forum 2013   S395 
Conclusions: IMRT planning achieves better dose coverage and 
homogeneity in comprehensive irradiation in breast cancer; however, 
it increases dose to carotid artery as compared to conventional 
3DCRT. Byspecifying dose constraint to the carotid artery, it is 
possible to reduce carotid artery doses in IMRT plans by improving 
dose conformity and homogeneity. It seems reasonable to designate 
carotid artery as a dose limited structure for long term survivors with 
high risks for vascular disorders.  
   
EP-1041   
Acute and late toxicity with hypofractionated radiation therapy for 
early breast cancer compared to conventional RT 
A. Podgornii1, M. Galeandro1, D. Ramundo1, F. Vigo1, R. Micera1, E. 
Cagni1, C. Bassi1, C. Iotti1, P. Ciammella1 
1Arcispedale S. Maria Nuova, Advanced thecnologies, Reggio Emilia, 
Italy  
 
Purpose/Objective: The purpose of the present study is to evaluate 
toxicity and cosmetic outcome in breast cancer survivors treated with 
hypo-fractionated adjuvant radiotherapy (HF-RT) and to identify risk 
factors for toxicity, with special focus on the impact of age, co 
morbidities and chemotherapy. For comparison, a group of 65 patients 
with similar characteristics and consecutively treated with 
conventional fractionation was retrospectively selected. 
Materials and Methods: From April 2010 and May 2012, 190 women 
with early breast cancer were treated with HF-RT, after conserving 
surgery. The patients received 40.05 Gy in 15 fractions. The boost to 
the tumour bed was administered with a total dose of 9 Gy in 3 
consecutive fractions in 50 women due to young age (< 50 yrs) or to 
positive margins. Physician-rated toxicity and cosmetic outcomes 
were prospectively assessed during yearly follow-up after 
radiotherapy.  
Results: In the HF-RT group, the mean age was 69 years. 11% and 32% 
patients were affected by diabetes mellitus and hypertension, 
respectively. 13% had tumors that were 2 cm or larger in diameter; 
pTis = 17%, pT1a= 6%, pT1b= 23%, pT1c=41%, pT2=13% ; 10% had 
estrogen-receptor–negative disease and 29 % had high-grade disease. 
Pre-operative chemotherapy was administered in 10 patients; 
adjuvant systemic therapy and hormone therapy were given in 19 
patients, while 11 and 115 patients received chemotherapy or 
hormone therapy alone, respectively. The mean follow-up was 19 
months (range 6-32 months). The median time from surgery was 29 
days, with overall median treatment duration of 22 days. At last 
follow up all patients are alive without local recurrence. By the end of 
RT 18% of the patients treated with HF-RT developed no toxicity, 
while 55.7% showed grade 1 and 13.3% grade 2 acute skin toxicity. 
Only one patient experienced a grade 3 acute skin toxicity. In the 
control group, early G1 reactions were observed in 24 patients (42%); 
19% of patients showed G2 acute toxicity and only one patient 
developed G3 acute reaction. Neither grade 4 skin ulceration nor soft 
tissue necrosis was observed. Late toxicity was assessed after 6 
months from RT completion in 120/190 patients in the 
hypofractionation group and in 51/65 patients in the standard RT 
group. Late toxicity according to the RTOG criteria was observed in 9 
patients (7.5%) in the HF-RT group and in 4 patients (8%) in the 
conventional fractionated radiation group. The difference was not 
statistically significant. Cosmetic result was assessed and scored at 
the RT end and 6 months later: at last follow up, 71% of women in the 
control-group as compared with 68.8% of the women in the HF-RT 
group had a good or excellent cosmetic outcome. 
Conclusions: Our results confirm the feasibility of the HF-RT with 2,67 
Gy/fx to a total dose of 40,05 Gy in patients with breast cancer. If 
compared with conventional RT group, the hypofractionation not 
seems to increase the late toxicity. Long-term follow up is need to 
confirm this finding. 
   
EP-1042   
Preliminary results of neoadjuvant chemotherapy for cN3 breast 
cancer patients 
S. Kim1, S. Ahn1, S. Lee1, E. Choi1, S. Ahn2, B. Son2, J. Lee2, S. Kim3, K. 
Jung3, J. Ahn3 
 
1Asan Medical Center Univ of Ulsan, Radiation Oncology, Seoul, Korea 
Republic of  
2Asan Medical Center Univ of Ulsan, Surgery, Seoul, Korea Republic of  
3Asan Medical Center Univ of Ulsan, Oncology, Seoul, Korea Republic 
of  
Purpose/Objective: To analyze the treatment results of cN3 breast 
cancer patients who treated with neoadjuvant chemotherapy 
Materials and Methods: Between 2003 and 2009, Of 241 breast cancer 
patients who received neoadjuvant chemotherapy, 52 cN3 non-
inflammatory patients were included. Median age was 43 years (range 
25-75). Clinical T-stage were T1 (5.8%), T2 (38.5%), T3 (48.0%) and T4 
(7.7%). Clinical N-stage were N3a (11.5%), N3b (25.0%), and 
N3c(63.5%). N3 lesions were detected on PET-CT in 43 patients (82.7%) 
and confirmed histolotically in 30 patients (57.7%). Antracycline- 
and/or taxane-based neoadjuvant chemotherapy were delivered to 
98.1% of patients. Breast conserving surgery was enabled to 14 
patients (26.9%), others received mastectomy alone (59.6%) or 
mastectomy with immediate reconstruction (13.5%). Excision of N3 
lesion was performed in 18 patients (34.6%). Adjuvant radiation 
therapy were performed in 44 patients (84.6%), and 23 patients 
received radiation dose more than 50.4 Gy to N3 region. 
Results: Median follow-up period was 41 months. Actuarial four-year 
overall, disease-free, locoregional-recurrence-free survival rate were 
72.4, 49.1, and 70.7% respectively. Actuarial four-year control rate of 
N3 region was 74.6%. Univariate risk factor analysis revealed ypN 
stage and ypStage as significant risk factors for loco-regional, disease-
free, and over survival rate. Excisional biopsy and higher dose to N3 
region were proved not to be correlated with regional control rate. 
Conclusions: Neoadjuvant chemotherapy followed by curative 
resection and adjuvant radiation therapy accomplished comparable 
treatment results for regionally-advanced breast cancer patients. 
More patients and longer follow-up are mandatory to investigate the 
optimal locoregional treatment regimen after neoadjuvant 
chemotherapy. 
   
EP-1043   
Target coverage and brachial plexus dose in regional adjuvant 
radiotherapy for breast cancer 
F. Duane1, E. McVeigh2, M. Dunne3, C. Faul1, O. McArdle1 
1St. Luke's Radiation Oncology Network, Department of Radiation 
Oncology, Dublin, Ireland Republic of  
2St. Luke's Radiation Oncology Network, Department of Radiation 
Therapy, Dublin, Ireland Republic of  
3St. Luke's Radiation Oncology Network, Clinical Trials Unit, Dublin, 
Ireland Republic of  
 
Purpose/Objective: This study aims to estimate the dose received by 
the supraclavicular fossa (SCF) and levels I,II and III of the axilla in 
patients with breast carcinoma undergoing regional adjuvant 
radiotherapy using routine planning techniques. Dose to the brachial 
plexus was also evaluated. 
Materials and Methods: A CT-planning study of 24 patients was 
conducted. The BP and nodal target volumes were contoured and five 
treatment plans were generated for each patient. Treatment 
techniques included (i) standard tangential fields; (ii) high tangential 
fields (HTF); (iii) 3-field technique targeting the SCF; (iv) 3-field 
technique targeting the SCF and axilla level III; (v) technique targeting 
the full nodal region, the SCF and axilla levels I-III. Dose-volume 
histograms were used to evaluate the percentage volume of the target 
covered by the 95% isodose (V95%) to assess target coverage, and the 
maximum and mean dose to the brachial plexus and the volume of this 
organ at risk receiving 45,48, and 50Gy. 
Results: Using standard tangential fields V95% for axilla level I was 
39.6% and for level II was 2.7%. Using HTF the V95% for axilla level I 
was 90% and 55% for level II. Suboptimal coverage of the SCF target 
volume was noted for each of the three techniques targeting this 
volume. The mean maximum BP dose was 50.9Gy for treatment to the 
SCF alone, 51.1Gy for treatment to the SCF and axilla level III, and 
53.2Gy for full nodal treatment. The mean irradiated BP volume 
receiveg > 45Gy was 49.5%, 65.4% and 77.7% for these groups 
respectively. 
Conclusions: It is important to be aware of the expected coverage for 
axillary levels I-III when using common radiotherapy regimens 
particularly given the current controversy over axillary management. 
Using conventional tangential fields suboptimal coverage of level I was 
achieved and Level II received only a minimal dose. Axillary levels 
should be contoured in node positive patients and coverage should be 
documented. As with previous studies our study shows that routine 
radiation prescriptions do not optimally cover intended targets for 
every patient. The BP dose should be considered for patients 
undergoing full nodal treatment.  
   
EP-1044   
Delineation of clinical target volumes for radiotherapy of the 
breast: consequences for treatment plans 
G. Pupovici1, E.K.M. Elisabeth Kildegaard Madsen1, M.B. Martin Berg1 
1Department of Oncology, Medical Physics, Vejle, Denmark  
 
Purpose/Objective: The delineation of target and organs at risk 
(OARs) is a central part of the treatment planning of postoperative 
radiotherapy for breast cancer patients. We performed an 
investigation of the consequences of inter-observer variation in the 
delineation of the clinical target volume (CTV), heart and left anterior 
S396  2nd ESTRO Forum 2013 
descending coronary artery (LADCA) for the dose distribution for a left 
sided breast cancer patient. 
Materials and Methods: One left-sided breast cancer patient treated 
with adjuvant radiotherapy after a breast-conserving operation in 
November 2012 was chosen randomly. The patient was scanned with 
2.5 mm slice thickness without contrast. Oncentra® External Beam 
v3.3 (Nucletron, An Elekta Company) was used for delineation and 
planning (collapsed cone algorithm).The individual delineations (IDs) 
of the CTV, heart and LADCA were performed by six experienced 
radiographers and one experienced radiation oncologist according to 
our written clinical guidelines. Finally, two experienced radiographers 
and two radiation oncologists agreed on consensus delineation (CD) of 
all three volumes.The dice similarity coefficient (DSC) was used to 
evaluate the overlap accuracy between the CTV and the heart for 
each ID using the CD as a reference. Treatment plans for each of the 
seven IDs and the CD were optimised according to the clinical 
guidelines by one radiographer. The volume of the CTV receiving 95 % 
of the prescribed dose (50 Gy/25 fractions) or higher (V95%) and dose 
to heart and LADCA from each treatment plan were found for the CD 
structures. 
Results: The volumes of the CD CTV and heart were 664.5 cm3 and 
550.8 cm3, respectively. For the seven IDs the median value for the 
CTV and heart were 672.1 cm3 (range 641.4 – 692.5 cm3) and 546.7 
cm3 (539.9 – 561.5 cm3), respectively. Median values of DSC for the 
CTV and heart were 0.96 (0.94 – 0.98) and 0.97 (0.95 – 0.98), 
respectively. All ID structures were delineated in the same slices as 
the CD ± one slice except for one LADCA delineation that differed by 
two slices. Delineations in one slice are shown in Figure 1. For the 
seven treatment plans, the median V95% for the ID CTVs was 97.8 % 
(97.3 – 98.0 %). Evaluation of dose to CTV as defined on the CD from 
each of the seven treatment plans resulted in a median V95% of 97.9 % 
(97.8 – 98.0). Dose constraints for the heart (V20Gy<10 %, V40Gy<5%) and 
LADCA (Dmax<20 Gy) were not violated in any of the seven treatment 
plans. 
Conclusions: The results of DSC for the delineated CTV and OARs for a 
left sided breast cancer patient show only a slight variation in 
delineation. No clinical relevant differences in delineation of CTV 
were seen between radiographers and the oncologist when using the 
same clinical guidelines. This is believed to be due to precisely 
described guidelines and education. Furthermore the small variations 
in delineations is believed to have no clinical influence on the 
treatments as seen from the very small differences in dose coverage 
for the CD CTV as well as the dose to the CD OARs in the treatment 
plans based on the IDs. 
 
 EP-1045   
Quality of life and cosmetic results in breast cancer patients after 
whole breast or partial breast irradiation 
E. Perrucci1, V. Lancellotta2, V. Bini3, A. Farneti2, L. Falcinelli1, I. 
Palumbo2, C. Zucchetti4, G. Capezzali1, C. Aristei2 
1University Hospital Santa Maria della Misericordia, Radiotherapy 
Oncology, Perugia, Italy  
2University Hospital Santa Maria della Misericordia, Department of 
Scienze Onco-Emato-Gastroenterologiche, Perugia, Italy  
3University Hospital Santa Maria della Misericordia, Department of 
Internal Medicine, Perugia, Italy  
4University Hospital Santa Maria della Misericordia, Department of 
Medical Physics, Perugia, Italy  
 
Purpose/Objective: In early breast cancer patients conservative 
therapy followed by whole breast radiotherapy (WBI) offers a good 
quality of life (QoL). Although partial breast irradiation (PBI) is 
increasingly used as an alternative to WBI in selected groups of 
patients, its impact on QoL has not been extensively studied. This 
study assessed patients’ QoL after PBI with high-dose rate interstitial 
brachytherapy (BRT) compared with WBI.  
Materials and Methods: QoL was evaluated in 39 PBI patients, 
enrolled in a phase II prospective study (32 Gy in two daily fractions 
over 4 days) and in 78 matched WBI controls (50 Gy standard 
fractionation ± 10 Gy boost). Ten-item self-administered close-
response questionnaire, exploring body image, fear of recurrence, 
satisfaction with treatment and cosmetic results, was administered 
twice during follow-up at a mean of 20 and 80 months after 
treatment. Italian version of questionnaire was asseverated. 
Physicians’ and patients’ cosmetic assessments were compared. 
Chemotherapy and hormonal therapy effect on cosmetics was 
analysed. The Mann-Whitney test and Wilcoxon test compared the 
results. The X2 test was used for categorical data. For concordance 
between judgements was used Cohen’s k-test of inter-rater 
agreement. Strength of agreement was interpreted according to the 
Landis and Koch’s gradation. P <0.05 was considered significant. 
Results: The two groups were well matched, except higher 
chemotherapy-treated patients in WBI group (41% vs 15%, p = 0.004). 
At first analysis no significant difference emerged on body image and 
fear of recurrence scales. PBI patients were more satisfied with 
treatment (p=0.019) and cosmetic outcome (p=0.0001). Second 
analysis included 96 patients, 33 in the PBI group, 63 in the WBI 
group. No significant differences were found on body image or fear of 
recurrence scales. Cosmetic outcome was better in PBI group 
(p=0.002). Results from the first and the second analysis were 
compared into each treatment group. Body image scale was 
significantly better at the first analysis in both groups (p=0.001 for 
PBI; p=0.0001 for WBI). Fear of recurrence scale was unchanged. No 
differences were found in cosmetic outcome as assessed by patients. 
In the first analysis physicians assessed cosmetic outcome as 
significantly better in PBI group (p= 0.0001) and confirmed it at 
second analysis. Physicians’ and patients’ opinions on cosmetics 
diverged (k = 0.148 at 2 years, 0.023 at 5 years) with physicians 
judging outcomes better than patients. Adjuvant chemotherapy had 
no impact of on cosmetics in either group according to physicians and 
patients.  
Conclusions: Even at longer follow-up, QoL is similar after BRT PBI or 
WBI in terms of body image, fear of recurrence and satisfaction with 
treatment; PBI provides a significantly better cosmetic outcome.  
 
EP-1046   
Comparison between different forms of assessment of in-air PTV in 
breast irradiation with forward IMRT 
P. Meireles1, A.R. Figueira1, A. Monteiro1, L. Osório1, A.P. Soares1, J. 
Pinheiro1, M.J. Fontes1, P. Varzim1, G. Pinto1 
1Centro Hospitalar São João, Radiotherapy, Porto, Portugal  
 
Purpose/Objective: The ICRU Report 83 suggests several methods to 
evaluate a PTV extending outside the contour of the body, ensuring an 
adequate treatment of the CTV volume. When Forward IMRT (F-IMRT) 
techniques are used, as is common in breast cases, tools like 
automatic fluence extension sometimes are not available. The 
purpose of this study was to analyse different approaches to correctly 
evaluate PTV dose in breast F-IMRT. 
Materials and Methods: We analyzed data from 40 patients 
undergoing radiotherapy after breast conserving surgery. The patients 
were submitted to a CT for virtual simulation with 3 mm slices. Target 
volumes were outlined: breast CTV and PTV (expansions of 10 mm 
were made for all directions except for the posterior one, which was 7 
mm). This PTV extends outside the body surface. Two sub-volumes of 
PTV were further established: a PTV-SV1, corresponding to the PTV 3 
mm inside the body, and a PTV-SV2, corresponding to the rest of the 
PTV (mostly air). Treatment plans were made with a forward IMRT 
technique using ELEKTA XiO 4.70 treatment planning system, with a 
superposition calculation algorithm. To each patient 3 dosimetric 
plans, to be delivered with a 6 MV SIEMENS Primus linac, were 
calculated according to the following situations:  
Plan 1. Using the delineated PTV extended outside the body surface. 
Plan 2. Extending the body surface to include all PTV volume. 
Plan 3. Same as Plan 2 but attributing a density to PTV-SV2 equal to 
the mean breast density. 
For each of these situations we evaluated the mean dose to PTV and 
PTV-SV1 according to the ICRU 83 Report. 
Results: We have obtained different results for each of the studied 
situations. In all approaches the Dmean to PTV-SV1 was similar to the 
prescription dose of 50Gy. However, only when a density was 
atributted to PTV-SV2 (Plan 3) the Dmean in PTV approached the 
prescription dose. 


EP-1044: Delineation of clinical target volumes for radiotherapy of the breast: consequences for treatment plans 

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EP-1044: Delineation of clinical target volumes for radiotherapy of the breast: consequences for treatment plans

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