title: Loco-regional conformal radiotherapy of the breast: delineation of the regional lymph node clinical target volumes in treatment position.
abstract: OBJECTIVE
  As the location of the regional lymph nodes (LNs) of the breast varies largely between patients and may be dependant on the position of the arm, adequate localization of these nodes is mandatory in order to fully take advantage of optimized conformal radiotherapy. For this purpose, the anatomical boundaries of the regional lymph node (LN) clinical target volumes (CTVs) for delineation on transverse CT-slices, made in treatment position, were established.
  
  
  METHODS
  Anatomical and surgical descriptions of the regional LNs of the breast, as well as a shoulder dissection, were studied. Axial slices of a human cadaver with one arm in abduction and the other in adduction were investigated, to assess the displacement of LNs by abduction of the arm into treatment position. Based on these findings, we defined the anatomical boundaries of the regional LN CTVs visible on transverse CT-slices.
  
  
  RESULTS
  Standard anatomical and surgical descriptions appeared to be inadequate for determination of the boundaries of the regional LN CTVs in treatment position. With abduction of the arm, a change in position of all regional LNs, except for the medial supraclavicular LNs and internal mammary LNs, was observed in the anatomical cross-sections. This was also taken into account in our delineation protocol proposal.
  
  
  CONCLUSIONS
  Anatomically based guidelines for delineation of the regional LN CTVs for loco-regional irradiation of the breast on transverse CT-slices, made in treatment position, have been developed in this study. These could be used as a basis for conformal radiotherapy.
authors.affiliation: Department of Radiotherapy, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
authors.forename: Ivessa M
authors.initials: IM
authors.lastname: Dijkema
authors.forename: Pieter
authors.initials: P
authors.lastname: Hofman
authors.forename: Cornelis P J
authors.initials: CP
authors.lastname: Raaijmakers
authors.forename: Jan J
authors.initials: JJ
authors.lastname: Lagendijk
authors.forename: Jan J
authors.initials: JJ
authors.lastname: Battermann
authors.forename: Berend
authors.initials: B
authors.lastname: Hillen
mesh_terms: D001132:Arm; D001365:Axilla; D001940:Breast; D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy*; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008198:Lymph Nodes / Q000000981:diagnostic imaging* / Q000473:pathology; D015182:Lymphatic Irradiation; D011187:Posture; D020266:Radiotherapy, Conformal / Q000379:methods; D014057:Tomography, X-Ray Computed