title: Mapping Patterns of Ipsilateral Supraclavicular Nodal Metastases in Breast Cancer: Rethinking the Clinical Target Volume for High-risk Patients.
abstract: OBJECTIVE
  To map the location of metastatic supraclavicular (SCV) lymph nodes (LNMs) in breast cancer patients with SCV node involvement and determine whether and where the radiation therapy clinical target volume (CTV) of this region could be modified in high-risk subsets.
  
  
  METHODS
  Fifty-five patients with metastatic SCV LNMs were eligible for geographic mapping and atlas coverage analysis. All LNMs and their epicenters were registered proportionally by referencing the surrounding landmarks onto simulation computed tomography images of a standard patient. CTVs based on selected SCV atlases, including the one by the Radiation Therapy Oncology Group (RTOG) were contoured. A modified SCV CTV was tried and shown to have better involved-node coverage and thus theoretically improved prophylaxis in this setting.
  
  
  RESULTS
  A total of 50 (91%) and 45 (81.8%) patients had LNMs in the medial and lateral SCV subregions, respectively. Also, 36 patients (65.5%) had LNMs located at the junction of the jugular-subclavian veins. All nodes were covered in only 25.5% to 41.8% of patients by different atlases. The RTOG atlas covered all nodes in 25.5% of patients. Stratified by the nodes in all the patients as a whole, 49.2% to 81.3% were covered, and the RTOG atlas covered 62.6%. The lateral and posterior borders were the most overlooked locations. Modification by extending the borders to natural anatomic barriers allowed the new CTV to cover all the nodes in 81.8% of patients and encompass 96.1% of all the nodes.
  
  
  CONCLUSIONS
  According to the distribution of SCV LNMs, the extent of existing atlases might not be adequate for potential metastatic sites in certain groups of patients. The extension of the lateral and posterior CTV borders in high-risk or recurrent patients might be a reasonable approach for increasing coverage. However, additional data in more homogeneous populations with localized disease are needed before routine application.
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Hao
authors.initials: H
authors.lastname: Jing
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China. Electronic address: wsl20040118@yahoo.com.
authors.forename: Shu-Lian
authors.initials: SL
authors.lastname: Wang
authors.affiliation: Department of Radiology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Jing
authors.initials: J
authors.lastname: Li
authors.affiliation: Department of Radiology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Mei
authors.initials: M
authors.lastname: Xue
authors.affiliation: Department of Radiology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Zu-Kun
authors.initials: ZK
authors.lastname: Xiong
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Jing
authors.initials: J
authors.lastname: Jin
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Wei-Hu
authors.initials: WH
authors.lastname: Wang
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Yong-Wen
authors.initials: YW
authors.lastname: Song
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Yue-Ping
authors.initials: YP
authors.lastname: Liu
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Hua
authors.initials: H
authors.lastname: Ren
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Hui
authors.initials: H
authors.lastname: Fang
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Zi-Hao
authors.initials: ZH
authors.lastname: Yu
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
authors.forename: Xin-Fan
authors.initials: XF
authors.lastname: Liu
authors.affiliation: Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China. Electronic address: yexiong12@163.com.
authors.forename: Ye-Xiong
authors.initials: YX
authors.lastname: Li
mesh_terms: D000328:Adult; D000368:Aged; D059925:Anatomic Landmarks / Q000000981:diagnostic imaging*; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000532:radiotherapy; D002968:Clavicle; D005260:Female; D006801:Humans; D007601:Jugular Veins / Q000000981:diagnostic imaging; D008198:Lymph Nodes / Q000000981:diagnostic imaging*; D008207:Lymphatic Metastasis; D008488:Medical Illustration; D008875:Middle Aged; D056888:Patient Positioning; D058996:Quality Improvement; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods; D018714:Radiotherapy, Adjuvant / Q000379:methods; D012189:Retrospective Studies; D013350:Subclavian Vein / Q000000981:diagnostic imaging; D014057:Tomography, X-Ray Computed / Q000379:methods*; D000069584:Unilateral Breast Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy