title: Breast, chest wall, and nodal irradiation with prone set-up: Results of a hypofractionated trial with a median follow-up of 35 months.
abstract: OBJECTIVE
  To test clinical feasibility, safety, and toxicity of prone hypofractionated breast, chest wall, and nodal radiation therapy.
  
  
  METHODS
  Following either segmental or total mastectomy with axillary node dissection, patients were treated in an institutional review board-approved prospective trial of prone radiation therapy to the breast, chest wall, and supraclavicular and level III axillary lymph nodes. A dose of 40.5 Gy/15 fractions with a concomitant daily boost to the tumor bed of 0.5 Gy (total dose, 48 Gy) was prescribed. In postmastectomy patients, the same treatment was prescribed, but without a tumor bed boost. The primary endpoint was incidence of >grade 2 acute skin toxicity. The secondary endpoints were feasibility of treatment using prone set-up, compliance with protocol-defined dosimetric constraints, and incidence of late toxicity. A dosimetric comparison was performed between protocol plans (prone) and nonprotocol plans (supine), targeting the same treatment volumes.
  
  
  RESULTS
  Sixty-nine patients with stage IB-IIIA breast cancer enrolled in this trial. Surgery was segmental mastectomy (n = 45), mastectomy (n = 23), and bilateral mastectomy (n = 1), resulting in 70 cases. None experienced >grade 2 acute skin toxicity according to the Common Terminology Criteria for Adverse Events, v 3.0, meeting our primary endpoint. Ninety-six percent of patients could be treated with this technique prone. However, 17 plans (24%) exceeded protocol constraints to the brachial plexus. Maximum long-term toxicity was 1 grade 2 arm lymphedema, 1 grade 3 breast retraction, and no occurrence of brachial plexopathy. Dosimetric comparison of protocol with nonprotocol plans demonstrated significantly decreased lung and heart doses in prone plans.
  
  
  CONCLUSIONS
  Prone hypofractionated breast, chest wall, and nodal radiation therapy is safe and well tolerated in this study. Although the initial pattern of local and regional control is encouraging, longer follow-up is warranted for efficacy and late toxicity assessment, particularly to the brachial plexus.
authors.affiliation: Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York.
authors.forename: Samuel Minkee
authors.initials: SM
authors.lastname: Shin
authors.affiliation: Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York.
authors.forename: Hyun Soo
authors.initials: HS
authors.lastname: No
authors.affiliation: Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York.
authors.forename: Raymond Mailhot
authors.initials: RM
authors.lastname: Vega
authors.affiliation: Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York.
authors.forename: Maria
authors.initials: M
authors.lastname: Fenton-Kerimian
authors.affiliation: Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York.
authors.forename: Olivier
authors.initials: O
authors.lastname: Maisonet
authors.affiliation: Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York.
authors.forename: Christine
authors.initials: C
authors.lastname: Hitchen
authors.affiliation: Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York.
authors.forename: J
authors.initials: J
authors.lastname: Keith DeWyngaert
authors.affiliation: Department of Radiation Oncology, New York Weill Cornell Medical Center, New York, New York. Electronic address: Formenti@med.cornell.edu.
authors.forename: Silvia Chiara
authors.initials: SC
authors.lastname: Formenti
mesh_terms: D000328:Adult; D001940:Breast / Q000473:pathology*; D001943:Breast Neoplasms / Q000532:radiotherapy*; D019583:Dose Fractionation, Radiation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016684:Prone Position; D035441:Thoracic Wall / Q000473:pathology*