Post mastectomy linac IMRT irradiation of chest wall and regional nodes: dosimetry data and acute toxicities

Background: Conventional post-mastectomy radiation therapy is delivered with tangential fields for chest wall and separate fields for regional nodes. Although chest wall and regional nodes delineation has been discussed with RTOG contouring atlas, CT-based planning to treat chest wall and regional nodes as a whole target has not been widely accepted. We herein discuss the dosimetric characteristics of a linac IMRT technique for treating chest wall and regional nodes as a whole PTV after modified radical mastectomy, and observe acute toxicities following irradiation. Methods: Patients indicated for PMRT were eligible. Chest wall and supra/infraclavicular region +/-internal mammary nodes were contoured as a whole PTV on planning CT. A simplified linac IMRT plan was designed using either integrated full beams or two segments of half beams split at caudal edge of clavicle head. DVHs were used to evaluate plans. The acute toxicities were followed up regularly. Results: Totally, 85 patients were enrolled. Of these, 45 had left-sided lesions, and 35 received IMN irradiation. Planning designs yielded 55 integrated and 30 segmented plans, with median number of beams of 8 (6-12). The integrated and segmented plans had similar conformity (1.41 +/- 0.14 vs. 1.47 +/- 0.15, p=0.053) and homogeneity indexes (0.13 +/- 0.01 vs. 0.14 +/- 0.02, p=0.069). The percent volume of PTV receiving >110% prescription dose was <5%. As compared to segmented plans, integrated plans typically increased V-5 of ipsilateral lung (p=0.005), and heart (p=0.001) in patients with left-sided lesions. Similarly, integrated plans had higher spinal cord D-max (p=0.009), ipsilateral humeral head (p<0.001), and contralateral lung D-mean (p=0.019). During follow-up, 36 (42%) were identified to have >= grade 2 radiation dermatitis (RD). Of these, 35 developed moist desquamation. The median time to onset of moist desquamation was 6 (4-7) weeks from start of RT. The sites of moist desquamation were most frequently occurred in anterior axillary fold (32/35), and secondly chest wall (12/35). The difference in occurrence of >= grade 2 RD between integrated and segmented plans was statistically insignificant (X-2=0.35, p=0.55). Only 2 were found to have grade 2 radiation pneumonitis. Conclusions: The linac IMRT technique applied in PMRT with chest wall and regional nodes as a whole PTV was dosimetrically feasible, and the treatment was proved to be well-tolerated by most patients.