Dosimetric Evaluation of Cervical Oesophagus as an Organ at Risk in Breast Cancer Radiotherapy
Objectives: The current study intends to analyze dose-volume parameters of the cervical oesophagus (CO) as an organ at risk (OAR) during radiotherapy (RT) to the supraclavicular fossa (SCF) in breast cancer (BC) patients.
Methods: Plans of 97 consecutive BC patients receiving 40 Gy/15 fractions were reviewed. The CO was retrospectively contoured from the cricopharyngeal junction to the sternal notch. Dmax, Dmean, V10, V20, and V30 to the CO, as well as the RT technique, were noted.
Results: 53/97 patients had right BC, and 44/97 had left BC. 69/97, 17/97, and 11/97 were treated with 3DCRT, IMRT, and VMAT, respectively. Mean length of CO=8.3±1.3 cm; CO-Dmax=37.95±5.16 Gy; Dmean=17.48±7.7 Gy. Mean V10=60.12±26%, V20=41.75±24%, V30=25.04±19.8%. Patients with right BC had a lower CO-Dmax of 36.45±6.9 Gy and lower Dmean=14.54±7.12 Gy to CO, compared to left BC with CO-Dmax=39.75±2.4 Gy (p=0.017), and Dmean=21.2±7.2 Gy (p=0.0001).
Conclusion: The cervical oesophagus receives significant doses in breast cancer patients during SCF irradiation, especially in left-sided breast cancer patients. Restricting and reporting doses to CO as an OAR must be adopted as a routine practice.
1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209–49.
2. EBCTCG (Early Breast Cancer Trialists' Collaborative Group); McGale P, Taylor C, Correa C, Cutter D, Duane F, Ewertz M, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: Meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet 2014;383:2127–35.
3. Wang DQ, Zhang N, Dong LH, Zhong YH, Wu HF, Zhong QZ, et al. Dose-volume predictors for radiation esophagitis in patients with breast cancer undergoing hypofractionated regional nodal radiation therapy. Int J Radiat Oncol Biol Phys 2023;117:186–97.
4. Zalfa Abdul A, Donald F, Sandesh BR, Krishnaraj H, Tony J, Lanisha SJ. Radiation-induced esophagitis in patients with breast cancer receiving supraclavicular nodal irradiation: A retrospective observational study. Cancer Res Stat Treat 2023;6:209–14.
5. Whelan TJ, Olivotto IA, Parulekar WR, Ackerman I, Chua BH, Nabid A, et al; MA.20 Study Investigators. Regional nodal ırradiation in early-stage breast cancer. N Engl J Med 2015;373:307–16.
6. Haviland JS, Owen JR, Dewar JA, Agrawal RK, Barrett J, BarrettLee PJ, et al; START Trialists' Group. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year followup results of two randomised controlled trials. Lancet Oncol 2013;14:1086–94.
7. Sun Q, Chen Y, Li T, Ni B, Zhu X, Xu B, Li J. Risk and prognosis of secondary oesophagus cancer after radiotherapy for breast cancer. Sci Rep 2023;13:3968.
8. Journy N, Schonfeld SJ, Hauptmann M, Roberti S, Howell RM, Smith SA, et al. Dose-volume effects of breast cancer radiation therapy on the risk of second oesophageal cancer. Radiother Oncol 2020;151:33–9.
9. Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK, et al., editors. AJCC Cancer Staging Manual. New York: Springer International Publishing; 2017.
10. Northern Cancer Alliance. Breast cancer clinical guidelines. Available at: https://northerncanceralliance.nhs.uk/wp-content/uploads/2019/02/NCA-Breast-Cancer-Guidelines-v2-.10.pdf. Accessed Aug 14, 2024.
11. Duane FK, Kerr A, Wang Z, Darby SC, Ntentas G, Aznar MC, et al. Exposure of the oesophagus in breast cancer radiotherapy: A systematic review of oesophagus doses published 2010-2020. Radiother Oncol 2021;164:261–7.
12. Werner-Wasik M, Yorke E, Deasy J, Nam J, Marks LB. Radiation dose-volume effects in the esophagus. Int J Radiat Oncol Biol Phys 2010;76:S86–93.
13. Singh AK, Lockett MA, Bradley JD. Predictors of radiationinduced esophageal toxicity in patients with non-small-cell lung cancer treated with three-dimensional conformal radiotherapy. Int J Radiat Oncol Biol Phys 2003;55:337–41.
14. Bradley JD, Bae K, Graham MV, Byhardt R, Govindan R, Fowler J, et al. Primary analysis of the phase II component of a phase I/II dose intensification study using three-dimensional conformal radiation therapy and concurrent chemotherapy for patients with inoperable non-small-cell lung cancer: RTOG 0117. J Clin Oncol 2010;28:2475–80.
15. Wei X, Liu HH, Tucker SL, Liao Z, Hu C, Mohan R, et al. Risk factors for acute esophagitis in non-small-cell lung cancer patients treated with concurrent chemotherapy and threedimensional conformal radiotherapy. Int J Radiat Oncol Biol Phys 2006;66:100–7.
16. Belderbos J, Heemsbergen W, Hoogeman M, Pengel K, Rossi M, Lebesque J. Acute esophageal toxicity in non-small cell lung cancer patients after high dose conformal radiotherapy. Radiother Oncol 2005;75:157–64.
17. Palma DA, Senan S, Oberije C, Belderbos J, de Dios NR, Bradley JD, et al. Predicting esophagitis after chemoradiation therapy for non-small cell lung cancer: An individual patient data meta-analysis. Int J Radiat Oncol Biol Phys 2013;87:690–6.
18. Rodríguez N, Algara M, Foro P, Lacruz M, Reig A, Membrive I, et al. Predictors of acute esophagitis in lung cancer patients treated with concurrent three-dimensional conformal radiotherapy and chemotherapy. Int J Radiat Oncol Biol Phys 2009;73:810–7.
19. Lamart S, Stovall M, Simon SL, Smith SA, Weathers RE, Howell RM, et al. Radiation dose to the esophagus from breast cancer radiation therapy, 1943-1996: An international population-based study of 414 patients. Int J Radiat Oncol Biol Phys 2013;86:694–701.
20. West K, Schneider M, Wright C, Beldham-Collins R, Coburn N, Tiver K, et al. Radiation-induced oesophagitis in breast cancer: Factors influencing onset and severity for patients receiving supraclavicular nodal irradiation. J Med Imaging Radiat Oncol 2020;64:113–9.
21. Yaney A, Ayan AS, Pan X, Jhawar S, Healy E, Beyer S, et al. Dosimetric parameters associated with radiation-induced esophagitis in breast cancer patients undergoing regional nodal irradiation. Radiother Oncol 2021;155:167–73.
22. Pulickal SG, Bhaskaran R, Perumangat A, Reghu H, Moolath GB. Dosimetric evaluation of oesophagus in hypofractionated supraclavicular nodal irradiation in breast cancer- A retrospective observational study in a tertiary care cancer centre in Alappuzha, Kerala. J Evid Based Med Healthcare 2021;8:2974–9.