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. 2025 Jul 30:64:989-996.
doi: 10.2340/1651-226X.2025.43716.

Internal mammary node irradiation in early breast cancer - target coverage and implications on dose to organs at risk

Lovisa Berg  1 , Jeanette Sporre  2 , Elisabeth Kjellén  2 , Sofie Ceberg  3 , Elinore Wieslander  4 , Sara Alkner  5
Affiliations

Internal mammary node irradiation in early breast cancer - target coverage and implications on dose to organs at risk

Lovisa Berg et al. Acta Oncol. .

Abstract

Purpose: Indications for radiotherapy (RT) of the internal mammary nodes (IMN) in early breast cancer vary between countries. While studies indicate benefits, IMN RT increases the dose to the heart and lungs, and the risk-benefit ratio of this treatment is debated. This study investigates how IMN RT affects dose to organs at risk (OAR) and pneumonitis incidence in a clinical setting.

Methods: This retrospective study includes breast cancer patients receiving adjuvant locoregional RT with and without IMN included in the target volume at Skåne University Hospital, Sweden, from 2018 to 2021. Treatment plans followed national dose-volume criteria, prioritizing lung and heart over IMN coverage. A total of 247 treatment plans for locoregional RT with IMN were compared to 397 without. Dose to OAR, IMN coverage and pneumonitis incidence were investigated.

Results: The mean ipsilateral lung dose increased by 2.7 Gy with IMN RT (p < 0.001), and the mean heart dose (left-sided treatment) by 0.5 Gy (p < 0.001). Both irradiated and treated volume in relation to planning target volume (PTV) increased with ~20% (p < 0.001). Desired IMN coverage was achieved in 76% of the plans, with lung dose exceeding recommended constraints as the primary reason for decreased target coverage in the remaining plans. Of the 220 patients with follow-up of ≥6 months, 2 (0.9%) were diagnosed with pneumonitis grade 2.

Interpretation: Introduction of IMN RT primarily resulted in an increased lung dose. However, rate of symptomatic pneumonitis was low. Most patients achieved desired IMN coverage using 3D-CRT, with lung dose being the limiting factor.

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Conflict of interest statement

The authors report that there are no competing interests to declare.

Figures

Figure 1
Figure 1
Consort diagram for patients with early-stage breast cancer registered for locoregional radiotherapy with and without internal mammary node irradiation. *Two bilateral patients, which results in 395 patients and 397 treatment plans. fr: fraction (fr); IMN: internal mammary nodes; n: number; RT: radiotherapy.
Figure 2
Figure 2
Mean DVH for the ipsilateral lung (a) and the heart (left-sided) (b) for patients with and without internal mammary node irradiation. DVH: dose-volume histogram; Gy: gray; IMN: internal mammary nodes; RT: radiotherapy.
Figure 3
Figure 3
IMN-coverage categorized into five groups (A–E) depending on V90% (a). Mean DVH for group A–E (b). CTV: clinical target volume; DVH: dose-volume histogram; IMN: internal mammary nodes.
See this image and copyright information in PMC

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