Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
Br J Radiol. 2022 Sep 1;95(1137):20220382. doi: 10.1259/bjr.20220382. Epub 2022 Aug 2.
OBJECTIVE: To localize the distribution of regional nodes in recurrent/advanced breast cancer patients based on 18-fludeoxyglucose (FDG) positron emission tomography/CT (PET/CT) images and validate the coverage of clinical target volumes (CTVs) for regional nodes with current contouring guidelines. METHODS: We enrolled 154 recurrent/advanced breast cancer patients with FDG-avid regional nodes who underwent PET/CT between January 2018 and June 2020. Involvement of lymph node regions including axillary lymph node level I-III (ALN-I, ALN-II, ALN-III), Rotter's nodes (RN), medial supraclavicular (SC-M), lateral supraclavicular (SC-L) and internal mammary nodes (IMN) was recorded respectively. Coverage of the CTVs in different atlases and the locations of out-of-field were evaluated. RESULTS: A total of 348 lymph node regions containing disease were identified, including ALN-I 109, ALN-II 46, ALN-III 36, RN 17, SC-M 68, SC-L 36 and IMN 36. Recurrent ALNs mainly located cranially and ventrally to the axillary vein (AV). Ipsilateral cervical nodes were simultaneously affected in 33/76 SC positive patients. RADCOMP (306/348) and RUIJIN (291/348) guidelines had higher coverage compared with RTOG (205/348) and ESTRO (202/348) guidelines ( < 0.001, respectively). In primary non-metastastic and recurrent patients, major missings located in SC-L (7/7, 17/17) and IMN (7/10, 15/19) for RTOG guideline while SC-L (7/7, 17/17) for ESTRO guideline ( < 0.001, respectively). Among recurrent patients, SC-M (22/31) was another major missing area for ESTRO guideline ( < 0.001). CONCLUSION: The current guidelines effectively cover most regional nodes in postoperative breast cancer patients. SC-L and IMN were the major missing regions. Recurrent ALNs were most often seen in cranial and ventral to the AV. The CTV of patients with clinically positive SC was recommended to extend up to the hyoid level. The CTVs should be adjusted based on risks of recurrence individually. ADVANCES IN KNOWLEDGE: The difference of regional nodes delineation between current guidelines mainly located in SC and IMN regions. High axilla including subclavicular nodes and the RN above AV for recurrent patients and the region between cricoid and hyoid for positive SC patients should be meticulously contoured.
目的：基于 18 氟脱氧葡萄糖（FDG）正电子发射断层扫描/计算机断层扫描（PET/CT）图像对复发性/晚期乳腺癌患者的局部区域淋巴结分布进行定位，并验证当前勾画指南对区域淋巴结临床靶区（CTV）的覆盖范围。
方法：我们纳入了 154 例在 2018 年 1 月至 2020 年 6 月期间因 FDG 摄取的区域淋巴结接受 PET/CT 的复发性/晚期乳腺癌患者。分别记录了淋巴结区域包括腋窝淋巴结水平 I-III 区（ALN-I、ALN-II、ALN-III）、Roter 淋巴结（RN）、锁骨上内侧（SC-M）、锁骨上外侧（SC-L）和内乳淋巴结（IMN）的受累情况。评估了不同图谱中的 CTV 覆盖范围和野外漏区的位置。
结果：共识别出 348 个包含疾病的淋巴结区域，包括 ALN-I 109 个、ALN-II 46 个、ALN-III 36 个、RN 17 个、SC-M 68 个、SC-L 36 个和 IMN 36 个。复发性 ALN 主要位于腋静脉（AV）的颅侧和腹侧。33/76 例 SC 阳性患者同时累及同侧颈部淋巴结。RADCOMP（306/348）和 RUIJIN（291/348）指南的覆盖范围高于 RTOG（205/348）和 ESTRO（202/348）指南（分别<0.001）。在原发性非转移性和复发性患者中，RTOG 指南的主要漏区位于 SC-L（7/7，17/17）和 IMN（7/10，15/19），而 ESTRO 指南的主要漏区位于 SC-L（7/7，17/17）（分别<0.001）。在复发性患者中，ESTRO 指南的另一个主要漏区为 SC-M（22/31）（分别<0.001）。
结论：目前的指南有效地覆盖了大多数术后乳腺癌患者的区域淋巴结。SC-L 和 IMN 是主要的遗漏区域。AV 颅侧和腹侧是复发性 ALN 最常见的部位。建议将临床阳性 SC 的 CTV 向上扩展至舌骨水平。应根据复发风险单独调整 CTV。
知识进展：当前指南在区域淋巴结勾画方面的差异主要位于 SC 和 IMN 区域。对于复发性患者，应仔细勾画包括锁骨下在内的高位腋窝淋巴结和 AV 上方的 RN，以及 SC 阳性患者的环状软骨和舌骨之间的区域。
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