{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T22:39:01Z","timestamp":1765233541620,"version":"build-2065373602"},"reference-count":26,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2023,6,3]],"date-time":"2023-06-03T00:00:00Z","timestamp":1685750400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Soonchunhyang University"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Intensity-modulated radiation therapy (IMRT) is becoming a more common method of performing whole breast irradiation (WBI) for early breast cancer. This study aimed to examine the incidental dose to the axillary region using tomotherapy, a unique form of IMRT. Patients and Methods: This study included 30 patients with early-stage breast cancer who underwent adjuvant WBI using TomoDirect IMRT. A hypofractionation scheme of 42.4 Gy delivered in 16 fractions was prescribed. The plan comprised of two parallel-opposed beams, along with two additional beams positioned anteriorly at gantry angles of 20\u00b0 and 40\u00b0 from the medial beam. The incidental dose received at axillary levels I, II, and III was evaluated using several dose-volume parameters. Results: The study participants had a median age of 51 years, and 60% had left-sided breast cancer. The mean dose of the axilla for levels I, II, and III were 15.5 \u00b1 4.8 Gy, 14.9 \u00b1 4.2 Gy, and 1.5 \u00b1 1.6 Gy, respectively. Adequate coverage of the axilla, defined as V95%[%], was achieved for 4.7 \u00b1 3.9%, 4.8 \u00b1 3.7%, and 0 \u00b1 0% for levels I, II, and III, respectively. The results were compared with those of previously published studies, and the axillary mean dose and V95%[%] of TomoDirect IMRT were low, comparable to other IMRT techniques, and lower than those of traditional tangential therapy. Conclusions: While incidental axillary radiation during WBI has been proposed to assist in regional disease control, the TomoDirect plan was demonstrated to decrease this dose, and a hypofractionation scheme would further lower its biological effectiveness. Future clinical studies should incorporate dosimetrical analysis of incidental axillary dose, in order to facilitate hypofractionated IMRT planning with risk-adjusted axilla coverage in early breast cancer.<\/jats:p>","DOI":"10.3390\/medicina59061081","type":"journal-article","created":{"date-parts":[[2023,6,5]],"date-time":"2023-06-05T01:53:25Z","timestamp":1685930005000},"page":"1081","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Incidental Axillary Dose of Tomotherapy in Hypofractionated Whole Breast Radiotherapy for Early Breast Cancer: A Dosimetrical Analysis"],"prefix":"10.3390","volume":"59","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1371-1381","authenticated-orcid":false,"given":"Seung-Gu","family":"Yeo","sequence":"first","affiliation":[{"name":"Department of Radiation Oncology, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Bucheon 14584, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cheol Wan","family":"Lim","sequence":"additional","affiliation":[{"name":"Department of Surgery, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Bucheon 14584, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sung-Mo","family":"Hur","sequence":"additional","affiliation":[{"name":"Department of Surgery, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Bucheon 14584, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1413-2800","authenticated-orcid":false,"given":"Zisun","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Surgery, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Bucheon 14584, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kwang Hwan","family":"Cho","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Bucheon 14584, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7484-5896","authenticated-orcid":false,"given":"Min-Jeong","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Radiology, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2023,6,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"820","DOI":"10.1007\/s00066-021-01808-y","article-title":"Incidental axillary dose delivery to axillary lymph node levels I-III by different techniques of whole-breast irradiation: A systematic literature review","volume":"197","author":"Schmitt","year":"2021","journal-title":"Strahlenther. Onkol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"3600","DOI":"10.1200\/JCO.2014.56.5838","article-title":"Radiation field design in the ACOSOG Z0011 (Alliance) Trial","volume":"32","author":"Jagsi","year":"2014","journal-title":"J. Clin. Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"349","DOI":"10.4048\/jbc.2022.25.e37","article-title":"Intensity Modulated Radiotherapy and Volumetric Modulated Arc Therapy in the Treatment of Breast Cancer: An Updated Review","volume":"25","author":"Chang","year":"2022","journal-title":"J. Breast Cancer"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1186\/s13014-014-0244-0","article-title":"A prospective cohort study on postoperative radiotherapy with TomoDirect using simultaneous integrated boost technique in early breast cancer","volume":"9","author":"Lee","year":"2014","journal-title":"Radiat. Oncol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1002\/jmrs.232","article-title":"Static beam tomotherapy as an optimisation method in whole-breast radiation therapy (WBRT)","volume":"64","author":"Squires","year":"2017","journal-title":"J. Med. Radiat. Sci."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1186\/s13014-019-1328-7","article-title":"Incidental dose distribution to locoregional lymph nodes of breast cancer patients undergoing adjuvant radiotherapy with tomotherapy\u2014Is it time to adjust current contouring guidelines to the radiation technique?","volume":"14","author":"Mayinger","year":"2019","journal-title":"Radiat. Oncol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.radonc.2014.11.030","article-title":"ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage breast cancer","volume":"114","author":"Offersen","year":"2015","journal-title":"Radiother. Oncol."},{"key":"ref_8","unstructured":"Kainz, K., Huang, M., Xiao, Y., Li, X.A., Moran, J.M., and Chen, G.-P. (2022). NRG Protocol Radiation Therapy Template (Whole Breast Photon and Proton Therapy). NRG Oncol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1016\/j.ijrobp.2004.04.065","article-title":"Analysis of axillary coverage during tangential radiation therapy to the breast","volume":"61","author":"Reznik","year":"2005","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"18183","DOI":"10.18632\/oncotarget.4301","article-title":"Dose coverage of axillary level I-III areas during whole breast irradiation with simplified intensity modulated radiation therapy in early stage breast cancer patients","volume":"6","author":"Zhang","year":"2015","journal-title":"Oncotarget"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"409","DOI":"10.5301\/tj.5000482","article-title":"Axillary coverage by whole breast irradiation in 1 to 2 positive sentinel lymph nodes in breast cancer patients","volume":"102","author":"Bonfantini","year":"2016","journal-title":"Tumori"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1016\/j.radonc.2014.10.005","article-title":"Evaluation of axillary dose coverage following whole breast radiotherapy: Variation with the breast volume and shape","volume":"114","author":"Aguiar","year":"2015","journal-title":"Radiother. Oncol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1016\/j.radonc.2021.10.005","article-title":"Unintended dose to the lower axilla in adjuvant radiotherapy for breast cancer: Differences between tangential beam and VMAT","volume":"164","author":"Ahrouch","year":"2021","journal-title":"Radiother. Oncol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1125","DOI":"10.1016\/j.breast.2013.07.054","article-title":"Incidental radiation to axilla in early breast cancer treated with intensity modulated tangents and comparison with conventional and 3D conformal tangents","volume":"22","author":"Kataria","year":"2013","journal-title":"Breast"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e4036","DOI":"10.1097\/MD.0000000000004036","article-title":"Dosimetric evaluation of incidental irradiation to the axilla during whole breast radiotherapy for patients with left-sided early breast cancer in the IMRT era","volume":"95","author":"Lee","year":"2016","journal-title":"Medicine"},{"key":"ref_16","first-page":"551","article-title":"Dosimetric comparison of incidental axillary irradiation between three-dimensional conformal and volumetric modulated arc techniques for breast cancer","volume":"12","author":"Jo","year":"2020","journal-title":"Mol. Clin. Oncol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"918","DOI":"10.1001\/jama.2017.11470","article-title":"Effect of Axillary Dissection vs. No Axillary Dissection on 10-Year Overall Survival among Women with Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial","volume":"318","author":"Giuliano","year":"2017","journal-title":"JAMA"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1097\/SLA.0b013e3181f08f32","article-title":"Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: The American College of Surgeons Oncology Group Z0011 randomized trial","volume":"252","author":"Giuliano","year":"2010","journal-title":"Ann. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"81","DOI":"10.3857\/roj.2016.01697","article-title":"Hypofractionated whole breast irradiation: New standard in early breast cancer after breast-conserving surgery","volume":"34","author":"Kim","year":"2016","journal-title":"Radiat. Oncol. J."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1007\/s00066-020-01636-6","article-title":"Effect of hypofractionation on the incidental axilla dose during tangential field radiotherapy in breast cancer","volume":"196","author":"Borm","year":"2020","journal-title":"Strahlenther. Onkol."},{"key":"ref_21","unstructured":"(2023). NCCN Practice Guidelines for Breast Cancer (Version 3. 2023), National Comprehensive Cancer Network."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Lee, T.H., Chang, J.H., Jang, B.S., Kim, J.S., Kim, T.H., Park, W., Kim, Y.B., Kim, S.S., Han, W., and Lee, H.-B. (2022). Protocol for the postoperative radiotherapy in N1 breast cancer patients (PORT-N1) trial, a prospective multicenter, randomized, controlled, non-inferiority trial of patients receiving breast-conserving surgery or mastectomy. BMC Cancer, 22.","DOI":"10.1186\/s12885-022-10285-0"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1016\/j.radonc.2018.10.038","article-title":"Location of arm draining lymph node in relation to breast cancer radiotherapy field and target volume","volume":"133","author":"Wang","year":"2019","journal-title":"Radiother. Oncol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1016\/j.ijrobp.2019.06.2509","article-title":"Determining the Organ at Risk for Lymphedema After Regional Nodal Irradiation in Breast Cancer","volume":"105","author":"Gross","year":"2019","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1016\/j.clbc.2021.06.003","article-title":"Regional Nodal Irradiation for Clinically Node-Positive Breast Cancer Patients with Pathologic Negative Nodes after Neoadjuvant Chemotherapy","volume":"22","author":"Schlafstein","year":"2022","journal-title":"Clin. Breast Cancer"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"549","DOI":"10.1001\/jamaoncol.2016.4163","article-title":"Axillary Nodal Management Following Neoadjuvant Chemotherapy: A Review","volume":"3","author":"Pilewskie","year":"2017","journal-title":"JAMA Oncol."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/6\/1081\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:48:27Z","timestamp":1760125707000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/6\/1081"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,6,3]]},"references-count":26,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2023,6]]}},"alternative-id":["medicina59061081"],"URL":"https:\/\/doi.org\/10.3390\/medicina59061081","relation":{},"ISSN":["1648-9144"],"issn-type":[{"type":"electronic","value":"1648-9144"}],"subject":[],"published":{"date-parts":[[2023,6,3]]}}}