Risk of Radiation Induced Carotid Artery Stenosis in Supraclavicular Lymph Node Irradiation in Breast Cancer Patients

Reham Abdulmoniem, Yasser Bayoumi, Mushabbab Al Asiri, Reem Zatar, Abdullah Al Amro, Majed Mosely, Mohamed Hamada, Eyad Al Saeed, Abdulrahman Al Hadab, Mutahir A. Tunio

King Saud University, Riyadh, KSA.
Medical Physics Department, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, KSA.
Radiation Oncology Department, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, KSA.
Radiation Oncology Department, National Cancer Institute, Cairo University, Giza, Egypt.

DOI: 10.4236/jct.2014.53031                

Abstract

Background: The risk of carotid vessel stenosis is high after radiotherapy (RT) to neck; however, carotid vessels are unavoidable during supraclavicular (SC-RT) in adjuvant treatment of breast cancer (BC). However, carotid vessels RT dose is less well-understood. We aimed to determine the carotid vessels doses received by different techniques for SC-RT. Materials and Methods: Thirty consecutive BC patients were planned to receive SC-RT and breast after breast conserving surgery (BCS) after taking 5 mm image slices on computed tomography (CT) simulation. Organs at risk (OAR) including carotid vessels, lungs, spinal cord alongwith clinical target volume (CTV) for primary tumor and lymph nodes were delineated. Comparative analysis was done between two treatment plans; three-field conformal radiation therapy (3F-CRT) and four field conformal RT (4F-CRT) for CTV and carotid vessels doses. Results: The 4F-CRT was found better than 3F-3DCRT regarding coverage and homogeneity of the CTV volume. The 98% of the CTV was covered by 84% dose in 3F-CRT and 95% in 4F-CRT (p 0.001). The carotid vessels maximum dose in the in 3F-CRT was 54.5 ± 1.3 Gy compared to 51.6 ± 1.3 Gy in 4F-CRT (p 0.014), however the mean dose did not differ significantly (p value 0.8). The ipsilateral lung dose did not differ between the two techniques (p Value 0.9). Conclusion: The 4F-CRT plan was found better than 3F-CRT in CTV coverage with minimal dose to the carotid vessel and without significant higher dose to the ipsilateral lung.

Keywords

Breast Cancer; Supraclavicular Radiotherapy; Carotid Vessel Dose

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Whelan, T.J., Olivotto, I., Ackerman, J., et al. (2011) NCIC-CTG MA.20: An Intergroup Trial of Regional Nodal Irradiation in Early Breast Cancer. Journal of Clinical Oncology, 29, LBA1003.
[2]	Truong, P.T., Jones, S.O., Kader, H.A., et al. (2009) Patients with t1 to t2 Breast Cancer with One to Three Positive Nodes Have Higher Local and Regional Recurrence Risks Compared with Node-Negative Patients after Breast-Conserving Surgery and Whole-Breast Radiotherapy. International Journal of Radiation Oncology . Biology . Physics, 73, 357-364. http://dx.doi.org/10.1016/j.ijrobp. 2008.04.034
[3]	Early Breast Cancer Trialists’ Collaborative Group (2000) Favourable and Unfavorable Effects on Long-Term Survival of Radiotherapy for Early Breast Cancer: An Overview of the Randomized Trials. Lancet, 355, 1757-1770. http://dx.doi.org/10.1016/S0140-6736(00)02263-7
[4]	Dubec, J.J., Munk, P.L., Tsang, V., et al. (1998) Carotid Artery Stenosis in Patients Who Have Undergone Radiation Therapy for Head and Neck Malignancy. The British Journal of Radiology, 71, 872-875.
[5]	Cheng, S.W., Wu, L.L., Ting, A.C., et al. (1999) Irradiation-Induced Extracranial Carotid Stenosis in Patients with Head and Neck Malignancies. The American Journal of Surgery, 178, 323-328. http://dx.doi.org/10.1016/S0002-9610(99)00184-1
[6]	Lam, W.W., Leung, S.F., So, N.M., et al. (2001) Incidence of Carotid Stenosis in Nasopharyngeal Carcinoma Patients after Radiotherapy. Cancer, 92, 2357-2363. http://dx.doi.org/10.1002/1097-0142(20011101)92:9<2357::AID-CNCR1583>3.0.CO;2-K
[7]	Dorresteijn, L.D., Kappelle, A.C., et al. (2002) Increased Risk of Ischemic Stroke after Radiotherapy on the Neck in Patients Younger Than 60 Years. Journal of Clinical Oncology, 20, 282-288. http://dx.doi.org/10.1200/JCO.20.1.282
[8]	Apryl, S.S., Luke, P.A. and Peter, J.A.S. (2009) Risk of Cerebrovascular Events after Neck and Supraclavicular Radiotherapy: A Systematic Review. Radiotherapy and Oncology, 90, 163-165. http://dx.doi.org/10.1016/j.radonc.2008.12.019
[9]	Kirova, Y.M., Castro Pena, P., Dendale, R., et al. (2010) Simplified Rules for Everyday Delineation of Lymph Node Areas for Breast Cancer Radiotherapy. The British Journal of Radiology, 83, 683-286. http://dx.doi.org/10.1259/bjr/28834220
[10]	Woodward, W.A., Giordano, S.H., Duan, Z., et al. (2006) Supraclavicular Radiation for Breast Cancer Does Not Increase the 10-Year Risk of Stroke. Cancer, 106, 2556-62. http://dx.doi.org/10.1002/cncr. 21943
[11]	Chung, T.S., Yousem, D.M., Lexa, F.J., et al. (1994) MRI of Carotid Angiopathy after Therapeutic Radiation. Journal of Computer Assisted Tomography, 18, 533-538. http://dx.doi.org/10.1097/000 04728-199407000-00003
[12]	Fonkalsrud, E.W., Sanchez, M., Zerubavel, R., et al. (1977) Serial Changes in Arterial Structure Following Radiation Therapy. Surgery, Gynecology & Obstetrics, 145, 395-400.
[13]	Elerding, S.C., Fernandez, R.N., Grotta, J.C., et al. (1981) Carotid Artery Disease Following External Cervical Irradiation. Annals of Surgery, 194, 609-615. http://dx.doi.org/10.1097/00000658-198 111000-00009
[14]	Shariat, M., Alias, N.A.A. and Biswal, B.M. (2008) Radiation Effects on the Intima-Media Thickness of the Common Carotid Artery in Post-Radiotherapy Patients with Head and Neck Malignancy. Postgraduate Medical Journal, 84, 609-612. http://dx.doi.org/10.1136/pgmj.2008.068569
[15]	Matthew H.C., Christopher M.G., Carl P.J., et al. (2003) Valvular Dysfunction and Carotid, Subclavian, and Coronary Artery Disease in Survivor of Hodgkin Lymphoma Treated with Radiation Therapy. JAMA, 290, 2831-2837. http://dx.doi.org/10.1001/jama.290.21.2831
[16]	Graus, F., Rogers, L.R. and Posner, J.B. (1985) Cerebrovascular Complications in Patients with Cancer. Medicine, 64, 16-35. http://dx.doi.org/10.1097/00005792-198501000-00002
[17]	Bilora, F., Pietrogrande, F., Petrobelli, F., et al. (2006) Is Radiation a Risk Factor for Atherosclerosis? An Echo-Color Doppler Study on Hodgkin and Non Hodgkin Patients. Tumori, 92, 295-298.
[18]	Bilora, F., Pietrogrande, F., Campagnolo, E., et al. (2009) Are Hodgkin and Non-Hodgkin Patients at a Greater Risk of Atherosclerosis? A follow-up of 3 years. European Journal of Cancer Care, 88, 134-139.
[19]	Gianicolo, M.E., Gianicolo, E.L., Tramacere, F., et al. (2010) Effects of External Irradiation of the Neck Region on Intima Media Thickness of the Common Carotid Artery. Cardiovascular Ultrasound, 8, 1-7. http://dx.doi.org/10.1186/1476-7120-8-8
[20]	Jephcott, C.R., Tyldesley, S. and Swift, C.L. (2004) Regional Radiotherapy to Axilla and Supraclavicular Fossa for Adjuvant Breast Treatment: A Comparison of Four Techniques. International Journal of Radiation Oncology . Biology . Physics, 60, 103-110. http://dx.doi.org/10.1016/j.ijrobp.2004.02.057
[21]	Wang, X., Yu, T.K., Salehpour, M., et al. (2009) Breast Cancer Regional Radiation Fields for Supraclavicular and Axillary Lymph Node Treatment: Is a Posterior Axillary Boost Field Technique Optimal? International Journal of Radiation Oncology . Biology . Physics, 74, 86-91. http://dx.doi.org/10.1016/j.ijrobp.2008.07.016
[22]	Lomax, A.J., Cella, L., Weber, D., et al. (2003) Potential Role of Intensity-Modulated Photons and Protons in the Treatment of the Breast and Regional Nodes. International Journal of Radiation Oncology . Biology . Physics, 55, 785-792. http://dx.doi.org/10.1016/S0360-3016(02)04210-4
[23]	Vitolo, V., Millender, L., Quivey, J., et al. (2009) Assessment of Carotid Artery Dose in the Treatment of Nasopharyngeal Cancer with IMRT versus Conventional Radiotherapy. Radiotherapy and Oncology, 90, 213-220. http://dx.doi.org/10.1016/j.radonc.2008.08.014