International Journal of Medical Physics, Clinical Engineering and Radiation Oncology, 2013, 2, 139-146
Published Online November 2013 (
Open Access IJMPCERO
Postmastectomy Scar Boost Irradiation Using HDR
Surface Mould Brachytherapy by 3D Image-Based Volume
Neelakandan Vijayaprabhu1, Karunanithi Gunaseelan1*, Nagarajan Vivekanandan2,
Nagamuthu Karthik3, Cholayil Shamsudheen1, K. S. Reddy1
1Department of Radiotherapy, Regional Cancer Center, Jawharlal Institute of Postgraduate Medical Education
and Research (JIPMER), Puducherry, India
2Department of Medical Physics, Cancer Institute (WIA), Chennai, India
3Department of Medical Physics, Anna University, Chennai, India
Email:, *,,,,
Received September 19, 2013; revised October 20, 2013; accepted November 2, 2013
Copyright © 2013 Neelakandan Vijayaprabhu et al. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Introduction: During postmastectomy radiotherapy (PMRT), it is recommended to boost the postmastectomy surgical
scar with additional 10 Gy in 5 fractions in the patients with close or positive surgical margins. The electron beam ther-
apy, though cumbersome, is usually preferred since it has the desired rapid fall of a dose beyond R85. An alternative but
easier and reproducible treatment method for PMRT surgical scar boost using 3D CT image-based HDR surface mould
brachytherapy is introduced and analyses of the target coverage and dose nearby organs-at-risk (OARs) using this
method are evaluated in this study. Methods and Materials: This study includes twelve patients (five left-sided and
seven right-sided chest wall), who were planned and treated with CT-image based surface mould HDR brachytherapy
for chest wall scar boost (CWB) using Catheter Flap SetTM (Varian Medical Systems, USA) that were given concur-
rently during external beam radiotherapy (EBRT) treatments. Since no guidelines are available for delineating clinical
target volume (CTV) structure to be used for postmastectomy scar boost, the CTV in this study was a uniform 5-mm
thick volume drawn at 5 mm beneath the skin (CTVhdr_evl) and its extent was made conforming to the boost area
marked on the skin and made visible in CT images by radiopaque wires. Results: Prescribed dose (PD) to CTVhdr_evl
is 7.5 Gy in 3 fractions, and 2.5 Gy per fraction. The CTVhdr_evl volume receives the PD with mean V100%, V98% and
V95% values which are 98.57%, 99.63% and 100% respectively. The mean dose for heart (MHD) is 2.71 Gy in left-sided
CWB and 1.80 Gy in right-sided CWB plans. Mean lung dose (MLD) is 2.48 Gy for ipsilateral lung and 0.76 Gy for
contralateral lung. Maximum dose to contralateral breast is 4.93 Gy and the mean dose is 0.79 Gy. The mean percent
dose to the skin volume overlying the CTVhdr_evl is 138.6% and 3.7% of skin volume received 200% of the PD. Con-
clusion: The 3D image-based HDR surface mould achieved good CTV coverage with acceptable doses to OARs. Pa-
tient preparation, treatment planning, and execution in this method are less cumbersome and reproducible. Thus surface
mould using flap applicator can be used whenever postmastectomy surgical scar boost is required.
Keywords: Postmastectomy Radiation; Surgical Scar Boost; HDR Surface Mould; Catheter Flap
1. Introduction
Postmastectomy radiotherapy (PMRT) to chest wall (CW)
is recommended in locally advanced breast cancer. In the
absence of radiotherapy (RT), loco-regional failure can
occur in approximately 25% - 40% of node-positive pa-
tients, and in up to 15% - 20% of node-negative patients
who do not receive systemic therapy [1]. Even after Da-
nish and British Columbia trials, the locoregional risk
reduction and impact on survival with PMRT are still de-
batable especially in patients with 1 to 3 positive nodes
[2-8]. But, it is well established that the surgical scar in
the CW is the most frequent site of locoregional recur-
*Corresponding author.
Open Access IJMPCERO
rence (LRR) [9,10].
Recent studies have suggested that when more than
one of the adverse risk factors viz., young age, premeno-
pausal status, tumour size, tumour grade, lymphovascular
invasion, margin status, nodal ration, estrogen receptor
status, tumour subtype, 21-gene recurrence score, and the
genomic predictive index are present in the setting of
nodal involvement, more aggressive locoregional man-
agement is warranted [11,12]. Even as the debate con-
tinues, the technological development in External Beam
Radiotherapy (EBRT) like Intensity Modulated Radio-
therapy (IMRT), Respiratory Gated Radiotherapy, and
Volumetric Modulated Radiotherapy (VMAT), and Im-
age-Guided Radiotherapy (IGRT), has made it now pos-
sible to deliver radiation to Planned Target Volumes
(PTV) with minimal setup errors and with acceptable
dose coverage, while sparing the organs at risk (OARs).
Moreover, efforts are also made to develop atlas-based
guidelines for implementing uniformity in delineation of
the target and critical structures which are expected to
minimize the interpersonal variations [13]. In PMRT, by
implementing these technologies and using electrons-
photon combinations, it is expected to bring down the
pulmonary or cardiac toxicities [14-18].
As the scar in the chest wall is clearly the most com-
mon site of loco-regional failure, whenever there is a clo-
se or positive margin, and boosting the surgical scar area
is considered with a dose of 10 Gy in 5 fractions. Usually
enfacing electrons is used to deliver the boost dose. How-
ever, planning and preparation for electron treatment are
complex, as electron cutouts and dose featherings re-
quire time and effort. In this study, an attempt is made to
reduce this complexity by introducing HDR surface
mould for the chest wall boost (CWB). While boost treat-
ment during adjunct radiotherapy following breast con-
servation surgery is documented [11], not many data are
available about effective methods for CWB during PMRT.
A new method for CWB during PMRT using Catheter
FlapTM (Varian Medical Systems, USA) surface mold
HDR brachytherapy was introduced and its efficacy in
dose coverage to tumour volume and sparing the un-
derlying critical organs is evaluated.
2. Methods and Materials
2.1. Patient Selection and Materials
In this study, the inclusion criteria for surgical scar boost
are women who have had mastectomy with positive or
close surgical margins; and without cardiac or pulmonary
co-morbidities. Twelve patients (five left-sided and seven
right-sided chest wall), who had positive or close surgical
margins were included prospectively in this study and
planned for PMRT with sandwich scar boost using HDR
flap surface mould. Commercially available CT/MR co-
mpatible flexible Catheter Flap® (Varian Medical Sys-
tems, Palo Alto, CA, USA) with 20 channels was used in
this study for HDR surface mould treatments (Figure 1).
Each channel is separated by 1 cm and this flap is capa-
ble of treatments up to 200 mm × 290 mm area. The
catheters are slightly radiopaque and thus visible in the
CT images. Contouring, segmentation and planning, eva-
luations are done by the same radiation oncologist and
physicist to minimize interpersonal variations. Optimiza-
tion and calculations were performed in BrachyVisionTM
(Version 10.0.42) which is integrated in the Eclipse treat-
ment planning environment (Varian Medical Systems
Inc., Palo Alto, CA, USA).
2.2. Immobilization Methods and Plan
Patients were immobilized with thermoplastic cast made
on full carbon fiber breast board in the same supine posi-
tion with the ipsilateral arm abducted above head as that
required for EBRT for easy image registration. Surface
markings were drawn around scar at a distance of 3 cm in
the craniocaudal direction and 2 - 3 cm along the medial
and lateral borders (Figure 2(a)) by the oncologist. Im-
mobilization casts for EBRT were made separately. For
CWB, the catheter flap was positioned beneath the cast
and on the patient’s chest wall so that the position of
catheter flap is fixed in the same position throughout
treatments and reproducible during subsequent fractions.
Care was taken to keep the patients position same for
both EBRT and HDR treatment plans for easy image
registrations so that plan sums can be generated later for
evaluation. Radioopaque wires were placed on the skin
markings and CT scans were taken in the CT-simulator
(Siemens Ltd., Germany) with 3 mm slice thickness sep-
arately for EBRT and for HDR. Registrations of the im-
ages were approved only after matching at least the
treatment area (i.e., Chest Wall). Contouring for EBRT
was done using RTOG atlas [13]. Before finalizing
EBRT plan, HDR Brachytherapy planning was also done
Figure 1. Catheter flap setTM (Varian medical systems,
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(a) (b)
(c) (d)
Figure 2. Method for CTV delineation: (a) Surface markings made on the patient; (b) Mould is prepared with immobilization
and in the same position as in EBRT; (c) 3D view of the surface wire markings; (d) CTVhdr_evl (red) and overlying skin
(blue) are delineated using wire images (other OAR structures are hidden); (e) 3D view of the reconstructed CTVhdr_evl (red)
conforming to surface markings.
with the catheter flap as described below and got evalu-
ated for both HDR plan and plan sum with EBRT.
2.3. Method for CTV Delineation
The CTV for HDR (CTVhdr_evl) is constructed using ra-
dio-opaque wire markers, which were placed along the
scar and 3 cm in craniocaudal direction and 2 - 3 cm in
lateral extension of the scar as shown in the Figure 2(a).
Using the CT images a uniform CTVhdr_evl is con-
structed as a 5-mm thick structure lying 5 mm beneath
the skin surface (body) using extract wall & cropping
tools available in the contouring workspace of the plan-
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ning system and by using Boolean operators and 3D live
view, the boundaries are clipped along the wire markers.
(Figures 2(b)-(e)). Five-mm-thick skin volume structure
is then created above the CTVhdr_evl structure up to the
skin level for giving dose constraints during volume op-
timization of the HDR plan.
2.4. Dose Prescription
The dose prescription to CTV hdr_evl was 2.5 Gy per
fraction given for 3 fractions so that the total dose to be
delivered as scar boost is 7.5 Gy for all patients in this
study. The EBRT dose prescription was 46 Gy in 23
fractions to entire ipsilateral chest wall and regional
nodes with additional two fractions given to supra-
clavicular and axillary level 3 nodes. The CTVevl in
EBRT is cropped to lie 5 mm from the skin level for
better dose coverage in IMRT or VMAT planning. The
HDR surface mould dose was limited to 7.5 Gy in 3
fractions which is less than the recommended 10 Gy in
5 fractions by ACR guidelines [11]. This was done
because the surface mould usually delivers higher dose
to the skin overlying the CTVhdr_evl (D90 120%)
when compared to dose by enface electrons along with
bolus. Thus giving 10 Gy with surface mould may re-
sult in higher skin reactions. The three HDR fractions
are interdigitated with EBRT treatments and scheduled
to be delivered after completion of every 5 fractions of
EBRT, with no EBRT delivered on the days of HDR
2.5. Catheter Reconstruction and Source
Dwell Positionings
The catheter auto-construction tool in the BrachyVi
sionTM is used to reconstruct the catheters. Once the ca-
theters are constructed, using the source dwell positions
placement tool, sources with 5 mm step sizes were made
to dwell only above this CTVhdr_evl area with two or
three additional dwell positions beyond its boundary (Fig-
ure 2(d)). These procedures are completed usually in 20
to 30 minutes.
2.6. Inverse Planning Optimization
In this study treatment planning was done using inverse
planning Adaptive Volume Optimization (AVOL) al-
gorithm available in the BrachyVisionTM Version
10.0.42. This optimization algorithm attempts to achieve
the specified objectives and constraints with smoother
dwell times and fewer hot spots inside the structures.
The system default minimum and maximum dose limits
to target are 95% and 120% with 100% priority for
both, which were modified during later iterations so
that V100% 98% is achieved. If dose to skin exceeds
beyond 200%, then the penalty score to skin constraint
is set higher in subsequent iterations. As the planning
optimization is interactive, normally two or three itera-
tions are enough to achieve the desired dose distribu-
tion. But in a few patients studied here, after perform-
ing optimization, isodose reshaper tool was used to
improve the dose distribution by dragging the isodose
lines using mouse in selected CT slices to achieve re-
quired dose values in them. Suitable plans for evalua-
tion are the ones whose V100% is at least 95%. Dose dis-
tributions are evaluated slice by slice qualitatively and
then quantitatively by using dose volume histograms
3. Results
Various volume and dosimetric parameters that show the
coverage of CTVhdr_evl are listed in Table 1. The sta-
tistical descriptive analysis (95% CI of mean & Quartile
deviation) were done using GraphPad Prism 6 (v6.02) for
Windows. V80% and V90% were chosen as these parame-
ters indicate minimum dose received by the CTV. The
parameters V95% and V98% show that there is a good cov-
erage of dose to CTV (mean = 99.8%, SD = 0.47, n = 12;
and mean = 99.47%, SD = 0.93, n = 12; respectively) and
that the level of homogeneity of dose inside the CTV.
V100% (%) indicates the proportion of CTV receiving at
least the prescribed dose, and it is seen that 98.57% of
the CTV volume receives 100% prescribed dose. To
show the level of maximum dose inside the CTV, V150%
is chosen, as it is used routinely in reporting brachyther-
apy treatments, whose values (mean = 2.58%, SD = 2.38,
n = 12) in this study are acceptable.
Table 2 lists the dose-volume parameters for the heart.
For the left-sided chest wall patients, the Dmean, and Dmedian
values are 36% and 33% of the prescribed dose respec-
tively. The maximum dose to heart is around 71% of the
prescribed dose. For the right-sided chest wall patients,
the corresponding values are 24%, 23%, and 50% re-
As for the other OARs, as given in Table 3, the dose-
volume parameters were chosen as relevant to total dose
of 7.5 Gy prescribed in this study. Thus, the volume pa-
rameter for lungs is limited to V5Gy, apart from giving
mean and maximum doses. For contralateral breast, V5%
and V10% were given, which will be required if EBRT for
the chest wall was delivered using IMRT or VMAT
techniques, which invariably delivers low doses to this
contralateral breast. Thus, the total value for V5% and
V10%, from plan sum of both EBRT and HDR, will give
the input for calculating secondary cancer incidence pro-
Table 3 also lists the dose delivered to the skin. The
parameters used are V150% and V200%, as they give the
level of high doses given to skin volumes. They also can
be used to predict and to explain various skin reactions
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Table 1. CTV dose-volume parameters.
CTV metrics Mean (SD) n = 12 Range 95% CI of mean
CTVhdr_evl volume: 78.79 (21.11) cm3
Volume Parameters
V80% (%) 100 (0.0) 100 - 100 100 - 100
V90% (%) 99.95 (0.14) 99.5 - 100 99.86 - 100
V95% (%) 99.8 (0.47) 98.33 - 100 99.80 - 100.1
V98% (%) 99.47 (0.93) 96.61 - 100 98.88 - 100.1
V100% (%) 98.57 (1.44) 94.49 - 99.95 97.66 - 99.49
V150% (%) 2.58 (2.38) 0.29 - 7.88 1.066 - 4.09
Dose Parameters
D90% (%) 103.5 (1.06) 101.9 - 106.1 102.8 - 104.2
D98% (%) 100.7 (1.79) 95.82 - 102.9 99.54 - 101.8
Abbreviations: SD = standard deviation; Vx% (%) = percent volume receiving at least x% of the prescribed dose; Dy% (%) = percent dose received by the y% of
the volume.
Table 2. Dose volume parameters for heart.
Left side chest wall (n = 5) Right side chest wall (n = 7)
Metric Mean (SD) Range 95% CI of Mean Mean (SD) Range 95% CI of Mean
Volume in cc 396 (116.6) 419.5 (105.1)
Dmean (cGy) 271.6 (42.87) 231 - 335.7 218.4 - 324.8 180.1 (27.13) 149.2 - 220.6 155 - 205.2
Dmedia n (cGy) 248.2 (45.23) 203.9 - 21.5 192.1 - 304.4 172.7 (30.55) 133.4 - 216.7 144.4 - 200.9
Dmax (c Gy ) 532.5 (88.22) 420.5 - 658.8 422.9 - 642 374 (48.13) 313.4 - 447.5 329.5 - 418.5
V5Gy (%) 4.886 (4.562) 0 - 10.28 0.78 - 10.55 0
Abbreviations: SD = standard deviation; CI = confidence interval; D2% (cGy) = Dose received by 2% of the volume; V5Gy (%) = percent volume receiving at
least 5 Gy dose.
Table 3. Dose volume parameters for OARs.
Both right & left side chest wall (n = 12)
Metrics Mean (SD) Range 95% CI of Mean
Ipsilateral Lung
Volume in cm3 876.6 (294.2)
DMean (cGy) 248.2 (28.23) 201.4 - 282.3 230.3 - 266.2
DMax (cGy) 711.6 (105.8) 438.4 - 846.6 644.4 - 778.9
D2% (cGy) 602.2 (54.69) 491.5 - 692.1 567.5 - 637
V5Gy (%) 3.606 (4.327) 0 - 12.63 0.86 - 6.35
Contralateral Lung
Volume in cm3 802.9 (188.2)
DMean (cGy) 76.13 (15.58) 59.2 - 113.8 66.23 - 86.03
DMax (cGy) 305.6 (126.9) 148.2 - 557.4 224.9 - 386.2
V5Gy (%) 0 (0) 0 - 0
Contralateral Breast
Volume in cm3 662.1 (263.1)
DMean (cGy) 79.28 (14.02) 55.2 - 102.5 70.38 - 88.19
DMax (cGy) 492.7 (166.2) 273.9 - 765.4 387.1 - 598.2
V5Gy (%) 0.27 (0) 0.27 - 0.27
V5% (%) 89.22 (11.44) 62.45 - 100 81.95 - 96.48
V10% (%) 34.69 (9.659) 17.49 - 53.1 28.55 - 40.82
Volume in cm3 78.43 (22.67)
DMean (%) 138.6 (3.183) 131.7 - 143.8 136.5 - 140.6
V150% (%) 18.85 (3.897) 10.93 - 25.7 16.38 - 21.33
V200% (%) 3.686 (1.765) 1 - 7.49 2.565 - 4.807
Abbreviations: SD = standard deviation; CI = confidence interval; DMean, DMax = Mean, Maximum doses; D2% (cGy) = Dose received by 2% of the volume;
V5Gy (%) = percent volume receiving at least 5Gy dose; Vx% (%) = percent volume receiving at least x% of the dose.
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during and post radiotherapy.
4. Discussion
4.1. CTV Coverage
It can be seen that the CTVhdr_evl has well received the
prescribed dose as the mean values for V95%, V98%, and
V100% were 99.8% (SD = 0.47), 99.47% (SD = 0.93), and
98.57% (SD = 1.47) respectively and their minimum
doses respectively were 98.33%, 96.61%, and 94.49%
(Table 1). The dose coverage to 90% and 98% of the
CTV volume was also well covered as indicated by D90%
and D98% respectively with their mean values of 103.5%
(SD = 1.06) and 100.7% (SD = 1.79), with the minimum
value 95.8%.
The graph in Figure 3 shows that there is high degree
of uniformity of the dose in the CTV, as the interquartile
ranges (IQRs) lie within 99% to 100% for V90%, V95%,
and V98%. The IQR for V100% is 99.6% - 98.3%.
Hence, the CTVhdr_evl receives the full prescribed
dose uniformly.
4.2. Dose to Heart
The mean and maximum dose (SD) to heart in left-sided
chest wall patients were 2.7 Gy (0.42), and 5.3 Gy (0.88)
respectively, which were 36% and 71% of the PD. The
mean dose is similar to the reported heart dose delivered
(2.3 Gy (0.7)) for 50 patients treated but when delivered
with 40 Gy in 15 fractions to left-sided breast cancers
[19]. These results are also comparable with mean car-
diac doses reported (Dmean of 2.45 for the heart and 3.29
Gy for the ventricles) when using balloon-based HDR bra-
chytherapy [20]. The volume receiving 5 Gy is 4.89% in
patient requiring left-side chest wall scar boost (Figure
4.3. Dose to Lungs
The mean ipsilateral lung dose (MLD) is 2.48 Gy (SD =
0.28, range 2.01 to 2.82 Gy) (Figure 5). D2% and Dmax
Figure 3. Box-and-whisper plot showing the coverage of
Figure 4. Dose to heart.
Figure 5. Dose to lungs (IL = ipsilateral, CL = contralat-
values are 6.02 Gy (SD = 0.54, range 4.91 to 6.92) and
7.11 Gy (SD = 1.05, range 4.38 to 8.47), which are about
80% and 95% of the PD. The volume of the lung receiv-
ing 5 Gy is 6.6 %. These values are well within the lung
tolerance dose (V30Gy < 20% & V20Gy < 30% - 35%,
with MLD of < 10 Gy when summed with EBRT dose
using IMRT/VMAT plans.
The mean contralateral lung dose (MLD) is 0.76 Gy
(SD = 0.16, range 0.59 to 1.14 Gy). The mean Dmax value
is 3.05 Gy (SD = 1.27, range 1.48 to 5.57 Gy) which are
about 41% of the PD. The volume of the contralateral
lung receiving 5 Gy is negligible (zero in DVH).
4.4. Dose to Contralateral Breast
The maximum dose to contralateral breast is 4.92 Gy
(SD = 1.66, range 2.74 to 7.65 Gy), which is 65% of the
PD and Dmean is 0.8 Gy (SD = 0.14, range 0.55 to 1.03
Gy) (Figure 6). The V5% and V10% values are 89% (SD =
0.11, range 62% to 100%) and 35% (SD = 9.7, range
17% to 53%) respectively. Thus around 90% of the vol-
ume is exposed to low doses. However, the dose due to
HDR is significantly less compared to scattered from
tangential fields by EBRT [19].
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4.5. Dose to Skin
The mean dose to skin is 138.6% (SD = 3.18, range
131.7% to 143.8%) of the PD, and the higher doses, like
150% and 200% doses were received by 18.85% (SD =
3.89, range 10.93% to 25.7%), and 3.686% (SD = 1.76,
range 1% to 7.49%) of skin volume (Figure 7). This is in
expected lines as the skin lies between the source and the
CTVhdr_evl. Moreover this is the reason for limiting the
scar boost dose to 7.5 Gy in 3 fractions, although dose
recommended is 10 Gy in 5 fractions [11]. Higher skin
dose is desirable during scar boost and it is the standard
feature in surface mould brachytherapy.
5. Conclusions
An alternative method for postmastectomy surgical scar
boost is designed here, which does not have the com-
plexities of the electron beam and electron arc techniques.
The latter techniques involve the design of custom made
cutouts to collimate the electron beam to the area of irra-
diation, since the chest wall is usually curvy and also
contains lung, bone and soft tissue heterogeneities, pos-
ing a heavy challenge to the planner. These challenges,
notwithstanding there are electrons, are still preferred
over EBRT photons due to their favourable depth dose
characteristics and better OAR sparing ability.
This HDR surface mould technique is simpler and re-
quires only an additional immobilization cast to be made
Figure 6. Dose to contralateral breast.
Figure 7. Dose to skin overlying the CTV.
ensuring reproducibility over fractions. The use of im-
mobilization cast also minimizes air gaps between the
flap and skin. If the scar length is more than 20 cm, then
this catheter flap orientation has to be changed so that the
treatment area is covered by the flap. The brachytherapy
volume-based inverse planning is interactive, and DVH-
based constraints can be given as input and do not take as
much time as that of inverse planning of EBRT. Planner
can still adjust the dose distribution, if needed, when op-
timization is not satisfactory.
Finally, HDR brachytherapy fractions can be inter-
digitated with EBRT, reducing the overall treatment time.
It also reduces the Linac’s usage time.
The downside of this HDR surface mould is that it in-
variably delivers low doses to lungs and contralateral
breast. While the dose to lungs cannot be reduced, the
low doses to the contralateral breast can be minimized by
shielding it using lead sheets.
Thus HDR surface mould is a promising technique and
can be made as a routine choice in the clinic, whenever
surgical scar boost is planned during PMRT.
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