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David Lloyd

RadOnc II
April 22, 2014

Prone Versus Supine for Adjuvant Breast Radiotherapy

Breast cancer occurs in the male and female populations. Breast cancer is more prevalent
in women. Nearly 300,000 women were estimated receive a diagnosis of breast cancer in 2013,
and approximately half of these women received radiation therapy during their treatment1. Many
patients with early-stage breast cancer have breast conservation therapy followed by whole
breast irradiation (WBI). Radiation therapy for breast cancer, in conjunction with other treatment
modalities, can enhance local control and improve overall survival. Positioning of patients during
radiation therapy of breast cancer can and often varies at different cancer treatment centers.
Positioning can be subdivided into two categories, supine positioning and prone positioning with
several variances of each position. Concerns for positioning of the patient include
reproducibility, acute and late toxicities, skin reactions, dose to healthy tissue and homogeneity
of the delivered treatment. In general there are benefits of each position. This paper will take a
look at three articles that compare the pros and cons of a supine position versus a prone position
of a breast cancer patient.
An article by Marco Krengli examined the results of 55 patients, with pendulous breasts,
receiving adjuvant breast radiotherapy in the prone versus supine position2. The article states
limitations of supine positioning include lateral dislocation of the breast, accentuation of the
infra-mammary and lateral skin folds, and inclusion of healthy lung and heart tissue in the
treatment field. The study set out to compare dosimetric parameters in prone versus supine

position in a cohort of women with pendulous breast. The criteria for the women of this study
required each patient to be receiving WBI with two tangent fields after conservative surgery. The
indication of regional node irradiation was an exclusion criterion. Forty-one of the 55 patients
were enrolled in the study2.
The method used preformed a CT simulation in both prone and supine position with
contiguous slices of 5mm thickness from apex of lung inferior to the diaphragm. The clinical
target volume (CTV), planning target volumes (PTV), ipsilateral lung, heart, and left anterior
descending (LAD) were outlined2. Two treatment plans were performed for each case in prone
and supine position respectively. Twenty-nine of the 41 patients were treated in the prone
position. The study shows all 29 patients treated with prone set-up had an advantage in terms of
dose to the lung, stating the reduction was due to breast dislocation and less influence of
respiratory movement. The article states treatment reproducibility in the prone position was
similar to supine position.
This was a good study. I would like to see a larger sample size. This study included 41
women. An increase in sample size would add to the reliability of the results being valid. The
inclusion criteria narrowed the sample size enough to reduce the introduction of error or
sampling bias. This article contains good information. This information is useful in knowing
there are alternatives to patient positioning, when treating breast. The options available should
best fit each individuals circumstance.
The second article was concerned with the damage to the heart and lung from breast
radiotherapy causing increased cardiovascular mortality and lung cancer development. They
conducted a study of 100 patients. The inclusion criteria included patients that were stage 0, I or

IIA after a mastectomy with negative margins3. All of the patients in this study consented to
additional exposure of CT simulation of both supine and prone positions. A volumetric analysis
using contouring tools of the Eclipse treatment system of Varian Medical System, determined the
volumes of the heart and lung included in the treatment fields for either set up. For each patient,
the same radiation oncologists approved target volumes and normal structures including lung and
heart in each set of images from the two CT simulations. The dosimetric analysis was performed
in both the prone and spine positions of the 100 patients. The 100 patients consisted of 53 left
breast and 47 right breast cancer patients3. The study showed the right breast cancer patients, infield lung volume in the prone position was reduced by a mean of 93.5cc compared to the supine
set-up. For the 46 left breasts cancer patients the in-field lung volume in the prone position was
reduced by a mean of 103.6cc compared to the supine set-up3. This study shows a significantly
lower in-field heart volume in the prone position. Limiting the inclusion of the heart and lungs
and decreasing the risk of late effects of radiation therapy is important. This article states, 93% of
the entire cohort; 87% left and 100% right breast cancer, benefitted from prone treatment. In all
100 patients studied, the lung was spared in the prone position, a finding common among reports
comparing prone versus supine setup3.
This study was conducted with a 95% confidence level. The statistics were compared
using descriptive summary statistics of chi-square tests for qualitative variables and t-tests for
continuous variables. The supine minus prone differences between in-field heart and lung
volumes and between mean doses to heart and lung were plotted and highly correlated. This is
using acceptable levels of research methods for determining the statistical information. Some of
the limiting factors associated with this study include a small sample size. There were
approximately 300,000 women diagnosed with breast cancer in 20131. This study included 100

patients. This is only a small percentage of the total population of breast cancer patients. As
stated from the previous, this second article contains good information. This information is
useful in knowing there are alternatives to patient positioning, when treating breast. The options
available should best fit each individuals circumstance.
The third article was more concerned with cosmetic outcomes in patients treated with
whole-breast radiation in the prone position. They wanted to report on using prone positioning in
a cohort of women with large pendulous breasts, to determine the rate of acute and late toxicities
and, more specifically, cosmetic outcomes4. The cohort consisted of 110 cases treated with
whole-breast irradiation in the prone position. All of the patients underwent CT planning in the
prone position. All of the patients were scored according to the National Cancer Institute
Common Terminology Criteria for Adverse Effects Version 3.04. The majority of the patients did
have large pendulous breasts. According to the study all patients experienced some degree of
dermatitis. Moist desquamation in the inframammary folds was only involved in 16 out of the
110 cases4. Treated in the supine position excess skin folds can create a bolus effect in the
inframammary and axillary areas. Prone breast irradiation in this study minimizes separation of
the breast tissue and reduces skin folds. Only 4.5% had above grade three acute dermatitis, with
16% of patients experiencing any moist desquamation and only 2% of patient experiencing moist
desquamation outside of the inframammary folds4. The late toxicity results were also favorable.
The study was informative. I would like to see more information on the inclusion and
exclusion criteria for the cohort. I believe the population could be narrowed down to include a
more specific group. Some examples of exclusion criteria could include Estrogen receptor or
Progesterone receptor positive. Also, patients with only breast tissue involved versus nodes
would reduce the fields to basically only tangents. This would introduce less bias to the study.

The late toxicity results may experience some reporting bias, as participants may not respond to
the evaluation process five years down the road. . As stated from the previous, this third article
contains good information. This information is useful in knowing there are alternatives to patient
positioning, when treating breast. The options available should best fit each individuals
circumstance.
The three articles that I reviewed all show treating breast cancer patients in the prone
position have proven ideal for multiple patients. Prone positioning has many benefits including:
reduced skin reactions, reduced dose to the ipsilateral lung and reduction of dose to the heart in
left breast cancer patients. These studies have shown positive results in these specific patients. It
is important to remember that this may not be the optimal set-up position for all patients. An
example would be a patient that has nodal involvement and requires treatment of supraclavicular
or of the internal mammary chain nodes. These patients may benefit form a supine set-up
position. These articles are informative and useful for a student in the field of radiation therapy.
It is important to remember that there are options when it comes to setting up a patient and each
patient should be evaluated on a case by case basis.

References
-----------------------------------------------------------------------------------------------------------1.

Olson KN. Improving Treatment Outcomes of Breast Radiation Therapy: The Prone
Position. Radiat Thera. 2014; 23(1):21-26

2. Krengli M, Masini L, Caltavuturo T, et al. Prone versus supine position for adjuvant
breast radiotherapy: a prospective study in patients with pendulous breasts. Radiat Oncol.
2013;8(1):232.
3.

Lymberis SC, Dewyngaert JK, Parhar P, et al. Prospective assessment of optimal


individual position (prone versus supine) for breast radiotherapy: volumetric and
dosimetric correlations in 100 patients. Int J Radiat Oncol Biol Phys. 2012;84(4):902-9.
doi10.1016/j.ijrobp.2012.01.040

4. Bergom C, Kelly T, Morrow N, et al. Prone whole-breast irradiation using threedimensional conformal radiotherapy in women undergoing breast conservation for early
disease yields high rates of excellent to good cosmetic outcomes in patients with large
and/or pendulous breasts. Int J Radiat Oncol Biol Phys. 2012;83(3):821-8.