Contouring

workshop
ESTRO Breast Course Director
Birgitte Offersen (DK)
Workshop Chair

BREAST
Philip Poortmans (F)
Workshop Tutors
Elizabeth Forde (IE)
Layth Mula Hussain (CA)
Sandra Hol (NL)
Hanene Oueslati (F)
ESTRO Course Coordinators
Miika Palmu (B)
Christine Verfaillie (B)
 Agenda
• Follow up from the first week
• Presentation of consensus delineation
• Presentation of delineations from participants
• Discussion and questions
• Plan for the week

BO speaking
Follow up from the first week

• Number of submitted delineations:

• Questions from students during the week:

BO speaking
• Breast
• Boost
• PBI
• Thoracic wall
• LN supraclavicular
• LN axilla level III
• LN axilla level II
• LN axilla Rotter
• LN axilla level I
• LN internal mammary
BO speaking
DICE similarity
coefficient

AI = 1
AC = 2
DA = 3
BO speaking
Presentation of the ESTRO
consensus guideline

Philip Poortmans

PP speaking
We will send you the pdf-file of the ESTRO consensus
delineation
Please feel free to pass it on to colleagues
 1) Brachiocephalic vein
2+7) Subclavian vessels
3+8) Axillary vessels
4) Internal jugular vein
5) External jugular vein
6) Brachiocephalic trunk
9 9 4 9) Common carotid artery
4 10) Vertebral artery
5 10 5
7 7
6 2 8
8 2 1
1
3 3

www.ikonet.com
 Supra- and
infraclavicular

Delineations made by students attending ESTRO´s breast teaching course

PP speaking
Supraclavicular LN area,
CTVn_L4
✓ Superior border: 1 slice cranially to subclavian artery arch
✓ Caudal border: 5mm caudal from junction of subclavian and
internal jugular veins
✓ Ventral border: sternocleidomastoid muscle, dorsal edge of
clavicle
✓ Dorsal border: pleura
✓ Medial border: including the jugular vein without margin;
excluding the thyroid gland and the common carotid artery
✓ Lateral border: includes the anterior scalene muscle
PP speaking
 CTVn_L4

Serial sections from 1 slice cranial of CTVn_L4 to 1 slice caudal of CTVn_L4

Slice thickness 3 mm
 CTVn_L4
Anterior scalene muscle Internal jugular vein Common carotid artery
 CTVn_L4

Subclavian artery
CTVn_L4
CTVn_L4
CTVn_L4
CTVn_L4
CTVn_L4
CTVn_L4
CTVn_L4
CTVn_L4
 CTVn_L4

Subclavian vein
CTVn_L4
CTVn_L4
Overview 1 slice caudal to
CTVn_L4
 Axillary lymph node areas 1-3

Traditionally  subdivided into 3 subregions:

- level 1 caudally from lower border of major pectoral muscle
- level 2 posterior to minor pectoral muscle
- level 3 located cranially from the pectoral muscles
+ Rotter located between minor and major pectoral muscle

DBCG consensus. Acta Oncologica 2013

PP speaking
Axillary lymph node area

level 3 - level 2 – Rotter - level 1

Axilla level III (infraclavicular)
✓ Cranial border: 1 slice cranial of the subclavian vessels. More
medially it is the clavicle
✓ Caudal border: 5mm caudal of the subclavian vein. If
appropriate top of surgical ALND
✓ Lateral border: medial side of the minor pectoral muscle
✓ Medial border: Junction of subclavian and
jugular vein
✓ Ventral border: pectoralis major muscle
✓ Dorsal border: up tp 5mm dorsal of subclavian vein or to costae
or intercostal muscle
PP speaking
Cranial border of CTVn_L3
Middle part of CTVn_L3
Caudal part of CTVn_L3
Axilla level II
✓ In between levels 1 and 3
✓ Dorsal to minor pectoral muscle
✓ Cranial includes subclavian artery
✓ Caudal to the border of the minor pectoral muscle

PP speaking
CTVn_L2
CTVn_L2
Axilla: Rotter (interpectoral )
✓ Between: pectoralis major and pectoralis minor muscles
✓ Cranio-caudal limited as CTVn_L2

PP speaking
 Supra- and
infraclavicular,
Rotter and axilla

Delineations made by students attending ESTRO´s breast teaching course

PP speaking
Axilla level I
✓General: use surgical effects to guide
✓Cranio-medial: lateral limit of level II/Rötter
✓Cranio-lateral: up to 1 cm below and following edge of
caput humeri, 5mm around axillary vessels except
cranial where it includes the artery with no margin
✓Caudal border: around the level of ribs 4 – 5
✓Lateral border: up to superficial part of muscles (line)
✓Medial border: level II and thoracic wall
✓Ventral border: pectoralis major & minor muscles
✓Dorsal border: up to the posterior blood vesselsPP speaking
CTVn_L1
 IMC, Rotter and
axilla

Delineations made by students attending ESTRO´s breast teaching course

PP speaking
Internal mammary lymph node area
✓ Cranial border: caudal limit of CTVn_L4 or where the internal
thoracic artery enters the subclavian vessels
✓ Caudal border: cranial side of the 4th rib
✓ Lateral border: 5mm lateral to the artery (the vein is medial to
the artery)
✓ Medial border: up to the edge of the sternal bone
✓ Ventral border: anterior limit of the vascular area
✓ Dorsal border: the pleura

PP speaking
 1) Brachiocephalic vein
2+7) Subclavian vessels
3+8) Axillary vessels
4) Internal jugular vein
5) External jugular vein
6) Brachiocephalic trunk
9 9 4 9) Common carotid artery
4 10) Vertebral artery
5 10 5
7 7
6 2 8
8 2 1
1
3 3

www.ikonet.com
The vein separates from the artery in the cranial part
 Internal mammary lymph node area

Critical area just

behind the
sternoclavicular
junction

PP speaking
 IMC, breast and
axilla

Delineations made by students attending ESTRO´s breast teaching course

Delineations made by BO and PP

PP speaking
CTVp breast
CTV breast = “whole glandular breast tissue”
✓ Not clearly visible on planning CT
✓ No clear anatomical borders visible (except dorsal)
Tips & tricks for delineation:
✓ Radio-opaque wire around breast helps but ≠ “true” border
✓ Take visible breast tissue into account
✓ Include visible surgical effects (seroma; clips, …)

PP speaking
CTVp breast
✓ Cranial: < sterno-clavicular joint
✓ Caudal: lowest side of visible breast contour
✓ Superficial: < 0.5 cm of skin (except T4b,c,d)
✓ Deep: superficial side of pectoral muscles/thoracic wall

PP speaking
CTVp breast
Medial:
✓ < ipsilateral edge of the sternum
✓ < vessels: rami mammarii (from thoracica int)

PP speaking
CTVp_breast
Lateral:
✓ < lateral side of the visible breast contour
✓ < mid-axillary line
✓ < vessel: thoracica lateralis

PP speaking
Breast and heart

Delineations made by students attending ESTRO´s breast teaching course

PP speaking
CTVp_breast
CTVp_breast
CTVp_breast and fatty tissue
3. Primary tumour bed
✓ Radio-opaque wire (scar & palpable area) to guide.
✓ Pre-operative localisation of tumour (phys ex, imaging).
✓ Features visible on the planning CT, such as clips, surgical
effects, seroma/haematoma can be used.

1.5 cm

Tumor
Micr. extension
Region with microscopic
extension, within 1.5 cm of
primary tumor

Boersma L, Poortmans P et al. Radiother Oncol. 2012;103:178-82

3. Primary tumour bed

PP speaking
3. Primary tumour bed

PP speaking
3. Primary tumour bed

PP speaking
Dice Coefficient

Delineations made by students attending

ESTRO´s breast teaching course
PP speaking
 General comments
• All guidelines are on CTV.
• A margin to PTV has to be added.
• We don’t have clinical reason to increase field
size compared to the old standard fields.
 mind resulting field size/including OAR!
 a margin of 5 mm from CTV to PTV should be
sufficient
• The different LN volume should all interconnect
(= touch each other at the edges)

BO speaking
Lymph node areas are connected
 Where do we see the RR?

RR after no RT RR after reg RT RR after WBI

Single institution, 101 reg recurrences (RR) listed according to primary therapy
RR diagnosed 2000-2013.
The 9-yr risk of RR was <2% (<0.5% as isolated RR)
Only 1 of the RR after reg RT occurred outside the RT fields
Nielsen & Offersen, R&O, 2015
 General comments,
recurrence risk
• Always individualise regarding the risk of LRR
• For example:
– Most recurrences are in the same quadrant as the
original tumour  if heart or lung constraints cannot
be met, shift the RT fields somewhat to spare more
heart/lung while excluding part of the CTV breast
remotely from the original tumour site.
– BUT: lobular carcinoma has a higher risk of local
recurrence compared to ductal carcinoma, so be even
more careful in these patients to fully include CTV
breast (REF: Poortmans et al R&O 2013).
– Special care is needed after oncoplastic surgery to
localise the tumour bed. If in doubt discuss with the
surgeon. Always use clips in the tumour bed before
rearrangement of breast tissue.
BO speaking
 General comments,
recurrence risk
• Always individualise regarding the risk of LRR
• For example, in locally advanced cases :
– Read carefully the surgical and pathology report to make
sure that all the volumes where tumour was located (and
removed) have been included in the fields.
– If pathological lymph nodes have been left behind (e.g. in
level III) consider to give a boost in that area. Optimally
the surgeon has placed a clip where the pathological LN
was felt. A limited boost volume may be treated to 60-62
Gy (2 Gy per fr), but be aware of the vessels and the
plexus brachialis.
– Consider making a CT-scan in treatment position
preceding systemic therapy/surgery for later image
fusion.

BO speaking
 General comments,
comorbidity
• Always individualise regarding the risk of late morbidity
(patient factors and treatment factors)
• Patient factors (examples)
– Heart disease, hypertension, obesity, diabetes
– Smoking: make them stop!
– Connective tissue disease
– Previous RT to the region
– Specific anatomy, e.g. pectus excavatus/carinatum
• Treatment factors
– Complications after the surgery with infection, poor wound healing,
stiff shoulder
– Systemic therapy (chemotherapy with anthracyclines, taxanes,
endocrine therapy, trastuzumab and other new drugs)

BO speaking
 General comments,
what to do
• Balance benefit and cost for the patient
when you approve the plan
• Consider more advanced techniques as
respiratory gating, VMAT

BO speaking
 General comments,
delineation
• Comparing DI is difficult
– depends on the volume size
– the ”direction” of the disharmony e.g. towards
the spinal cord or the heart

BO speaking
 Questions?

Now we will look at the submitted delineations and

discuss them……
Sandra Hol

BO speaking
 Thank you for
your hard work!