Post mastectomy chest wall irradiation using mixed electron-photon beams with or without isocentric technique

To describe our technique in delivering post mastectomy radiotherapy to chest wall using electron-photon mixed beam with or without isocentric application of the tangential photon portals, and to evaluate the associated acute and delayed morbidities.

Twenty-two females with invasive breast cancer were subjected to modified radical mastectomy with adequate axillary dissection. All the patients have either tumour > or = 5 cm and/ or positive axillary nodes > 3. Chest wall was irradiated by a mixed beam of 6-Mev electrons (10Gy) and opposed tangential fields using 6 Mev-photons (36 Gy) followed by 6-Mev electrons boost to the scar of mastectomy for 4 Gy/2 fractions. We randomly allocated our patients to receive the photon beam with or without the isocentric technique.

The mean dose to the planned target volume (PTV) by mixed beam was 44 Gy (96%) with a mean dose of 42 Gy (91%) to the overlying skin for the whole study group. In cases with right breast disease (17 cases), the mean right lung tissue volume within the PTV was 220 ml (15%). It was relatively higher with the non-iscocentric technique, 281 ml (19%), compared to the isocentric technique of 159 ml (10.5%). In cases with left breast disease (5 cases), the mean left lung volume within the PTV was 175 ml (14%). Larger volume of the lung tissue was included with the non-isocentric technique, 197 ml (16%) compared to the isocentric technique of 153 ml (12%). The mean scattered doses to the rest of the lung tissue, the rest of the heart in left breast cases, and the contra-lateral breast for the whole study group were 2.8 Gy, 1.8 Gy, and 1.4 Gy respectively and was comparable in both treatment arms. None of the cases developed any element of acute radiation related pneumonitis. Delayed radiation induced pneumonitis was seen in 2 cases (18%), with the chest wall treated with radiation with the non-isocentric technique.

This study clearly demonstrated the utility of mixed beam in irradiating the chest wall after mastectomy with the dose prescription we proposed. An adequate homogeneous dose level was delivered to the chest wall. The treatment was administered with accepted level of both acute and delayed treatment related morbidity especially when the photons were delivered by the isocentric technique.