The Prone-Position Whole Breast Irradiation Paradox: Where Do We Stand? A Comprehensive Review

Area of Science:

• Radiation Oncology
• Medical Physics

Background:

• Interest in prone-position whole breast irradiation (WBI) has grown over two decades.
• Solid scientific data shows dosimetric benefits and decreased toxicity with prone WBI.
• Despite evidence, there's community conflict regarding its routine clinical adoption.

Purpose of the Study:

• To evaluate the real-world advantages of prone-position WBI.
• To contextualize prone WBI for specific scenarios like large breasts, left-sided breast cancer, and nodal irradiation.
• To encourage the clinical implementation of prone WBI.

Main Methods:

• Comprehensive literature review over the past two decades.
• Assessment of trials addressing concerns in large/pendulous breasts, left/right breast cancer, and nodal irradiation.
• Evaluation of reproducibility with deep inspiration breath hold (DIBH) using photons or protons.

Main Results:

• Numerous trials have explored prone treatment, defining atlases for nodal irradiation.
• Customized immobilization couches facilitate Intensity-Modulated Radiation Therapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT).
• Despite growing evidence, prone WBI remains underused in clinical practice.

Conclusions:

• Prone WBI presents significant dosimetric advantages and reduced toxicity.
• Specific scenarios like large breasts, left-sided breast cancer, and nodal irradiation benefit from prone positioning.
• Further promotion and implementation of prone WBI in routine practice are warranted.