Selective Axillary Sparing Regional Nodal Irradiation for Lymphedema Risk Reduction in Breast Cancer: A Planning Study using Tomotherapy

Background and Objectives: The axillary lateral vessel thoracic junction (ALTJ) is a key lymphatic drainage pathway for the arm and a potential structure to spare during regional nodal irradiation (RNI) to reduce lymphedema risk in breast cancer patients. This study aims to demonstrate the feasibility of ALTJ-sparing radiation therapy (RT) planning using Tomotherapy. Materials and Methods: Ten breast cancer patients who had undergone axillary lymph node dissection and whose dissected axillary levels were excluded from the RNI target volume were included. A TomoDirect intensity-modulated RT plan was generated at a dose of 50 Gy in 25 fractions. The dissected axilla was not designated as an organ at risk (OAR) in the original treatment plan. For this study, the axillary lymph node level I (AXL1) and the ALTJ were delineated retrospectively, with the ALTJ considered an OAR in the newly generated study plan. A total of 20 RT plans (10 per group) were statistically compared using various dose-volume parameters. Results: Compared to the original plans, the study plans with ALTJ as an OAR significantly reduced the incidental dose to both the ALTJ (mean: 41.7 ± 3.4 Gy vs. 27.2 ± 1.3 Gy; p=0.005) and the AXL1 (mean: 43.9 ± 2.0 Gy vs. 37.7 ± 1.9 Gy; p=0.005). All other dosimetric parameters (V25Gy, V35Gy, V40Gy, Dmin, Dmax) for the ALTJ were also significantly lower in the study plans. This ALTJ sparing was achieved while maintaining all required dose-volume constraints for target volumes and standard OARs such as the lung and heart. Conclusions: This study demonstrates that simply excluding the dissected axilla from the target volume without designating it as an OAR still results in a substantial incidental dose to this region. Our findings also show the feasibility of using Tomotherapy to selectively spare the axilla, particularly the ALTJ subregion of AXL1, which is critical for lymphedema risk in breast cancer patients.