Can you cover me?

Speaking of high risk nodal disease falling through the cracks of standard treatment, this German retrospective study takes an interesting look at locations of pre-treatment PET-avid nodal disease for localized and metastatic breast cancer. First they compiled locations of involved regional nodes from 235 patients and superimposed them all on a single “standard” patient scan. As expected, over half of involved nodes were in level I with the remaining ones dispersed pretty evenly among the other nodal regions. Then they contoured regional nodal coverage using each RTOG and ESTRO guidelines (slight differences exist between them). Good news was coverage with RTOG and ESTRO was pretty consistent. Bad news was only 51-70% of initially involved areas were covered. Missed pre-treatment disease most commonly happened in level II, supraclavicular, and internal mammary regions. TBL: Contouring guidelines are fine for standardizing care, but they may be bad for individual treatment plans. | Borm, Int J Radiat Oncol Biol Phys 2018