Vessel based delineation guidelines for the elective lymph node regions in breast cancer radiation therapy – PROCAB guidelines

Published:November 19, 2014DOI:



      A national project to improve the quality of breast radiation therapy was started, named PROCAB (PROject on CAncer of the Breast). One of the objectives was to reach a national consensus guideline for the delineation of the regional lymph node areas in breast radiation therapy.


      The realization of the new guidelines was a step by step process that started with multiple expert meetings where the existing guidelines were analyzed and the delineations of the lymph node regions were performed together with a surgeon, specialized in the anatomy of the drainage of the breast.


      The delineation guidelines are vessel-based. Since the occurrence of pathological lymph nodes is typically around the veins, the cranial and caudal borders of all different nodal regions are based on a 5 mm margin around the veins, except for the parasternal lymph node area. Compared to the existing guidelines there are some major changes.


      With this project a national as well as a European (ESTRO) consensus guideline for the delineation of the regional lymph node areas in breast RT is reached. The new delineation atlas is vessel-based and no longer field-based.


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        • Darby S.
        • McGale P.
        • Correa C.
        • et al.
        Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials.
        Lancet. 2011; 378: 1707-1716
        • EBCTCG Early Breast Cancer Trialists’ Collaborative Group
        Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials.
        Lancet. 2014;
        • Whelan T.
        • Olivotto I.
        • Ackerman I.
        • et al.
        NCIC-CTG MA.20: an intergroup trial of regional nodal irradiation in early breast cancer.
        J Clin Oncol. 2011; 29 ([suppl.; abstr. LBA1003])
        • Budach W.
        • Kammers K.
        • Boelke E.
        • Matuschek C.
        Adjuvant radiotherapy of regional lymph nodes in breast cancer - a meta-analysis of randomized trials.
        Radiat Oncol. 2013; 8: 267
        • Poortmans Philip
        • Struikmans Henk
        • Kirkove Carine
        • et al.
        Irradiation of the internal mammary and medial supraclavicular lymph nodes in stage I to III breast cancer: 10 years results of the EORTC radiation oncology and breast cancer groups phase III trial 22922/10925.
        Eur. J. Cancer. 2013; 47 ([suppl. 2])
        • Thorsen L.
        • Berg M.
        • Brodersen H.J.
        • et al.
        Improved survival with internal mammary node irradiation: a prospective study on 3072 breast cancer patients.
        Radiat Oncol. 2014; 111 ([suppl. 1]): 67-68
        • Verhoeven K.
        • Sweldens C.
        • Petillion S.
        • et al.
        Breathing adapted radiation therapy in comparison with prone position to reduce the doses to the heart, left anterior descending coronary artery, and contralateral breast in whole breast radiation therapy.
        Pract Radiat Oncol. 2014; 4: 123-129
        • Mulliez T.
        • Speleers B.
        • Madani I.
        • De G.W.
        • Veldeman L.
        • De N.W.
        Whole breast radiotherapy in prone and supine position: is there a place for multi-beam IMRT?.
        Radiat Oncol. 2013; 8: 151
        • Osman S.O.
        • Hol S.
        • Poortmans P.M.
        • Essers M.
        Volumetric modulated arc therapy and breath-hold in image-guided locoregional left-sided breast irradiation.
        Radiother Oncol. 2014;
        • Dijkema I.M.
        • Hofman P.
        • Raaijmakers C.P.
        • Lagendijk J.J.
        • Battermann J.J.
        • Hillen B.
        Loco-regional conformal radiotherapy of the breast: delineation of the regional lymph node clinical target volumes in treatment position.
        Radiother Oncol. 2004; 71: 287-295
        • Kirova Y.M.
        • Castro Pena P.
        • Dendale R.
        • et al.
        Simplified rules for everyday delineation of lymph node areas for breast cancer radiotherapy.
        Br J Radiol. 2010; 83: 683-686
        • Nielsen M.H.
        • Berg M.
        • Pedersen A.N.
        • et al.
        Delineation of target volumes and organs at risk in adjuvant radiotherapy of early breast cancer: national guidelines and contouring atlas by the Danish Breast Cancer Cooperative group.
        Acta Oncol. 2013; 52: 703-710
      1. RTOG breast cancer contouring atlas. Available at: <>.

        • Li X.A.
        • Tai A.
        • Arthur D.W.
        • et al.
        Variability of target and normal structure delineation for breast cancer radiotherapy: an RTOG multi-institutional and multiobserver study.
        Int J Radiat Oncol Biol Phys. 2009; 73: 944-951
        • Marks L.B.
        • Hebert M.E.
        • Bentel G.
        • et al.
        To treat or not to treat the internal mammary nodes: a possible compromise.
        Int J Radiat Oncol Biol Phys. 1994; 29: 903-909
      2. Ashwell K The Lymphatic System. Lecture presented on 17 September 2008 in Clancy Auditorium. The University of New South Wales, Sydney, Australia. Conducted by the Faculty of Medicine. University of New South Wales, Sydney 2008.

        • Joye I.
        • Lambrecht M.
        • Jegou D.
        • Hortobagyi E.
        • Scalliet P.
        • Haustermans K.
        Does a central review platform improve the quality of radiotherapy for rectal cancer? Results of a national quality assurance project.
        Radiother Oncol. 2014;