The dosimetric impact of axillary nodes contouring variability in breast cancer radiotherapy: an AIRO multi-institutional study

Published:January 13, 2022DOI:


      • Contouring variability is a well-known issue in breast cancer radiotherapy.
      • Dosimetric impact of contouring variability of axillary nodes is scarcely investigated.
      • Variations in dosimetric coverage of axillary nodes emerged from a multicentric study.
      • The use of intensity modulated radiotherapy has amplified the dosimetric variations.
      • Consensus, quality assurance programme and automated outlining techniques are encouraged.



      To quantify the dosimetric impact of contouring variability of axillary lymph nodes (L2, L3, L4) in breast cancer (BC) locoregional radiotherapy (RT).

      Materials and Methods

      18 RT centres were asked to plan a locoregional treatment on their own planning target volume (single centre, SC-PTV) which was created by applying their institutional margins to the clinical target volume of the axillary nodes of three BC patients (P1, P2, P3) previously delineated (SC-CTV). The gold standard CTVs (GS-CTVs) of P1, P2 and P3 were developed by BC experts’ consensus and validated with STAPLE algorithm. For each participating centre, the GS-PTV of each patient was created by applying the same margins as those used for the SC-CTV to SC-PTV expansion and replaced the SC-PTV in the treatment plan. Datasets were imported into MIM v6.1.7 [MIM Software Inc.], where dose-volume histograms (DVHs) were extracted and differences were analysed.


      17/18 centres used intensity-modulated RT (IMRT). The CTV to PTV margins ranged from 0 to 10 mm (median 5 mm). No correlation was observed between GS-CTV coverage by 95% isodose and GS-PTV margins width. Doses delivered to 98% (D98) and 95% (D95) of GS-CTVs were significantly lower than those delivered to the SC-CTVs. No significant difference between SC-CTV and GS-CTV was observed in maximum dose (D2), always under 110%. Mean dose ≥ 99% of the SC-CTVs and GS-CTVs was satisfied in 84% and 50%, respectively. In less than one half of plans, GS-CTV V95% was above 90%. Breaking down the GS-CTV into the three nodal levels (L2, L3 and L4), L4 had the lowest probability to be covered by the 95% isodose.


      Overall, GS-CTV resulted worse coverage, especially for L4. IMRT was largely used and CTV-to-PTV margins did not compensate for contouring issues. The results highlighted the need for delineation training and standardization.


      3D-CRT (Three-dimensional conformal RT), AAA (Analytical anisotropic algorithm), AIRO (Associazione Italiana di Radioterapia e Oncologia Clinica (Italian Association of Radiotherapy and Clinical Oncology)), ABAS (Atlas-based automated segmentation), BC (Breast cancer), BSG (Breast study group), CCC (Collapsed cone convolution), CT (Computed tomography), CTV (Clinical target volume), D98, D95, D2 (Dose delivered to 98%, 95%, and 2% of volume), DEGRO (German Society of Radiation Oncology), Dmean (Mean dose), DVH (Dose-volume histogram), GS (Gold Standard), ICRU (International Commission on Radiation Unit & Measurements), IEO (Istituto Europeo di Oncologia (European Institute of Oncology)), IMRT (Intensity-modulated RT), IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico (Scientific Institute for Research, Hospitalization and Healthcare)), L2/L3/L4 (Lymph node level 2/3/4), MDC (Mean distance to conformity), MLC (Multileaf collimator), N (Number of plans), OAR (Organ at risk), P1/P2/P3 (Patient 1/2/3), PTV (Planning target volume), RO (Radiation oncologist), RT (Radiotherapy), SC (Single centre), SD (Standard deviation), SPS (Software package system), STAPLE (Simultaneous truth and performance level estimation), V95 (Volume receiving at least 95% of the prescribed dose), VMAT (Volumetric modulated arc therapy), WB/CW (Whole breast/chest wall)


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