Radiotherapy and Oncology 118 (2016) 209–210

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Radiotherapy and Oncology

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PROCAB guidelines

Vessel based delineation guidelines for the our modification. With this adaptation, the PROCAB guideline is
elective lymph node regions in breast cancer also in coherence with the ESTRO guideline [2].
radiation therapy – PROCAB guidelines
Best regards,
Karolien Verhoeven,
Dear Editor, On behalf of the PROCAB team.
Hereby, we present a small adaptation of the PROCAB guideline
for lymph node delineation in breast cancer [1]. Conflict of interest statement
It was decided to modify the definition of the caudal
border of level II and the interpectoral (or Rotter) space. A None.
few slices are added to lower the caudal border until the
insertion of the pectoralis minor muscle with the chest wall Acknowledgments
(see Table 1).
Radiological observation of nodes in the fatty space more than Financial support was provided by the Belgian College of
5 mm below the axillary vein and/or the vessels perforating the Physicians in Radiation Oncology (the Belgian Cancer Plan, action
pectoral muscles in early-stage breast cancer patients explain 16 – fgov.be) and the Myny Vanderpoorten Foundation.

Table 1
Adapted PROCAB/ESTRO delineation guidelines for the clinical target volume (CTV) definition for elective irradiation of lymph node level 2–4, interpectoral and internal
mammary node region in breast cancer.

Cranial Caudal Anterior Posterior Lateral Medial

Level IV Cranial edge of the 5 mm caudal of the ⁄ Cranially: dorsal ⁄Cranially: Ventral ⁄ Cranially: lateral The medial edge of the
CTVn_L4 subclavian A. Arch junction of the surface of the SCM edge of the Subclavian border of the Anterior Internal Jugular Vein,
Subclavian and the ⁄ Caudally: the Artery Scalene m. without any margin
Internal Jugular Vein Infrahyoid Muscle ⁄Caudally: lung ⁄ Caudally: joining medially, excluding the
(Strap muscles) and CTVn_L3, excluding the Carotid A. and thyroid
Clavicle Subclavian A gland
Level III of the axilla When the 5 mm below the Posterior surface of the Ribs and Intercostal Medial border of the Clavicle and/or lateral
CTVn_L3 subclavian A. exist Axillary Vein when it pectoralis Major m. and muscles. Try to exclude Pectoralis Minor m border of CTVn_L4
the thorax (crosses crosses the medial the clavicle the brachial plexus if
the vertical line border of the Pectoralis visible
between the clavicle Minor m
and the first rib) and
becomes the
Axillary A
Level II of the axilla When the axillary A. The caudal border of Dorsal surface of the Ribs and Intercostal Lateral border of the Medial border of the
CTVn_L2 crosses the medial the Pectoralis Minor m Pectoralis Minor m muscles Pectoralis Minor m Pectoralis Minor m
edge of the
Pectoralis Minor m
Rotter or interpectoral Idem CTVn_L2 Idem CTVn_L2 Dorsal surface of the Ventral surface of the Lateral border of the Idem CTVn_L2
space Pectoralis Major m Pectoralis Minor m Pectoralis Major m
Internal mammary In conjunction with Cranial edge of the 4th ⁄ Cranially: 5 mm fatty space 5 mm lateral of the IM ⁄ Cranially: lateral
node region the caudal edge of rib Manubrium Sterni dorsal of the IM Vessels border of the
CTVn_IMN In CTVn_L4 ⁄ Caudally: the dorsal Vessels, excluding the Brachiocephalic Vein
surface of the pleura ⁄ Caudally: up to the
intercostal muscles sternal bone

Abbreviations: SCM = sternocleidomastoid muscle; A. = artery; m. = muscle, IM = internal mammary.

http://dx.doi.org/10.1016/j.radonc.2015.12.005
0167-8140/Ó 2015 Elsevier Ireland Ltd. All rights reserved.
210 PROCAB guidelines / Radiotherapy and Oncology 118 (2016) 209–210

References Karolien Verhoeven

Caroline Weltens
[1] Verhoeven K, Weltens C, Remouchamps V, Mahjoubi K, Veldeman L, Lengele B,
et al. Vessel based delineation guidelines for the elective lymph node regions in
University Hospitals Leuven/KU Leuven, Belgium
breast cancer radiation therapy – PROCAB guidelines. Radiother Oncol 2015 E-mail address: karolien.verhoeven@uzleuven.be (K. Verhoeven)
Jan;114:6–11.
[2] Offersen BV, Boersma LJ, Kirkove C, Hol S, Aznar MC, Biete Sola A, et al. ESTRO
Vincent Remouchamps
consensus guideline on target volume delineation for elective radiation therapy Clinique Sainte Elisabeth (AMPR), Namur, Belgium
of early stage breast cancer. Radiother Oncol 2015 Jan;114:3–10.
Khalil Mahjoubi
Tunis El Manar University, Salah Azaiez Institute, Tunis, Tunisia
Liv Veldeman
Ghent University Hospital, Belgium
Benoit Lengelé
Catholic University of Louvain, Brussels, Belgium
Eszter Hortobagyi
University Hospitals Leuven/KU Leuven, Belgium
Carine Kirkove
Catholic University of Louvain, Brussels, Belgium
Received 5 December 2015
Accepted 19 December 2015

Available online 29 December 2015