Abstract
Most patients undergoing breast conservation therapy receive radiotherapy in the supine position. Historically, prone breast irradiation has been advocated for women with large pendulous breasts in order to decrease acute and late toxicities. With the advent of CT planning, the prone technique has become both feasible and reproducible. It was shown to be advantageous not only for women with larger breasts but in most patients since it consistently reduces, if not eliminates, the inclusion of heart and lung within the field. The prone setup has been accepted as the best localizing position for both MRI and stereotactic biopsy, but its adoption has been delayed in radiotherapy. New technological advances including image-modulated radiation therapy and image-guided radiation therapy have made possible the exploration of accelerated fractionation schemes with a concomitant boost to the tumor bed in the prone position, along with better imaging and verification of reproducibility of patient setup. This review describes some of the available techniques for prone breast radiotherapy and the available experience in their application. The NYU prone breast radiotherapy approach is discussed, including a summary of the results from several prospective trials.
Highlights
As an alternative to mastectomy for breast cancer, approaches that permitted breast conservation began in France in the thirties and from the very beginning, included radiation therapy (Baclesse et al, 1939)
Limitations are the absence of a holding bar to maintain the arms and hands in the same position, and the fact that it was not designed to be indexed to the couch, requiring therapists experienced in prone breast radiation and the accurate use of positioning lasers to prevent differences in a dayto-day setup
OF NYU PRONE BREAST RADIATION THERAPY TRIALS While many breast cancer patients requiring whole breast radiation therapy have been treated in the prone position with standard fractionation regimens, NYU conducted a series of clinical trials to test hypo-fractionated, accelerated regimens of breast radiotherapy
Summary
As an alternative to mastectomy for breast cancer, approaches that permitted breast conservation began in France in the thirties and from the very beginning, included radiation therapy (Baclesse et al, 1939). Since it was found that utilizing small tangential fields resulted in acceptable dose distribution, the requirement for full couch rotation became unnecessary, and permitted modification of the design of the table to accommodate a more comfortable position (Figure 3, version 2), which greatly increased patients’ comfort. Limitations are the absence of a holding bar to maintain the arms and hands in the same position, and the fact that it was not designed to be indexed to the couch, requiring therapists experienced in prone breast radiation and the accurate use of positioning lasers to prevent differences in a dayto-day setup While better engineered devices have permitted better indexing of the table and more comfortable and reproducible positioning, the basic dosimetric advantages of a prone setup became apparent since the beginning, reflecting the more advantageous access to the target when gravity distances the breast parenchyma from the chest wall
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