Different radiation techniques to deliver therapeutic dose to the axilla in patients with sentinel lymph node-positive breast cancer: Doses, techniques challenges and clinical considerations.

PURPOSE: To evaluate the coverage of different levels of axillary lymph nodes and organs at risk according to the field design of AMAROS study (levels I-II-III-IV), breast tangents with supraclavicular and infraclavicular fields (levels II-III-IV) and high tangent fields to the breast after breast-conserving surgery. MATERIALS AND METHODS: We delineated the axillary lymph nodes levels I-IV in 34 patients treated with breast-conserving surgery and sentinel lymph nodes biopsy. Field design according to AMAROS study - levels I-IV in patients without axillary dissection - as well as irradiation of levels II-IV used in N+ patients after axillary dissection, and also high tangent fields was simulated. Mean dose levels and volumes covered by 95% or 80% isodoses were evaluated. Doses to ipsilateral lung, heart and brachial plexus were compared. Paired t test was used. RESULTS: AMAROS study and levels II-IV plans delivered therapeutic dose to high axilla (levels II-IV), but the high tangent fields showed inefficacy to cover these volumes, P<0.001). In terms of organs at risk, especially, ipsilateral lung, AMAROS study plan was found to significantly increase the volume receiving at least 10Gy (I-IV:46.8%, II-IV: 39%), but also the volume receiving at least 20Gy (I-IV: 39.3%, II-IV: 31.3%), and V30Gy (I-IV: 34.2% vs II-IV: 26.1%), as well as the mean dose (I-IV: 18.6Gy, II-IV: 15.2Gy, P<0.001). CONCLUSIONS: The omission of axillary dissection and the axilla irradiation need is associated with high dose irradiation of the lungs, and with higher toxicity. The indication of axillary dissection or irradiation of low axilla could be individualized in relation with individual comorbidities and factors of risk.

Experimental study on the mechanical properties of the horn sheaths from cattle.

Bovine horn is composed of a sheath of keratin overlying a bony core. Previous studies of the bovine horn sheath have focused mainly on its morphology and compositions. In the present paper, we performed a series of uniaxial tension, three-point bending, and fracture tests to investigate the structural and mechanical properties of the horn sheaths from subadult cattle, Bos taurus. The effects of hydration on the mechanical properties were examined and their variations along the longitudinal direction of the horn sheath were addressed. Scanning electron microscopy of the fracture surfaces showed that the horn sheath has a layered structure and, more interestingly, the laminae have a rippled appearance. The Young's modulus and tensile strength increase from 850 MPa and 40 MPa at 19% water content to 2.3 GPa and 154 MPa at 0% water content, respectively. The Poisson's ratio of the horn sheath was about 0.38. The critical stress intensity factor was about 4.76 MPa m1/2 at an intermediate hydration (8% water content), greater than that at 0% water content (3.86 MPa m1/2) and 19% water content (2.56 MPa m1/2). The bending properties of the samples varied along the length of the horn. The mean flexural moduli of the specimens in the distal, middle and proximal parts were about 6.26 GPa, 5.93 GPa and 4.98 GPa, respectively; whereas the mean yield strength in the distal segment was about 152.4 MPa, distinctly higher than that in the middle (135.7 MPa) and proximal parts (116.4 MPa). This study deepens our understanding of the relationships among optimal structure, property and function of cattle horn sheaths.