Regional nodal irradiation adds the axillary, supraclavicular and sometimes internal mammary nodes to breast or chest wall treatment. The volumes are larger and closer to the lung, heart and neck, so organ limits are different from breast-only treatment.
Adding the regional nodes extends the target up into the lower neck and, for the internal mammary chain, medially along the sternum. Randomized trials including MA.20 and EORTC 22922 underpin modern nodal treatment.
Common schedules include 45–50 Gy at 1.8–2 Gy per fraction and 40 Gy in 15 fractions for the nodes; hypofractionated nodal treatment is being studied in trials such as SKAGEN Trial 1.
What changes for the planner:
As for breast or chest wall treatment, with the neck included.
Supine on a breast board with the arm above the head, scanned from the neck to below the diaphragm with the whole lungs included. More →
The scan has to cover the supraclavicular region; breath hold matters more when the internal mammary nodes are treated.
A reproducible arm-up position, with the head position set by the immobilization device.
Arm and shoulder position move the axilla and supraclavicular region, so small changes shift the nodal targets relative to the beams.
Image fusion aligns an outside scan with the planning CT so the target can be drawn using information the CT doesn't show. For nodal treatment this means any staging PET/CT, MRI or CT, plus the mammogram and ultrasound, from before surgery.
They show which axillary, supraclavicular or internal mammary nodes were involved, which affects the nodal volumes. The axilla and supraclavicular region move with arm and shoulder position, so a diagnostic scan taken in a different arm position won't line up with the planning CT — check the registration at the nodes themselves.
Which nodal regions are treated, and where each starts and stops, come from your protocol and the consensus atlases.
The nodes above the clavicle, drawn around the vessels in the lower neck.
Its upper border and how far it extends toward the thyroid and trachea differ between atlases, which changes thyroid, esophagus and cord dose.
The axillary nodes, divided into levels by their relation to the pectoralis minor muscle.
Which levels are treated depends on surgery and risk; the atlases define each level's borders.
The internal mammary nodes, drawn around the internal mammary vessels in the upper intercostal spaces.
A small target right next to the heart and lung. Including it is one of the biggest drivers of heart dose in breast planning.
The breast or chest wall volume treated together with the nodes. More →
Planned as on the whole-breast or post-mastectomy pages, but it has to join the nodal volumes cleanly.
Click an organ for its anatomy, why it matters and contouring resources. Superscripts link to the study behind each value.
| Organ | 45–50 Gy / 25 fx1.8–2 Gy per fraction | 40 Gy / 15 fx |
|---|---|---|
| Ipsilateral Lung15 fx: dose from the breast or chest wall and nodal plans combined. |
| |
| Contralateral Lung |
| — |
| Heart / PericardiumMean <5 Gy may be hard to achieve; keep as low as reasonably achievable. Consider breath hold. |
| |
| LAD (Left Anterior Descending Artery)Left-sided treatment. May not be achievable when the internal mammary nodes are treated. |
|
|
| Contralateral BreastKeep as low as reasonably achievable, especially with VMAT or fields crossing the midline. | — | |
| Spinal CordNot expected to come near this limit. | — |
Values quoted from eviQ 1924 (last reviewed 28 March 2024; review due 30 June 2026) and DEGRO 2019, checked by DoseLab on 2026-09-23. Verify against your protocol, institutional policy and physician directive before clinical use.
Results of the NCIC CTG MA.20 randomized trial of whole-breast irradiation with or without regional nodal irradiation. Citation as given in the eviQ reference list; not yet checked against the journal.
Results of the EORTC 22922/10925 randomized trial of internal mammary and medial supraclavicular nodal irradiation. Citation as given in the eviQ reference list; not yet checked against the journal.
Randomized trial of 40 Gy in 15 fractions versus 50 Gy in 25 fractions for loco-regional breast radiotherapy. The protocol lists the DBCG organ limits used in the trial (Table 7) and quotes the DBCG guideline LAD maximum of 17 Gy (hypofractionated) and 20 Gy (normofractionated), noting that heart limits were under review because of the benefit of treating the internal mammary nodes — so the trial asked centers to delineate the LAD and report its dose rather than enforce a limit.
NRG Oncology's protocol page for NSABP B-51 / RTOG 1304, a phase 3 trial of regional nodal irradiation after neoadjuvant chemotherapy. The protocol document holds the trial's normal-tissue requirements.
The heart chapter of the 2010 QUANTEC supplement, covering pericarditis and long-term cardiac effects and the dose–volume relationships reported for them. A later letter in the same journal comments on its breast-cancer conclusions.
Planning study comparing IMRT with 3D-conformal whole-breast radiotherapy and proposing a normal tissue index for plan evaluation. Citation as given in the eviQ reference list; not yet checked against the journal.
ESTRO consensus on target volume delineation for elective breast and nodal radiotherapy, with a version 1.1 correction published in 2016. Citation as given in the eviQ reference list; not yet checked against the journal.
NRG Oncology's breast downloads page, which links the RTOG Breast Cancer Atlas for Radiation Therapy Planning, an NRG whole-breast radiation therapy template and the RADCOMP breast atlas.
Endorsed eviQ protocol for regional nodal irradiation (axilla, supraclavicular fossa and internal mammary chain). DoseLab's regional nodal constraint table reproduces selected values from its organs-at-risk table, keeping eviQ's citation for each. The review date eviQ lists had passed when DoseLab checked this page — check the live page for the current version.