Vol 26, No 6 (2021)
Research paper
Published online: 2021-09-29

open access

Page views 5795
Article views/downloads 261
Get Citation

Connect on Social Media

Connect on Social Media

Lateral wedge with medial only cardiac shielding (LEMONADE) technique in left chest wall adjuvant radiotherapy

Reduan Abdullah12, Gokula Kumar Appalanaido2, Syadwa Abdul Shukor3, Hafiz Zin2, Mohd Zahri Abdul Aziz2, Norhafizah Ishak2
Rep Pract Oncol Radiother 2021;26(6):892-898.


Background: This dosimetric study compared lateral wedge with medial only cardiac shielding (LEMONADE) technique, for left chest wall (LCW) irradiation against three other commonly used techniques.

Materials and methods: Dosimetric parameters of 22 consecutive LBC patients treated using the P1 (LEMONADE technique) were compared with 3 other virtually reconstructed plans: no cardiac shielding with paired wedges; P2 (paired wedges and medial only Y-direction shielding) and P3 (paired wedges and bilateral Y-direction shielding).

Results: P1 showed better target volume (TV) coverage with the mean 90% isodose coverage of 85.59% ± 5.44 compared to 78.90% ± 8.59 and 74.22% ± 9.50 for P2 and P3, respectively. Compared to no cardiac shielding, for a 4.65% drop in TV coverage the V26Gy of heart dropped from 6.68% to a negligible 0.85% for P1. TV receiving < 30Gy is also significantly lesser for P1 compared to P2 and P3 (5.42% vs 10.64% and 15.8%), whilst there is a small difference of 2.75% between no cardiac shielding and P1.

Conclusion: With the improvement in BC survival rate, cardiac toxicity associated with adjuvant irradiation for LBC is a major concern. P1 (LEMONADE) technique has a good compromise between cardiac sparing and target coverage and should suffice for most LCW irradiations. Furthermore, the LEMONADE technique is a simple, reproducible and involves fast planning for cardiac sparing, which is ideal for under-resourced departments with heavy workload.

Article available in PDF format

View PDF Download PDF file


  1. McGale P, Taylor C, Correa C, et al. EBCTCG (Early Breast Cancer Trialists' Collaborative Group). Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014; 383(9935): 2127–2135.
  2. Jones JM, Ribeiro GG. Mortality patterns over 34 years of breast cancer patients in a clinical trial of post-operative radiotherapy. Clin Radiol. 1989; 40(2): 204–208.
  3. Clarke M, Collins R, Darby S, et al. Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005; 366(9503): 2087–2106.
  4. Gujral DM, Lloyd G, Bhattacharyya S. Radiation-induced valvular heart disease. Heart. 2016; 102(4): 269–276.
  5. Posner MR, Cohen GI, Skarin AT. Pericardial disease in patients with cancer. The differentiation of malignant from idiopathic and radiation-induced pericarditis. Am J Med. 1981; 71(3): 407–413.
  6. Duane FK, McGale P, Brønnum D, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013; 368(11): 987–998.
  7. Breast cancer contouring atlas. https://www.rtog.org/corelab/contouringatlases/breastcanceratlas.aspx.
  8. Gokula K, Earnest A, Wong LC. Meta-analysis of incidence of early lung toxicity in 3-dimensional conformal irradiation of breast carcinomas. Radiat Oncol. 2013; 8: 268.
  9. Poitevin-Chacón A, Chávez-Nogueda J, Prudencio RR, et al. Dosimetry of the left anterior descending coronary artery in left breast cancer patients treated with postoperative external radiotherapy. Rep Pract Oncol Radiother. 2018; 23(2): 91–96.

Reports of Practical Oncology and Radiotherapy