Postoperative proton radiotherapy for localized and locoregional breast cancer: potential for clinically relevant improvements?

Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.
International journal of radiation oncology, biology, physics (Impact Factor: 4.59). 08/2009; 76(3):685-97. DOI: 10.1016/j.ijrobp.2009.02.062
Source: PubMed

ABSTRACT To study the potential reduction of dose to organs at risk (OARs) with intensity-modulated proton radiotherapy (IMPT) compared with intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) photon radiotherapy for left-sided breast cancer patients.
Comparative treatment-planning was performed using planning computed tomography scans of 20 left-sided breast cancer patients. For each patient, three increasingly complex locoregional volumes (planning target volumes [PTVs]) were defined: whole breast (WB) or chest wall (CW) = (PTV1), WB/CW plus medial-supraclavicular (MSC), lateral-supraclavicular (LSC), and level III axillary (AxIII) nodes = (PTV2) and WB/CW+MSC+LSC+AxIII plus internal mammary chain = (PTV3). For each patient, 3D-CRT, IMRT, and IMPT plans were optimized for PTV coverage. Dose to OARs was compared while maintaining target coverage.
All the techniques met the required PTV coverage except the 3D-CRT plans for PTV3-scenario. All 3D-CRT plans for PTV3 exceeded left-lung V20. IMPT vs. 3D-CRT: significant dose reductions were observed for all OARs using IMPT for all PTVs. IMPT vs. IMRT: For PTV2 and PTV3, low (V5) left lung and cardiac doses were reduced by a factor >2.5, and cardiac doses (V22.5) were by a factor of >20 lower with IMPT compared with IMRT.
When complex-target irradiation is needed, 3D-CRT often compromises the target coverage and increases the dose to OARs; IMRT can provide better results but will increase the integral dose. The benefit of IMPT is based on improved target coverage and reduction of low doses to OARs, potentially reducing the risk of late-toxicity. These results indicate a potential role of proton-radiotherapy for extended locoregional irradiation in left breast cancer.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Breast cancer radiotherapy represents an essential component in the overall management of both early stage and locally advanced breast cancer. As the number of breast cancer survivors has increased, chronic sequelae of breast cancer radiotherapy become more important. While recently published data suggest a potential for an increase in cardiac events with radiotherapy, these studies do not consider the impact of newer radiotherapy techniques commonly utilized. Therefore, the purpose of this review is to evaluate cardiac dose sparing techniques in breast cancer radiotherapy. Current options for cardiac protection/avoidance include (1) maneuvers that displace the heart from the field such as coordinating the breathing cycle or through prone patient positioning, (2) technological advances such as intensity modulated radiation therapy (IMRT) or proton beam therapy (PBT), and (3) techniques that treat a smaller volume around the lumpectomy cavity such as accelerated partial breast irradiation (APBI), or intraoperative radiotherapy (IORT). While these techniques have shown promise dosimetrically, limited data on late cardiac events exist due to the difficulties of long-term follow up. Future studies are required to validate the efficacy of cardiac dose sparing techniques and may use surrogates for cardiac events such as biomarkers or perfusion imaging.
    Radiotherapy and Oncology 05/2014; · 4.86 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Purpose In left-sided breast cancer radiotherapy, tangential intensity modulated radiotherapy combined with breath-hold enables a dose reduction to the heart and left anterior descending (LAD) coronary artery. Aim of this study was to investigate the added value of intensity modulated proton therapy (IMPT) with regard to decreasing the radiation dose to these structures. Methods In this comparative planning study, four treatment plans were generated in 20 patients: an IMPT plan and a tangential IMRT plan, both with breath-hold and free-breathing. At least 97 % of the target volume had to be covered by at least 95 % of the prescribed dose in all cases. Specifically with respect to the heart, the LAD, and the target volumes, we analyzed the maximum doses, the mean doses, and the volumes receiving 5-30 Gy. Results As compared to IMRT, IMPT resulted in significant dose reductions to the heart and LAD-region even without breath-hold. In the majority of the IMPT cases, a reduction to almost zero to the heart and LAD-region was obtained. IMPT treatment plans yielded the lowest dose to the lungs. Conclusions With IMPT the dose to the heart and LAD-region could be significantly decreased compared to tangential IMRT with breath-hold. The clinical relevance should be assessed individually based on the baseline risk of cardiac complications in combination with the dose to organs at risk. However, as IMPT for breast cancer is currently not widely available, IMPT should be reserved for patients remaining at high risk for major coronary events.
    Breast Cancer Research and Treatment 10/2014; · 4.47 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose To compare 3 different treatment positions in whole breast radiation therapy in terms of target volume coverage and doses to the organs at risk (OAR). Methods and Materials Thirty-four breast cancer (BC) patients (17 right-sided and 17 left-sided) were included in this dosimetric planning study. They all underwent a computed tomography (CT) scan in standard supine position in free-breathing (FB), supine position with gating in deep inspiratory breath hold (DIBH)(G), and prone position (P). Three-dimensional treatment plans were made for all 3 CTs. Target coverage and OAR sparing were evaluated. Results Breast volumes varied between 209 and 2814 cm3. The target coverage, expressed as the mean volume of the breast receiving at least 95% of the prescription dose, was similar for the 3 treatment positions. The mean lung dose and the volume of the lungs receiving > 20 Gy were significantly lower in P (1.7 Gy; 2.3%) compared with G (3.4 Gy; 5.6%; P < .0001) and FB (4 Gy; 7.3%; P < .0001). The volume of the contralateral breast receiving > 5 Gy was significantly lower in G (P = .001) or FB (P = .004) versus prone. The supine position with gating in DIBH significantly reduced the volume of the heart receiving > 30 Gy (V30heart), the mean heart (Dheart), and mean left anterior descending coronary artery (LAD) dose (DLAD) for left-sided BC patients (V30heart 0.9%, Dheart 1.6 Gy, DLAD 22.4 Gy) with respect to FB (V30heart 4.3%, Dheart 3.5 Gy, DLAD 30.9 Gy)(V30heart and mean Dheart: P ≤ .0001; mean DLAD: P = .008) and P (V30heart 7.9%, Dheart 5.4 Gy, DLAD 36.4 Gy)(V30heart and mean Dheart: P = .0004; mean DLAD: P = .01). Conclusions The coverage of the planning target volume breast was equal for the 3 treatment positions. The lowest doses to the lungs were achieved in prone. The heart, LAD, and contralateral breast were best spared in the supine position with gating in DIBH.
    Practical Radiation Oncology. 03/2014; 4(2):123–129.