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A Dosimetric Study Comparing Different Radiotherapy Planning Techniques With and Without Deep Inspiratory Breath Hold for Breast Cancer


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Objective: To analyze whether deep inspiratory breath hold (DIBH) would be dosimetrically beneficial irrespective of radiotherapy planning techniques for patients with left breast cancers requiring adjuvant radiotherapy. Methods: Planning CT scans were taken in free-breathing (FB) as well as deep-inspiration breath hold (DIBH) for patients requiring adjuvant radiotherapy for left breast cancers. After registration, three radiotherapy plans - 3D-conformal radiotherapy (3DCRT), intensity modulated RT (IMRT), and volumetric modulated arc-therapy (VMAT) - were generated for both FB and DIBH scans for each patient. The dose-volume parameters were collected from the dose-volume histogram and analyzed. A paired t-test is used for statistical analysis of the parameters. Findings: The study was conducted on thirteen patients. The mean dose of the left lung was reduced with DIBH by 32%, 24%, and 6% (8.6 Gy, 6.6 Gy, and 6.4 Gy) with 3DCRT, IMRT, and VMAT, respectively. The mean heart dose was reduced by 3.3 Gy (2.2 vs 5.5 Gy), 2.2 Gy (7.5 vs 9.7 Gy), and 1.2 Gy (5.8 vs 7 Gy) with 3DCRT, IMRT, and VMAT with DIBH. Similarly, the left anterior descending artery (LAD) mean dose was relatively reduced by 80%, 34%, and 20% when compared with the FB scans for 3DCRT, IMRT, and VMAT respectively, with max dose in the 3DCRT plan. Novelty/applications: DIBH appears to have maximum benefit in achieving a better sparing of organs-at-risk for patients being considered for 3DCRT, and to a lesser extent with even IMRT and VMAT techniques.
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A Dosimetric Study Comparing Different
Radiotherapy Planning Techniques With and Without
Deep Inspiratory Breath Hold for Breast Cancer
Sarath S Nair
, V N Meena Devi
, Krishna Sharan
, Jyothi Nagesh
, Brahmaiah Nallapati
Shambhavi Kotian
Department of Physics, Noorul Islam Centre for Higher Education Kumaracoil, Tamilnadu, India;
Department of Radiotherapy & Oncology, Kasturba
Medical College Manipal, Manipal Academy of Higher Education, Manipal, India;
Department of Medical Physics, Manipal College of Health
Professions, Manipal Academy of Higher Education, Manipal, India
Correspondence: Sarath S Nair, Email
Objective: To analyze whether deep inspiratory breath hold (DIBH) would be dosimetrically benecial irrespective of radiotherapy
planning techniques for patients with left breast cancers requiring adjuvant radiotherapy.
Methods: Planning CT scans were taken in free-breathing (FB) as well as deep-inspiration breath hold (DIBH) for patients requiring
adjuvant radiotherapy for left breast cancers. After registration, three radiotherapy plans 3D-conformal radiotherapy (3DCRT),
intensity modulated RT (IMRT), and volumetric modulated arc-therapy (VMAT) – were generated for both FB and DIBH scans for
each patient. The dose-volume parameters were collected from the dose-volume histogram and analyzed. A paired t-test is used for
statistical analysis of the parameters.
Findings: The study was conducted on thirteen patients. The mean dose of the left lung was reduced with DIBH by 32%, 24%, and
6% (8.6 Gy, 6.6 Gy, and 6.4 Gy) with 3DCRT, IMRT, and VMAT, respectively. The mean heart dose was reduced by 3.3 Gy (2.2 vs 5.5
Gy), 2.2 Gy (7.5 vs 9.7 Gy), and 1.2 Gy (5.8 vs 7 Gy) with 3DCRT, IMRT, and VMAT with DIBH. Similarly, the left anterior
descending artery (LAD) mean dose was relatively reduced by 80%, 34%, and 20% when compared with the FB scans for 3DCRT,
IMRT, and VMAT respectively, with max dose in the 3DCRT plan.
Novelty/Applications: DIBH appears to have maximum benet in achieving a better sparing of organs-at-risk for patients being
considered for 3DCRT, and to a lesser extent with even IMRT and VMAT techniques.
Keywords: deep inspiration breath hold, DIBH, active breath coordinator, ABC, volumetric modulated arc therapy, VMAT, intensity
modulated radiation therapy, IMRT, left anterior descending coronary artery, LAD
Breast cancer is an important cause of cancer morbidity and mortality in women worldwide. It is a well-known fact that
adjuvant radiation therapy is an integral component of therapy in the management of non-metastatic early as well as locally
advanced breast cancer.
3D-Conformal radiotherapy (3DCRT) is the most common technique of adjuvant RT by virtue of its
simplicity, but more recent treatment techniques such as intensity modulated radiotherapy (IMRT), volumetric modulated arc
therapy (VMAT), tomotherapy, etc offer the potential to reduce volumes of organs-at-risk (OARs) exposed to high doses.
These techniques are more likely to be considered in more complex cases such as patients requiring internal mammary node
radiation. Cardiotoxicity resulting from radiotherapy for breast cancers has been associated with morbidity and mortality.
The most common cause of cardiac mortality is ischemic cardiac disease, believed to be the result of radiation exposure to the
anterior heart, predominantly the left anterior descending artery (LAD). This makes it pertinent to maximally reduce the
radiation dose exposure to organs-at-risk (OARs). However, optimum dose reduction of the heart cannot be always achieved
with these new techniques. Advanced techniques can arguably reduce the volume of heart and lung exposed to high radiation
doses. Nevertheless, there are several unanswered questions with these treatment techniques, the most important concern
Cancer Management and Research 2022:14 3581–3587 3581
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being a higher integral dose. Even though offering higher conformity and superior target coverage, advanced techniques such
as IMRT and VMAT are invariably associated with increased low-dose exposure to OARs.
In this particular scenario,
respiratory immobilization plays a vital role in reducing the heart as well as the lung dose to a lesser extent. This can be
achieved using gating, tracking, and optimized free breathing modules. Out of these, DIBH breathing gating is the most
common module used. There are multiple methods present now to achieve the gating technique, out of which the two most
widely used are ABC and RPM. An Active Breathing Coordinator (ABC; Elekta Oncology Systems, Stockholm, Sweden)
respiratory gating device allows the patient to breathe in a controlled manner, so that the heart, as well as lung volume dose,
can be reduced.
This is usually executed with the deep inspiration breath-hold (DIBH) technique. During both simulation
and treatment delivery, the patient takes a deep breath and holds it in for some time to negate respiratory movement, expand the
lung, and push the heart away from the chest wall. Some studies have reported that prone breast irradiation could be an
alternative for DIBH.
But prone position immobilization has its own limitations. The second method is by using the Real-
Time Position Management (RPM) system (Varian Medical Systems, Palo Alto, CA, USA), where the patient’s breath cycles
are tracked using an infrared tracker placed on the patient monitored by a dedicated camera.
Besides these gating systems,
manual gating in DIBH and voluntary breath hold were also commonly used by many departments.
The purpose of this study was to dosimetrically evaluate the additional benet of different planning techniques such
as 3DCRT, IMRT, and VMAT in left breast cancer when used with DIBH, in order to identify if DIBH continued to offer
superior OAR dosimetry despite the technique of RT.
Materials and Methods
The study was conducted on patients with left-sided breast cancer reporting for adjuvant radiotherapy to our department
after obtaining institutional ethics committee approval. Patients with a history of lung and/or heart diseases and those
who could not execute DIBH were excluded. Informed consent was taken from all patients prior to recruitment. The
eligibility criteria are given in Table 1. Patients with left sided-breast cancers who were able to comprehend the breath-
Table 1 Patient Inclusion Criteria for the Study
Demographic Variables Value
Mean age in years (range) 50.9 (31–74)
Pathological T stage
≤T2 (%) 7 (53.8%)
≥T3 (%) 6 (46.2%)
Pathological N stage
N0 (%) 7 (53.8%)
N1 (%) 4 (30.8%)
≥N2 (%) 2 (15.4%)
Group stage
II (%) 6 (46.2%)
III (%) 7 (53.8%)
Type of surgery
BCS (%) 11 (84.6%)
MRM (%) 2 (15.4%)
Inclusion of supraclavicular fossa (%) 4 (30.8%)
Inclusion of internal mammary nodes (%) 0 (0%)
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hold procedure, and were able to hold breath for at least 20 seconds at a stretch, were included. The desired breath-hold
threshold was 1.25 liters. Edentulous patients who could not hold the mouthpiece, those with respiratory comorbidities
which precluded the required breath-hold duration, and patients planned for simultaneous integrated boost techniques
were excluded. Patients were immobilized either by using a vacuum cushion or by breast board, in a supine position with
both hands above the head. All patients were trained to execute breath-hold through the mouthpiece attached to the
spirometer with a lter kit, which is of single use (shown in Figure 1A).
Breath taken through the mouthpiece is monitored by a spirometer, an integral part of the Active Breath Coordinator
(ABC) device (Elekta, Stockholm, Sweden), that monitors the airow in a controlled threshold volume and time to
maintain a predened lung volume and breath-hold time for each patient. A screen attached to the gating device monitors
the respiratory cycle of the patients (Figure 1B).
Once the patient was able to adequately execute DIBH, planning computed tomography images were taken with 3 mm
slice thickness for free-breathing (FB) and DIBH in a Philips brilliance 16 big bore CT machine. Free-breathing images were
taken for reference as well as comparison purposes only, and patient treatment was executed with DIBH only. Volume
delineation of the target and OAR in each image set was done as per standard RTOG contouring protocol in the Monaco
contouring station. For each patient image set, 3DCRT, IMRT, and VMAT plans were generated. The Monaco 5.11 Treatment
Planning System with collapsed cone and Monte Carlo algorithm was used for planning. All patients were planned for
hypofractionated whole-breast/chest-wall RT of 42.5 Gy in 16 fractions using 6 or 10 MV photon beams. All patients were
contoured and plans were generated by the same oncologist and physicist in order to reduce inter-personal errors.
For 3DCRT, two oblique-opposed tangential beams were used, and an anterior–posterior beam was placed for the
supraclavicular eld. For IMRT, ve beams (330°, 10°, 50°, 100°, 150°) were used and for VMAT a double arc of 200°
arc was used. Dose-constraint parameters and identical beam parameters were used for FB and DIBH image sets for
planning purposes. Once the treatment plan achieved the prescribed constraints, it was reviewed by the treating
oncologist for approval and execution. The dose distribution of the 3DCRT planning technique in DIBH and FB is
given in Figure 2A and B with IMRT and VMAT planning in ABC gating in Figure 3A and 7B.
The dose-volume parameters for each OAR such as the left and right lung, heart, LAD, and target volumes were
recorded for each patient. Once the plan was veried and approved, a dose-volume histogram was generated, and
parameters such as mean dose, V10, and V20 for the heart, mean dose, V20, and V30 for the lung, and mean and
maximum doses for LAD were recorded. The heterogeneity index and conformity index for the target were directly
calculated from the Treatment Planning System, wherein the heterogeneity index describes the uniformity of dose within
a target volume, calculated as ratio of dose received by 5% volume divided by the dose received by 95% target volume
and the conformity index describes the degree to which the prescribed dose conrms the target volume, derived from the
prescription isodose volume divided by the PTV volume with both an ideal value of one.
For statistical analyzing,
paired t-test was used to compare and was considered signicant if the P-value was <0.05.
Figure 1 Main parts of ABC gating (Elekta): (A) spirometer, (B) ABC gating monitor.
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Results and Discussion
A total of thirteen patients' (six patients with stage IIA, four with stage IIIB, and three with stage IIIA) data were taken
up for comparison of FB and DIBH dosimetry. While target and other OAR volumes were found to be similar between
FB and DIBH scans, as expected, the lung volume increased with DIBH by an average of 39% and 28% on the left and
right sides respectively when compared with FB. The change in contour volumes in both methods with its statistical
signicance is given in Table 2.
The dose-volume parameters for the heart, right and left lung, left anterior descending artery (LAD), and PTV of
individual patients were collected and compared for different planning technique with DIBH and FB using the cumulative
dose-volume histogram (DVH) shown in Table 3. While all plans had an improvement in terms of OAR sparing when DIBH
Figure 3 Planning in DIBH gating module: (A) IMRT plan in DIBH ABC gating module, (B) VMAT plan in DIBH ABC gating.
Table 2 Organ-at-Risk and Target Volumes in DIBH and Free Breathing Method with Its
Statistical Signicance
Organs DIBH Gating Volume (cc)
Median (Range)
Free Breathing Volume (cc)
Median (Range)
Heart 469 (327–613) 478 (357.3–599) 0.156
LAD 3.2 (1.5–4.9) 3.18 (1.56–4.8) 0.218
Left lung 1403.5 (970–1837) 1010 (657–1363) 0.004
Right lung 1583.5 (1203–1964) 1236.5 (778–1695) 0.002
PTV 687.5 (288–1087) 701 (302–1100) 0.232
Note: Test was considered signicant if the P-value was <0.051.
Figure 2 3DCRT planning in both modules: (A) 3DCRT planning in DIBH ABC gating, (B) with free breathing module.
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was used, the 3DCRT technique best benetted the most from it. Moreover, the volume of OARs irradiated, especially
volumes exposed to low doses, had substantially reduced with the combination of 3DCRT and DIBH.
Also, while maintaining the predened adequacy of target coverage of V95 >95%, 3DCRT was found to consistently
provide the lowest dose exposure to all OARs. The only exception was maximum dose to the LAD which was slightly
lower with VMAT (25 Gy vs 31 Gy), though the difference in mean dose was more striking in favor of 3DCRT (5 Gy vs
15 Gy), suggesting that the overall dose exposure to LAD is least with it. In contrast, the maximum dose to LAD was
highest with free-breathing 3DCRT plans. Similarly, a reduction in mean heart dose was noted in all three planning
techniques when DIBH was implemented, with both the lowest absolute doses and relative dose reduction being best-
achieved with 3DCRT. The relative dose difference was reduced with more advanced treatment techniques such as IMRT
and VMAT. Cardiac morbidity due to ischemic disease in breast cancer, especially in left side carcinoma, in radiotherapy
is a major long-term toxicity of concern.
Any gating, whether voluntary, moderate, or abdominal breathing
maneuvered DIBH, could dramatically reduce the dose exposure, thereby potentially reduce cardiac morbidity.
A study done by Hong et al found that patients treated with DIBH had heart doses less than those with FB.
has also been reported to greatly benet in decreasing dose exposure to the lungs.
A review study comparing FB and
DIBH gating during tangential eld irradiation found that the mean heart dose was 3.8 Gy with FB compared to 1.59 Gy
with ABC, and the mean dose to the LAD was reduced by more than 50% while retaining an equivalent target
Other similar studies comparing DIBH and FB have generally focused on either 3DCRT or VMAT.
A study done by Heiddi Stranz and Brigittie Zurl to evaluate the impact on heart dose using a 3DCRT plan in free
Table 3 Comparison of Dose Exposure in Free-Breathing (FB) and Deep-Inspiratory Breath-Hold (DIBH) with
the Three Treatment Techniques
FB DIBH P value FB DIBH P value FB DIBH P value
Planning target volume
V95% 95.0 95.8 0.083 97.3 98.0 0.290 98.5 98.1 0.044
HI 1.41 1.40 0.370 1.15 1.13 0.047 1.06 1.05 0.018
Conformity index 0.67 0.68 0.333 0.76 0.76 0.211 0.84 0.85 0.091
Mean (Gy) 5.5 2.2 0.012 9.7 7.5 0.012 7.0 5.8 0.079
V10 (%) 14.0 4.04 0.014 72.0 60.0 0.004 38.5 33.0 0.049
V20 (%) 10.0 1.9 0.009 38.5 33.0 0.041 18.0 14.0 0.015
Left lung
Mean (Gy) 12.6 8.6 0.015 8.7 6.6 0.024 6.8 6.4 0.011
V20 (%) 19.0 17.7 0.024 17.0 16.0 0.016 15.5 15.1 0.024
V30 (%) 16.3 13.5 0.048 15.0 12.5 0.003 13.8 12 0.003
Right lung
Mean 0.5 0.3 0.021 6.0 5.6 0.146 5.2 4.8 0.058
Left anterior descending artery
Mean (Gy) 26.0 5.5 0.006 24.5 16.5 0.048 19.0 15.0 0.013
Maximum (Gy) 38 31 0.006 27 23 0.017 28 25 0.001
Notes: V20%, volume received by 20 Gy dose; V10%, volume received by 10 Gy dose; V95, target volume received by 95% of the prescribed dose.
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breathing and DIBH found that irradiated cardiac volume can be signicantly reduced by the DIBH technique.
et al state that, using a DIBH protocol in treatment will help in small setup variability with signicance heart and LAD
dose reduction.
However, studies on the relative benet of DIBH with different radiotherapy planning techniques have
been limited, and our study suggests the continued benet of DIBH in reducing OAR doses irrespective of treatment
technique used. This makes an important implication on the benet of DIBH in all patients with left-sided breast cancer
requiring radiotherapy.
Regarding the contoured volume, a small decrease in volume of PTV and heart, and a negligible reduction in LAD volume
was observed with gating compared to FB. While this variation could be possibly attributed to increased intrathoracic pressure
induced by lung ination, it is also at least partly the result of minor variations in contouring. The variation in volume was not
statistically signicant, except for the lungs, where there was an expected increase in the average volume by more than a third
with DIBH. With regard to the target volume, coverage, 3DCRT provided a marginally lower coverage that was statistically
non-signicant. However, conformity and heterogeneity indices were best with VMAT, while 3DCRT provided acceptable
results. FB and gating appeared to have no impact on conformity and homogeneity indices with specic planning technique.
Our study has several limitations. It was conducted on a small sample size, and none of the patients received
treatment to the internal mammary nodes, which pose an even greater challenge in RT planning for breast cancers.
Moreover, it does not address the question of patient selection for DIBH. The major drawback with gating is its difculty
in implementing it for all patients. DIBH gating necessitates patient training, and only cooperative patients who can hold
breath for a reasonable duration can be selected. Further, another signicant problem noticed is in patient setup
verication using volumetric cone beam CT acquisition. Adequate time was spent for this, due to the shorten breath
hold time (average of 20 sec) a patient can hold, as a result, an average of 3–4 breath breaks were needed to complete one
full image acquisition. Not all left breast patients benet equally from DIBH technique. Therefore, such a technique may
be unjustiably labor intensive in nature and time-consuming as well as unnecessarily expensive.
A study by Ferini
et al suggests the possibility of predicting the benet of DIBH-RT using anatomical patterns.
Moreover which patients
will benet most from the DIBH technique other than the left breast is also debatable.
DIBH was found to reduce unwanted dose exposure to all the relevant organs-at-risk in radiotherapy for breast cancer.
This benet persisted despite the technique of treatment used for radiotherapy delivery. In our study, a combination of
DIBH and 3DCRT planning was found to provide the best plans in terms of reducing OAR dose, while retaining a similar
coverage. Despite the benet being lesser with more advanced radiotherapy planning techniques, namely IMRT and
VMAT, DIBH was nevertheless contributing to a potentially clinically relevant relative dose reduction. We conclude that
respiratory management using DIBH is a benecial tool for adjuvant radiotherapy for all patients with left breast cancers,
and should be considered especially when 3DCRT planning is used. The results of this study rmly depend on the choice
of the beam, its parameters, and optimization time spent for each plan in the treatment planning station.
Ethics Approval and Consent to Participate
Kasturba hospital institutional ethics committee of Manipal, Manipal Academy of Higher Education approved the study
(Approval number is −186/2019) and informed written consent was obtained from all subjects. The study was performed
following the approved guidelines and complies with the Declaration of Helsinki.
There is no funding to report.
The authors have no relevant conict of interest to disclose for the present study.
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Radiotherapy represents an essential part of the therapeutic algorithm for breast cancer patients after conservative surgery. The treatment of left-sided tumors has been associated with a non-negligible risk of developing late-onset cardiovascular disease. The cardiac risk perception has especially increased over the last years due to the prolongation of patients’ survival owing to the advent of new drugs and an ever earlier cancer detection through screening programs. Improvements in radiation delivery techniques could reduce the treatment-related heart toxicity. The deep-inspiration-breath-hold (DIBH) irradiation is one of the most advanced treatment approaches, which requires specific technical equipment and uses inspiration to displace the heart from the tangential radiation fields. However, not all patients benefit from its use. Moreover, DIBH irradiation needs patient compliance and accurate training. Therefore, such a technique may be unjustifiably cumbersome and time-consuming as well as unnecessarily expensive from a mere healthcare cost point of view. Hence the need to early select only the true beneficiaries while tailoring more effective heart-sparing techniques for the others and streamlining the workflow, especially in high-volume radiation oncology departments. In this literature overview, we collected some possible predictors of cardiac dose sparing in DIBH irradiation for left breast treatment in an effort to provide an easy-to-consult summary of simple instruments to insiders for identifying patients actually benefitting from this technique. We critically reviewed the reliability and weaknesses of each retrieved finding, aiming to inspire new insights and discussions on this much-debated topic. Statement of Search Strategies Used and Sources of Information The search strategy for this overview was based on the scanning of works retrieved by PubMed/Medline using “DIBH” and “predict” terms.
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Introduction Post-mastectomy radiation in left-sided breast cancer in women continues to pose a significant risk to the underlying lungs and heart. This study analyzed the difference in planning target volume (PTV) coverage and dose to the organs at risk (OAR) by using three different planning methods for the same patient - three-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT), and volumetric-modulated arc therapy (VMAT). Material and methods Thirty-five left-sided breast cancer patients' post-mastectomy were included in this study, and three different plans for adjuvant radiation were created using 3D-CRT, IMRT, and VMAT. The prescribed dose was 50Gy in 25 fractions. Kruskal-Wallis analysis of variance (ANOVA) was done, followed by a pairwise t-test to establish a hierarchy of plan quality and dosimetric benefits. The plans were compared with PTV95, homogeneity index (HI), conformity index (CI), hotspot (V107%), left lung V20Gy, mean lung dose, heart V25Gy, mean heart dose, and integral dose (ID) to the body. Results Both VMAT and IMRT led to improved PTV95% coverage (95.63±1.82%, p=0.000 in VMAT; 93.70±2.16 %, p=0.000; 81.40±6.27% in 3D-CRT arm) and improved CI (0.91±0.06 in IMRT [p<0.05] and 0.96±0.02 for VMAT plans [p<0.05]) as compared to 3D-CRT (0.66±0.11), which was statistically significant on pairwise analysis. In contrast, the difference in HI and reduction in hotspots were not significantly different. Left lung V20 was statistically very different between the three arms with the highest values in IMRT (36.64±4.45) followed by 3D-CRT (34.80±2.24) and the most negligible value in VMAT (33.03±4.20). Mean lung dose was also statistically different between the three arms. There was a statistically significant difference in mean heart dose between the three arms on pairwise analysis. Both the inverse planning methods led to a statistically significant increase in low dose volume (V5 and V10) of the ipsilateral lung, opposite lung, and heart, and increased ID to the body excluding the PTV. Conclusion While both the inverse planning modalities led to increased coverage, better CI, and better HI and decreased high dose volumes in OARs, there was increased low volume irradiation of heart, lungs, and body with VMAT faring marginally better than IMRT in coverage and decreasing lung irradiation with comparable heart irradiation.
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Background Intraoperative electron radiotherapy (IOERT) followed by hypofractionated whole breast irradiation (HWBI) provides the shortest possible time of adjuvant breast irradiation. The efficacy of either method has been described in previous reports; however, to our knowledge, the efficacy of combined therapy has not been reported. Aim To compare the toxicity and cosmetic outcome of IOERT as a tumor bed boost followed by HWBI with conventional whole breast irradiation (CWBI) followed by external electron tumor bed boost (EETBB) after breast conserving surgery (BCS) in patients with invasive breast cancer. Methods In 2019, a prospective noninferiority trial (IRCT20180919041070N2) was started. After BCS, early‐stage breast cancer patients were treated by IOERT (10 Gy) and HWBI (42.56 Gy in 16 fractions) or CWBI (50 Gy in 25 fraction) and EETBB (10 Gy in 5) in a double‐arm design. Acute/late toxicity and cosmetic outcome were evaluated by common toxicity criteria (CTC) after 1‐year follow‐up (FUP) at the level of p < .05. Results Of 60 eligible patients, 30 were allocated to each group. Regarding acute effects after a median FUP of 12 months, CTC‐score of grade II‐III erythema (p = .001) and desquamation (p = .005) were significantly higher in CWBI+EETBB compared to IOERT+ HWBI. However, there were no significant differences at the end of radiotherapy and after 1 month, 6 months, and 1 year. Cosmetic outcome after radiation was similar in both groups mostly rating as good/excellent after 1‐year FUP. Conclusions Boost‐IOERT/HWBI regimen has comparable acute and late treatment toxicity profiles compared to the CWBI.
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Introduction: The risk of radiotherapy-associated cardiovascular disease has been a concern for decades in breast cancer survivors. The objective of our study is to evaluate the dosimetric benefit of Deep Inspiratory Breath-hold technique (DIBH) on organs-at-risk (OAR) sparing in left-sided breast cancer radiotherapy and to find out pre-treatment predictors of cardiac doses for guiding patient selection for DIBH. Material and methods: Pre-radiotherapy planning CT scans were done in Free Breathing (FB) and in DIBH [using Active Breathing Coordinator system (ABC™)] in 31 left sided breast cancer patients. 3DCRT plans were generated for both scans. Comparison of anatomical and dosimetric variables were done using paired t test and correlation was evaluated using Pearson correlation. Linear regression was used to get independent predictors of cardiac sparing and Receiver Operating Characteristic (ROC) curve analysis was done to find out the specific threshold of the predictors. Results: There was a 39.15% reduction in mean heart dose in DIBH compared to FB (2.4 Gy vs 4.01 Gy) (p < 0.001), 19% reduction in maximum Left Anterior Descending (LAD) dose and a 9.9% reduction in ipsilateral lung mean dose (p = 0.036) with DIBH. A significant correlation was observed between reduction in Heart Volume in Field (HVIF) and Maximum Heart Depth (MHD) with reduction in mean heart dose. Reduction in HVIF (ΔHVIF) independently predicted cardiac sparing. Conclusion: DIBH leads to significant reduction in OAR doses and is suggested for all patients of left-sided breast cancer undergoing radiotherapy. However, HVIF and MHD predicted for cardiac sparing and threshold criteria of ΔHVIF and ΔMHD may be used by centres with high workload to select patients for DIBH.
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Although radiation-induced cardiotoxicity has been addressed, its prognostic relevance to modern radiotherapy (RT) techniques is unclear. This study assessed the impact of adjuvant RT on heart-related deaths in patients with ductal carcinoma in situ. Patients who underwent adjuvant RT after breast-conserving surgery between 1988 and 2008 were identified from the Surveillance, Epidemiology, and End Results database. Kaplan‒Meier and competing risks analyses were conducted after propensity score-matching according to tumor laterality. A total of 41,526 propensity-matched patients were identified (n = 20,763 for either left- or right-sided tumor). In the analysis of the cumulative incidence of heart-related mortality events, there was a greater risk increment in the left-sided group over the first to second decades after RT in patients aged ≤ 50 years ( P = 0.048). Competing risks analysis of the young patients showed that left-sided RT was associated with higher heart-related mortality rates (Grey’s test, P = 0.049). The statistical significance remained after adjusting for other covariates (subdistribution hazard ratio 2.35; 95% confidence interval 1.09‒5.10). Regarding the intrinsic effect of modern RT techniques, further strategies to reduce heart-related risks are needed for young patients. Close surveillance within an earlier follow-up period should be considered for these patients in clinics.
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The impact of radiotherapy on the heart has become an area of interest in recent years. Many different cardiac dose volume constraints have been associated with cardiac toxicity and survival however, no consistent constraint has been found. Many patients undergoing treatment for lung cancer have risk factors for cardiovascular disease or known cardiac comorbidities however, there is little evidence on the effects of radiotherapy on the heart in these patients. We aim to provide a summary of the existing literature on cardiac toxicity of lung cancer radiotherapy, propose strategies to avoid and manage cardiac toxicity and suggest avenues for future research.
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Background: Adjuvant radiotherapy (RT) for breast cancer (BC) has been associated with an increased risk of ischemic heart disease (IHD). We examined the incidence of IHD in a large population-based cohort of women with BC. Methods: The Breast Cancer DataBase Sweden (BCBaSe) includes all women diagnosed with BC from 1992 to 2012 (n = 60,217) and age-matched women without a history of BC (n = 300,791) in three Swedish health care regions. Information on comorbidity, educational level, and incidence of IHD was obtained through linkage with population-based registries. The risk of IHD was estimated by Cox proportional hazard regression analyses and cumulative incidence by the Kaplan-Meier method. Results: Women with BC had a lower risk of IHD compared to women without BC with a hazard ratio (HR) of 0.91 (95% CI 0.88-0.95). When women with left-sided BC were compared to right-sided BC, an increased HR for IHD of 1.09 (95% CI 1.01-1.17) was seen. In women receiving RT, a HR of 1.18 (95% CI 1.06-1.31) was seen in left-sided compared to right-sided BC, and the HRs increased with more extensive lymph node involvement and with the addition of systemic therapy. The cumulative IHD incidence was increased in women receiving left-sided RT compared to right-sided RT, starting from the first years after RT and sustained with longer follow-up. Conclusions: Women given RT for left-sided BC during 1992 to 2012 had an increased risk of IHD compared to women treated for right-sided BC. These women were treated in the era of three-dimensional conformal RT (3DCRT), and the results emphasize the importance of further developing and implementing RT techniques that lower the cardiac doses, without compromising the beneficial effects of RT.
Background/aim: This study aimed to analyze the dosimetric gain of the deep-inspiration-breath-hold (DIBH) technique over the free-breathing (FB) one in left breast cancer (LBC) 3D-conformal-radiotherapy (3D-CRT), and simultaneously investigate the anatomical parameters related to heart RT-exposure. Patients and methods: Treatment plans were generated in both DIBH and FB scenarios for 116 LBC patients monitored by the Varian RPM™ respiratory gating system for delivery of conventional or moderately hypofractionated schedules (±sequential boost). For comparison, we considered cardiac and ipsilateral lung doses and volumes. Results: A significant reduction of cardiac and pulmonary doses using DIBH technique was achieved compared to FB plans. Larger clinical target volumes generally need longer distance between medial and lateral entrances of tangent fields at body surface, thus conditioning a worse heart RT-exposure. Conclusion: The DIBH technique reduces cardiac and pulmonary doses for LBC patients. Through easily detectable anatomical parameters, it is possible to predict which patients benefit most from DIBH-RT.
Objective To evaluate dose to organs at risk, target coverage and treatment compliance in left sided breast cancer patients (LSBCP) treated with deep inspiration breath hold (DIBH) and intensity modulated radiation therapy (IMRT) technique in a contest of daily clinical practice. Methods A total of 280 consecutive LSBCP referred for adjuvant radiotherapy were systematically screened for suitability of DIBH technique. Two hundred thirty-nine were able to comply with the requirement for DIBH. Whole breast or chest wall were irradiated in DIBH, monitored by Varian RPM ™ Respiratory Gating System, and two tangential inverse-planned beams with dynamic dose delivery. Dose prescription was 42.4 Gy/16 fractions in 205 patients and 50 Gy/25 fractions in 34. 23 patients received local and nodal treatment. Boost to tumor bed, of 10 Gy/5 fractions was used in 135 patients. Relevant dose metrics for heart, left anterior descending coronary artery (LAD), lungs, contralateral breast and PTV were retrospectively analyzed. Results The average mean heart dose (MHD) for all patients was 0.94 Gy and mean maximum LAD dose was 13.82 Gy. MHD and LAD maximum dose were significantly higher in patients treated with conventional fractionation whether expressed in absolute dose (1.44 vs 0.85 Gy, p < 0.0005 and 20.78 vs 12.45 Gy, p < 0.0005 respectively) or in equivalent doses of 2 Gy fractionation (0.88 vs 0.52 Gy, p =< 0.0005 and 17.68 vs 10.63 Gy, p = 0.0002 respectively). In 57 patients (23.8%) the maximum LAD dose was >20 Gy. Mean V20 ipsilateral lung dose was 8.5%. Mean doses of contralateral breast and lung were 0.13 Gy and 0.09 Gy respectively. Mean PTV V95% coverage was 96.1%. Compliance rate of DIBH technique was 84.5% (239/280). Conclusions DIBH and IMRT in daily clinical practice are feasible in high percentage of unselected patients and allows low levels of irradiation of organs at risk without compromising target coverage. However, despite low MHD a significant proportion of patients receives a maximum LAD dose superior to 20 Gy. Advances in knowledge The value of MHD used exclusively is not able to describe entirely the risk of late heart toxicity, which can be better evaluated with the joint analysis of the maximum dose to LAD region. The vast majority of LSBCP referred to adjuvant radiotherapy in the setting of routine practice are able to comply with the requirement of DIBH.
We present our seven-year experience of using moderate deep inspiration breath-hold (mDIBH) with an active breathing control (ABC) device for patients with early-stage breast cancer and dosimetric comparison to evaluate the benefit of mDIBH on the heart, lung, and liver.We retrospectively reviewed all patients with newly diagnosed breast cancer and having clinical stage Tis, I, or II disease treated between November 2010 and October 2017. Among the 369 patients included in this study, 107 patients were treated with mDIBH and 262 patients were treated with free breathing (FB). Dosimetric analysis was performed to compare dose distribution in the heart, lung, and liver between the two treatment groups. The chi-square test was used to compare the distribution of stage and tumor site between the two groups. The independent samples t-test was used to compare the remaining parameters between the two groups.For all 369 patients, there was a significantly lower ipsilateral lung V5 (relative volume receiving ≧5 Gy), ipsilateral lung V10, ipsilateral lung V20, mean ipsilateral lung dose, whole lung V5, whole lung V10, whole lung V20, mean whole lung dose, heart V10, heart V30, heart V40, and mean heart dose in the mDIBH group. For 184 patients with a left-sided breast tumor, significantly lower ipsilateral lung V5, ipsilateral lung V10, ipsilateral lung V20, mean ipsilateral lung dose, whole lung V10, whole lung V20, mean whole lung dose, heart V10, heart V30, heart V40, and mean heart dose were observed in the mDIBH group. For 185 patients with a right-sided breast tumor, significantly lower ipsilateral lung V5, ipsilateral lung V10, ipsilateral lung V20, mean ipsilateral lung dose, whole lung V5, whole lung V10, whole lung V20, mean whole lung dose, heart V10, heart V30, heart V40, mean heart dose, liver V30, and mean liver dose were observed in the mDIBH group.For early-stage breast cancer patients, mDIBH reduces not only the heart dose but also the lung and liver doses. The routine integration of mDIBH using an ABC device may decrease radiation-induced toxicity in the heart, lung, and liver.