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

Abstract

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.

Full text

ORIGINAL RESEARCH
A Dosimetric Study Comparing Different
Radiotherapy Planning Techniques With and Without
Deep Inspiratory Breath Hold for Breast Cancer
Sarath S Nair
1,2
, V N Meena Devi
1
, Krishna Sharan
2
, Jyothi Nagesh
2
, Brahmaiah Nallapati
2
,
Shambhavi Kotian
3
1
Department of Physics, Noorul Islam Centre for Higher Education Kumaracoil, Tamilnadu, India;
2
Department of Radiotherapy & Oncology, Kasturba
Medical College Manipal, Manipal Academy of Higher Education, Manipal, India;
3
Department of Medical Physics, Manipal College of Health
Professions, Manipal Academy of Higher Education, Manipal, India
Correspondence: Sarath S Nair, Email sarathshyam007@gmail.com
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
Introduction
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.
1
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.
2,3
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.
4,5
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
© 2022 S Nair et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.
php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the
work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
Cancer Management and Research Dovepress
open access to scientific and medical research
Open Access Full Text Article
Received: 21 July 2022
Accepted: 24 November 2022
Published: 29 December 2022
Cancer Management and Research downloaded from https://www.dovepress.com/ on 30-Dec-2022
For personal use only.

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.
3
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.
6,7
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.
8
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.
9
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%)
https://doi.org/10.2147/CMAR.S381316
DovePress
Cancer Management and Research 2022:14
3582
S Nair et al Dovepress
Powered by TCPDF (www.tcpdf.org)Powered by TCPDF (www.tcpdf.org)

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.
10
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.
Cancer Management and Research 2022:14 https://doi.org/10.2147/CMAR.S381316
DovePress
3583
Dovepress S Nair et al
Powered by TCPDF (www.tcpdf.org)Powered by TCPDF (www.tcpdf.org)

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)
p-value
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.
https://doi.org/10.2147/CMAR.S381316
DovePress
Cancer Management and Research 2022:14
3584
S Nair et al Dovepress
Powered by TCPDF (www.tcpdf.org)Powered by TCPDF (www.tcpdf.org)

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.
11,12
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.
13
DIBH
has also been reported to greatly benet in decreasing dose exposure to the lungs.
14–16
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
coverage.
17
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
Dosimetric
Parameters
3DCRT IMRT VMAT
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
Heart
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.
Cancer Management and Research 2022:14 https://doi.org/10.2147/CMAR.S381316
DovePress
3585
Dovepress S Nair et al
Powered by TCPDF (www.tcpdf.org)Powered by TCPDF (www.tcpdf.org)

breathing and DIBH found that irradiated cardiac volume can be signicantly reduced by the DIBH technique.
18
Borst
et al state that, using a DIBH protocol in treatment will help in small setup variability with signicance heart and LAD
dose reduction.
19
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.
20,21
A study by Ferini
et al suggests the possibility of predicting the benet of DIBH-RT using anatomical patterns.
22
Moreover which patients
will benet most from the DIBH technique other than the left breast is also debatable.
Conclusion
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.
Funding
There is no funding to report.
Disclosure
The authors have no relevant conict of interest to disclose for the present study.
https://doi.org/10.2147/CMAR.S381316
DovePress
Cancer Management and Research 2022:14
3586
S Nair et al Dovepress
Powered by TCPDF (www.tcpdf.org)Powered by TCPDF (www.tcpdf.org)

References
1. Fadavi P, Nassi N, Mahdavi SR, Jafarnejadi B, Javadinia SA. Outcome of hypofractionated breast irradiation and intraoperative electron boost in
early breast cancer: a randomized non-inferiority clinical trial. Cancer Rep. 2021;4(5):e1376. doi:10.1002/cnr2.1376
2. Teoh M, Clark CH, Wood K, Whitaker S, Nisbet A. Volumetric modulated arc therapy: a review of current literature and clinical use in practice. Br
J Radiol. 2011;84(1007):967–996. PMID: 22011829; PMCID: PMC3473700. doi:10.1259/bjr/22373346
3. Das Majumdar SK, Amritt A, Dhar SS, et al. A dosimetric study comparing 3D-CRT vs. IMRT vs. VMAT in left-sided breast cancer patients after
mastectomy at a tertiary care centre in Eastern India. Cureus. 2022;14(3):e23568. PMID: 35494897; PMCID: PMC9045011. doi:10.7759/
cureus.23568
4. Hufnagle JJ, Andersen SN, Maani EV. Radiation therapy induced cardiac toxicity. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022. Available from https://www.ncbi.nlm.nih.gov/books/NBK554453/. Accessed December 12, 2022.
5. Banll K, Giuliani M, Aznar M, et al; IASLC Advanced Radiation Technology committee. Cardiac toxicity of thoracic radiotherapy: existing
evidence and future directions. J Thorac Oncol. 2021;16(2):216–227. PMID: 33278607; PMCID: PMC7870458. doi:10.1016/j.jtho.2020.11.002
6. Desai N, Currey A, Kelly T, Bergom C. Nationwide trends in heart-sparing techniques utilized in radiation therapy for breast cancer. Adv Radiat
Oncol. 2019;4(2):246–252. PMID: 31011669; PMCID: PMC6460327. doi:10.1016/j.adro.2019.01.001
7. Lin CH, Lin LC, Que J, Ho CH. A seven-year experience of using moderate deep inspiration breath-hold for patients with early-stage breast cancer
and dosimetric comparison. Medicine. 2019;98(19):e15510. PMID: 31083193; PMCID: PMC6531160. doi:10.1097/MD.0000000000015510
8. Verhoeven K, Sweldens C, Petillion S, et al. Breathing adapted radiation therapy in comparison with prone position to reduce the doses to the heart,
left anterior descending coronary artery, and contralateral breast in whole breast radiation therapy. Pract Radiat Oncol. 2014;4(2):123–129. PMID:
24890353. doi:10.1016/j.prro.2013.07.005
9. Oh SA, Yea JW, Kim SK, et al. Optimal gating window for respiratory-gated radiotherapy with real-time position management and respiration
guiding system for liver cancer treatment. Sci Rep. 2019;9(1):4384. doi:10.1038/s41598-019-40858-2
10. Petrova D, Smickovska S, Lazarevska E. Conformity index and homogeneity index of the postoperative whole breast radiotherapy. Open Access
Maced J Med Sci. 2017;5(6):736–739. PMID: 29123573; PMCID: PMC5672112. doi:10.3889/oamjms.2017.161
11. Wennstig AK, Wadsten C, Garmo H, et al. Long-term risk of ischemic heart disease after adjuvant radiotherapy in breast cancer: results from
a large population-based cohort. Breast Cancer Res. 2020;22:10. doi:10.1186/s13058-020-1249-2
12. Lim YJ, Koh J. Heart-related mortality after postoperative breast irradiation in patients with ductal carcinoma in situ in the contemporary
radiotherapy era. Sci Rep. 2021;11:2790. doi:10.1038/s41598-021-82263-8
13. Hong JC, Rahimy E, Gross CP, et al. Radiation dose and cardiac risk in breast cancer treatment: an analysis of modern radiation therapy including
community settings. Pract Radiat Oncol. 2018;8(3):e79–e86. PMID: 28888675. doi:10.1016/j.prro.2017.07.005
14. Bergom C, Currey A, Desai N, Tai A, Strauss JB. Deep inspiration breath hold: techniques and advantages for cardiac sparing during breast cancer
irradiation. Front Oncol. 2018;8:87. doi:10.3389/fonc.2018.00087
15. Estolin A, Ciccarelli S, Vidano G, Avitabile R, Dusi F, Alongi F. Deep inspiration breath-hold intensity modulated radiation therapy in a large
clinical series of 239 left-sided breast cancer patients: a dosimetric analysis of organs at risk doses and clinical feasibility from a single center
experience. Br J Radiol. 2019;92(1101):20190150. PMID: 31265316; PMCID: PMC6732919. doi:10.1259/bjr.20190150
16. Ferdinand S, Mondal M, Mallik S, et al. Dosimetric analysis of DIBH in left-sided breast cancer radiotherapy and evaluation of pre-treatment
predictors of cardiac doses for guiding patient selection for DIBH. Tech Innov Patient Support Radiat Oncol. 2021;17:25–31. PMID: 33681484;
PMCID: PMC7930610. doi:10.1016/j.tipsro.2021.02.006
17. Kunheri B, Kotne S, Nair SS, Makuny D. A dosimetric analysis of cardiac dose with or without active breath coordinator moderate deep inspiratory
breath hold in left sided breast cancer radiotherapy. J Cancer Res Ther. 2017;13(1):56–61. PMID: 28508834. doi:10.4103/jcrt.JCRT_1414_16
18. Stranzl H, Zurl B. Postoperative irradiation of left-sided breast cancer patients and cardiac toxicity. Dose deep inspiration breath-hold (DIBH)
technique protect the heart? Strahlenther Onkol. 2008;184:354–358. doi:10.1007/s00066-008-1852-0
19. Borst GR, Sonke JJ, den Hollander S, et al. Clinical results of image-guided deep inspiration breath hold breast irradiation. Int J Radiat Oncol Biol
Phys. 2010;78:1345–1351. doi:10.1016/j.ijrobp.2009.10.006
20. Ferini G, Valenti V, Viola A, Umana GE, Martorana E. A critical overview of predictors of heart sparing by deep-inspiration-breath-hold irradiation
in left-sided breast cancer patients. Cancers. 2022;14(14):3477. PMID: 35884538; PMCID: PMC9319386. doi:10.3390/cancers14143477
21. Latty D, Stuart KE, Wang W, Ahern V. Review of deep inspiration breath-hold techniques for the treatment of breast cancer. J Med Radiat Sci.
2015;62(1):74–81. PMID: 26229670; PMCID: PMC4364809. doi:10.1002/jmrs.96
22. Ferini G, Molino L, Tripoli A, et al. Anatomical predictors of dosimetric advantages for deep-inspiration-breath-hold 3D-conformal radiotherapy
among women with left breast cancer. Anticancer Res. 2021;41(3):1529–1538. PMID: 33788746. doi:10.21873/anticanres.14912
Cancer Management and Research Dovepress
Publish your work in this journal
Cancer Management and Research is an international, peer-reviewed open access journal focusing on cancer research and the optimal use
of preventative and integrated treatment interventions to achieve improved outcomes, enhanced survival and quality of life for the cancer
patient. The manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to
use. Visit http://www.dovepress.com/testimonials.php to read real quotes from published authors.
Submit your manuscript here: https://www.dovepress.com/cancer-management-and-research-journal
Cancer Management and Research 2022:14 DovePress
3587
Dovepress S Nair et al
Powered by TCPDF (www.tcpdf.org)Powered by TCPDF (www.tcpdf.org)