Respiration Induced Heart Motion and Indications of Gated Delivery for Left-Sided Breast Irradiation

Department of Radiation Oncology, University of Colorado Denver, Aurora, CO, USA.
International journal of radiation oncology, biology, physics (Impact Factor: 4.26). 04/2011; 82(5):1605-11. DOI: 10.1016/j.ijrobp.2011.01.042
Source: PubMed


To investigate respiration-induced heart motion for left-sided breast irradiation using a four-dimensional computed tomography (4DCT) technique and to determine novel indications to assess heart motion and identify breast patients who may benefit from a gated treatment.
Images of 4DCT acquired during free breathing for 20 left-sided breast cancer patients, who underwent whole breast irradiation with or without regional nodal irradiation, were analyzed retrospectively. Dose distributions were reconstructed in the phases of 0%, 20%, and 50%. The intrafractional heart displacement was measured in three selected transverse CT slices using D(LAD) (the distance from left ascending aorta to a fixed line [connecting middle point of sternum and the body] drawn on each slice) and maximum heart depth (MHD, the distance of the forefront of the heart to the line). Linear regression analysis was used to correlate these indices with mean heart dose and heart dose volume at different breathing phases.
Respiration-induced heart displacement resulted in observable variations in dose delivered to the heart. During a normal free-breathing cycle, heart-induced motion D(LAD) and MHD changed up to 9 and 11 mm respectively, resulting in up to 38% and 39% increases of mean doses and V(25.2) for the heart. MHD and D(LAD) were positively correlated with mean heart dose and heart dose volume. Respiratory-adapted gated treatment may better spare heart and ipsilateral-lung compared with the conventional non-gated plan in a subset of patients with large D(LAD) or MHD variations.
Proposed indices offer novel assessment of heart displacement based on 4DCT images. MHD and D(LAD) can be used independently or jointly as selection criteria for respiratory gating procedure before treatment planning. Patients with great intrafractional MHD variations or tumor(s) close to the diaphragm may particularly benefit from the gated treatment.

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    • "However, in recent years, with the development of sophisticated image-guided online and offline setup verification and correction techniques, such as the electric portal imaging device (EPID) and cone-beam CT (CBCT), the interfraction setup error has been significantly reduced during delivery of irradiation in breast cancer patients [4-7]. Although the intrafractional breathing motion is usually only a few millimeters [8-10], respiratory-induced movement during free breathing has recently become the focus of radiotherapy research [8,9,11,12]. A number of studies have shown that the dosimetric impact of respiratory motion was clinically insignificant during free breathing [8,9]. "
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