An Innovative VMAT Technique for Left-sided Breast Cancer Patients With Postmastectomy Radiotherapy (PMRT) Evaluated by Ratio of Heart Volume in Tangent Line (RHVTL)

Abstract For patients with left-sided breast cancer (LBC), postmastectomy radiotherapy (PMRT) has been shown to improve the overall survival and many advanced planning techniques was adopted in PMRT. We aim to use an innovative VMAT technique to enhance the conformity of PTV and reduce the scattering dose of surrounding OARs, thereby reducing the long-term toxicity of the heart as well as ipsilateral lung (IL). The study further analyzes the more appropriate treatment planning techniques for personalized LBC patients with PMRT. 35 LBC patients were retrospectively selected undergoing PMRT. The PTV included lymph nodes, chest walls, excluding internal mammary nodes, where 95% of PTV receiving the prescription dose of 50Gy (2Gy/fraction) with three different techniques, VMAT, IMRT, Hybrid VMAT. Furthermore, the ratio of Heart Volume in Tangent line and heart volume (RHVTL) was proposed to evaluate the relative antonymy position between patient's heart and PTV, which hypothetically represents the complexity of treatment planning. The data from this study showed that for LBC patients undergoing PMRT, the CI from VMAT was 0.85 (IMRT and H-VMAT were 0.77 and 0.83), the heart D mean was 502.9cGy (IMRT and H-VMAT were 675.6cGy and 687cGy) and the V20 of IL was 21.3 as the lowest of the three techniques, but the dose of the contralateral breast (CB) and contralateral lung increased noticeably. In H-VMAT and IMRT, the mean heart dose was significantly related to RHVTL, with R-values of 0.911 and 0.892 respectively, while the values in VMAT was 0.613, thus the VMAT technique was relatively unaffected by the difficulty of treatment plan. For RHVTL values exceed than 0.06, the mean heart dose under VMAT technique raised by 98.7cGy compared to the RHVTL value of less than 0.06, but H-VMAT and IMRT increased by 233cGy and 261.58cGy individually. This study illustrates that separated fields and adjacent fields in VMAT technique obtained the optimal conformality and lowest doses of heart in three techniques for LBC with PMRT. Thus, based on the results of our preliminary study, the VMAT technique is highly recommended when RHVTL is exceeded 0.06.

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Dose Volume Relationship in Estimating Cardiac Doses in Breast Cancer Radiotherapy

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2020/45357.14249 ◽

2020 ◽

Author(s):

Lucy Pattanayak ◽

Swodeep Mohanty ◽

Deepak Kumar Sahu ◽

Tapas Kumar Dash ◽

Itishree Priyadarsini

Keyword(s):

Breast Cancer ◽

Radiation Therapy ◽

Conformal Radiotherapy ◽

Free Breathing ◽

P Value ◽

Carcinoma Breast ◽

Heart Dose ◽

Cardiac Dose ◽

The Mean ◽

Mean Heart Dose

Introduction: Radiation therapy is an integral part of adjuvant treatment for breast cancer which reduces local recurrence and significantly increases survival. But, radiation therapy also has the propensity to increase cardiac morbidity and mortality due to dose received by the heart which is more in left-sided breast cancer. Mean Heart dose and Maximum Heart Distance (MHD) are two parameters to study dose received by the heart. Aim: The purpose of this study was to determine individual doses received by the heart and to correlate MHD with the mean heart dose received by heart in carcinoma breast patients receiving radiotherapy. Materials and Methods: Ninety patients of histologically proven carcinoma breast who attended the Department of Radiotherapy, Acharya Harihar Regional Cancer, Cuttack from January 2017 to January 2019 were selected for a prospective observational study. All patients were treated with 3D Conformal Radiotherapy technique using free breathing multi slice Computed Tomography (CT) scans to contour target and vital organs. Parallel opposed tangential treatment plans were generated for each patient. Individual dose received by the heart and MHD was assessed for each case. SPSS version 21 used for statistical analysis. The Spearman’s Rho test was used for correlation of MHD with Mean heart dose. The Mann-Whitney U test was used for comparing mean of MHD in left-sided and right-sided breast cancer. The Independent t-test was used for comparing means of Mean heart dose in left-sided and right-sided breast cancer. A p-value <0.05 was considered as statistically significant. Results: The Mean Heart Dose was 4.63 Gy for left-sided breast carcinoma patients and 0.846 Gy for right-sided breast cancer and there was a significant difference (p<0.001). Mean MHD for left-sided breast cancer was 2.974 cm while for right-sided it was 0.017 cm, the difference was statistically significant (p-value <0.001). MHD also correlated positively with Mean Heart Dose with correlation coefficient of 0.849 and p-value <0.001. Conclusion: MHD and Mean Heart dose were significantly higher in left-sided breast cancer receiving radiotherapy. MHD was also found to be positively related to Mean Heart dose and therefore found to be an important predictor of cardiac dose. For right-sided breast carcinoma receiving radiotherapy, free breathing technique using 3-Dimensional Conformal Radiotherapy (3DCRT) will suffice in terms of cardiac dose.

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Dosimetric Correlation Between The Depth of Chest Wall Expansion and Heart Dose in Left Breast Cancer Irradiation Using Deep Inspiratory Breath Hold Technique

Tumori Journal ◽

10.1177/0300891620914166 ◽

2020 ◽

Vol 106 (1_suppl) ◽

pp. 34-34

Author(s):

Ehab Saad ◽

Khaled.M. Elshahat ◽

Sarah Hazem ◽

Nadia Ebrahim ◽

Nada Osama ◽

...

Keyword(s):

Breast Cancer ◽

Chest Wall ◽

Adjuvant Radiotherapy ◽

Left Lung ◽

Left Breast ◽

Breath Hold ◽

Heart Dose ◽

The Mean ◽

Mean Heart Dose ◽

Cancer Irradiation

Introduction and Objective: In adjuvant radiotherapy for left breast cancer, a significant heart volume may be included in the radiation field leading to long-term cardiac toxicities. Deep inspiratory breath hold technique (DIBH) leads to chest wall separation away from the heart and thus can reduce the heart dose compared to free breathing technique. The aim of this study is to correlate dosimetrically the degree of chest wall expansion measured on planning 4D-CT scan to the heart dose in left breast cancer irradiation using DIBH technique. Materials and Methods: Thirty four patients with left breast cancer planned for adjuvant radiotherapy were included. All patients were scanned by Varian RPM (Real Time Position Managment) respiratory gating system using infrared reflecting markers and a video camera to detect the respiratory motion. IMRT or VMAT plans were done for all patients with a prescribed dose 50Gy/25fr/5w with or without operative bed boost dose 10Gy/5fr/1w. The degree of chest wall expansion was identified by measuring the amplitude of DIBH breathing curve from baseline in planning 4D-CT scan in centimeters. The depth of expansion was correlated dosimetrically with the heart V20, V30, and mean heartdose. Results: The mean distance of chest wall expansion was 2.9cm. The mean left lung dose was 8.6Gy. The mean left lung V20 was 13.8%. The mean heart dose was 1.8Gy. The mean heart V30 was 0.6%. A statistically significant reduction of the mean heart dose and V30 was observed with chest wall expansion of 1.4cm or higher (p<0.05). Conclusion: In DIBH technique, the depth of chest wall expansion in 4DCT planning is dosimetrically correlated with the cardiac dose reduction during adjuvant irradiation of left breast cancer. Further clinical studies are needed to translate this dosimetric advantage into clinical benefit.

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Deep inspiration breath hold reduces the mean heart dose in left breast cancer radiotherapy

Radiology and Oncology ◽

10.2478/raon-2021-0008 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Michał Falco ◽

Bartłomiej Masojć ◽

Agnieszka Macała ◽

Magdalena Łukowiak ◽

Piotr Woźniak ◽

...

Keyword(s):

Breast Cancer ◽

Free Breathing ◽

Left Breast ◽

Breath Hold ◽

Deep Inspiration ◽

Breast Cancer Patients ◽

Deep Inspiration Breath Hold ◽

Heart Dose ◽

The Mean ◽

Mean Heart Dose

Abstract Background Patients with left breast cancer who undergo radiotherapy have a non-negligible risk of developing radiation-induced cardiovascular disease (CVD). Cardioprotection can be achieved through better treatment planning protocols and through respiratory gating techniques, including deep inspiration breath hold (DIBH). Several dosimetric studies have shown that DIBH reduces the cardiac dose, but clinical data confirming this effect is limited. The aim of the study was to compare the mean heart dose (MHD) in patients with left breast cancer who underwent radiotherapy at our institution as we transitioned from non-gated free-breathing (FB) radiotherapy to gated radiotherapy (FB-GRT), and finally to DIBH. Patients and methods Retrospective study involving 2022 breast cancer patients who underwent radiotherapy at West Pomeranian Oncology Center in Szczecin from January 1, 2014 through December 31, 2017. We compared the MHD in these patients according to year of treatment and technique. Results Overall, the MHD for patients with left breast cancer in our cohort was 3.37 Gy. MHD values in the patients treated with DIBH were significantly lower than in patients treated with non-gated FB (2.1 vs. 3.48 Gy, p < 0.0001) and gated FB (3.28 Gy, p < 0.0001). The lowest MHD values over the four-year period were observed in 2017, when nearly 85% of left breast cancer patients were treated with DIBH. The proportion of patients exposed to high (> 4 Gy) MHD values decreased every year, from 40% in 2014 to 7.9% in 2017, while the percentage of patients receiving DIBH increased. Conclusions Compared to free-breathing techniques (both gated and non-gated), DIBH reduces the mean radiation dose to the heart in patients with left breast cancer. These findings support the use of DIBH in patients with left breast cancer treated with radiotherapy.

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Mean radiation dose to the heart in patients with breast cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.26_suppl.56 ◽

2013 ◽

Vol 31 (26_suppl) ◽

pp. 56-56 ◽

Cited By ~ 2

Author(s):

Geraldine Meerbott Jacobson ◽

Sijin Wen ◽

Jianjun Zhang ◽

Hannah Hazard ◽

Jame Abraham

Keyword(s):

Breast Cancer ◽

Treatment Planning ◽

Left Breast ◽

Current Treatment ◽

Heart Dose ◽

Treatment Regimens ◽

Significant Difference ◽

Treatment Plans ◽

Heart Injury ◽

Mean Heart Dose

56 Background: Breast irradiation may expose a portion of the heart to radiation. Heart irradiation is associated with late risk of ischemic heart disease, proportional to dose. A recent publication of patients treated with 2-D planning prior to 2001 noted average mean heart dose (MHD) of 6.6 Gy for left breast tumors, 2.9 Gy for right breast. Current treatment planning can minimize the MHD, reducing the risk of late heart injury. Methods: We reviewed treatment plans of 78 patients (86 breasts) treated 1/2012-3/2013 to obtain MHD. Treatment plans were CT-based, field-in-field forward planning with heart blocking. Two treatment regimens were used; hypofractionation (HF) (16 x 2.66 Gy, no boost) or standard (SF) (46.8-50.4 Gy +/- 10 Gy boost). Statistics were obtained for MHD based on right (N = 44) or left breast (N = 42); HF (N = 31) vs SF (N = 55), and total dose. Results: Average (av) MHD for left breast was 1.45 Gy (range 0.19-3.12), for right breast 0.70 Gy (0.12-1.54). For HF patients av MHD left was 1.16 Gy (0.19-1.90), MHD right was 0.48 Gy (0.12-0.91). For SF av MHD left was 1.60 Gy (0.80-3.12), MHD right was 0.84 Gy (0.39-1.54). There was a significant difference in MHD between left and right breasts (p = 0.002) and significant correlation between breast dose and MHD (p = 0.026). Conclusions: MHD from breast RT with current treatment planning is much lower than published reports from 2-D planning. MHD correlates with total breast dose and is greater for the left than right side. Techniques to reduce MHD should be utilized, especially for left-sided breast cancer.

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Treatment planning comparison of volumetric modulated arc therapy with Trilogy and Halcyon for bilateral breast cancer

10.21203/rs.3.rs-92224/v2 ◽

2021 ◽

Author(s):

Tao Sun ◽

Xiutong Lin ◽

Guifang Zhang ◽

Qingtao Qiu ◽

Chengqiang Li ◽

...

Keyword(s):

Breast Cancer ◽

Treatment Planning ◽

Volumetric Modulated Arc Therapy ◽

Bilateral Breast Cancer ◽

Planning System ◽

Skin Dose ◽

Delivery Time ◽

Dose Volume ◽

Arc Therapy ◽

The Mean

Abstract Background: The Halcyon is a new machine from the Varian company. The purpose of this study was to evaluate the dosimetry of the Halcyon in treatment of bilateral breast cancer with volumetric modulated arc therapy. Methods: On CT images of 10 patients with bilateral breast cancer, four Halcyon plans with different setup fields were generated, and dosimetric comparisons using Bonferroni’s multiple comparisons test were conducted among the four plans. Whole and partial arc plans on the Trilogy and the Halcyon, referred to as T-4arc, T-8arc, H-4arc and H-8arc, were designed. The prescription dose was 50 Gy in 2-Gy fractions. All plans were designed with the Eclipse version 15.5 treatment planning system. The dosimetric differences between whole and partial arc plans in the same accelerator were compared using the Mann-Whitney U test. The better Halcyon plan was selected for the further dosimetric comparison of the plan quality and delivery efficiency between the Trilogy and the Halcyon. Results:Halcyon plans with high‐quality megavoltage cone beam CT setup fields increased the Dmean, D2 and V107 of the planning target volume (PTV) and the V5 and Dmean of the heart, left ventricle (LV) and lungs compared with other Halcyon setup plans. The mean dose and low dose volume of the heart, lungs and liver were significantly decreased in T-8arc plans compared to T-4arc plans. In terms of the V5, V20, V30, V40 and Dmean of the heart, the V20, V30, V40 and Dmean of the LV, the V30, V40, Dmax and Dmean of the left anterior descending artery (LAD), and the V5 and V40 of lungs, H-8arc was significantly higher than H-4arc (p<0.05). Compared with the Trilogy’s plans, the Halcyon’s plans reduced the high-dose volume of the heart and LV but increased the mean dose of the heart. For the dose of the LAD and the V20 and V30 of lungs, there was no significant difference between the two accelerators. Compared with the Trilogy, plans on the Halcyon significantly increased the skin dose but also significantly reduced the delivery time. Conclusion: For the Halcyon, the whole-arc plans have more dosimetric advantages than partial-arc plans in bilateral breast cancer radiotherapy. Although the mean dose of the heart and the skin dose are increased, the doses of the cardiac substructure and other OARs are comparable to the Trilogy, and the delivery time is significantly reduced.

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Mono versus dual isocentric technique for breast cancer radiotherapy: evaluation of planning, dosimetry and treatment delivery

Journal of Radiotherapy in Practice ◽

10.1017/s1460396920000667 ◽

2020 ◽

pp. 1-6

Author(s):

Tabassum Wadasadawala ◽

Shirley Lewis ◽

Utpal Gaikwad ◽

Umesh Gayake ◽

Reena Phurailatpam ◽

...

Keyword(s):

Breast Cancer ◽

Total Error ◽

Breast Cancer Patients ◽

Breast Radiotherapy ◽

Imaging Device ◽

Heart Dose ◽

Breast Cancer Radiotherapy ◽

Field Junction ◽

Set Up ◽

Mean Heart Dose

Abstract Aim: To compare the dosimetry and reproducibility of set-up with monoisocentric technique (MIT) and dual isocentric technique (DIT) in adjuvant breast radiotherapy (RT). Material and methods: Breast cancer patients treated with MIT or DIT were retrospectively studied. The organ-at-risk dose was compared between two groups. All patients underwent set-up verification with an electronic portal imaging device, and set-up time was recorded for each fraction. Treatment reproducibility was assessed in terms of systematic and random error. Results: Twenty patients were included (11 right and 9 left-sided tumours) and ten received whole breast RT, while the rest received chest wall RT. Overall, the mean heart dose was less with MIT (0.40 versus 0.79, p = <0.001) as well as in left-sided tumours (0.37 versus 0.98, p = 0.003). The maximum dose at the field junction was significantly higher with DIT (43 Gy, 107%, p = 0.003). The maximum total error was 1 cm in lateral for supraclavicular field and 8 mm in superior–inferior in tangents for both techniques. There was no difference in set-up errors between the two techniques. Findings: MIT resulted in better dose homogeneity at the field junctions and reduced mean heart dose as compared to DIT. MIT is safe for implementation in clinical practice for breast cancer treatment. Conclusion: This study is one of the few studies comparing MIT with DIT in terms of the dosimetry and the first one to compare set-up errors between the two techniques. The ease of set-up and better dosimetry with MIT was achieved.

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PO-0762 Low predictive value of mean heart dose for coronary artery dosimetry in breast cancer radiotherapy

Radiotherapy and Oncology ◽

10.1016/s0167-8140(19)31182-x ◽

2019 ◽

Vol 133 ◽

pp. S391-S392

Author(s):

S. JACOB ◽

J. Camilleri ◽

S. Derreumaux ◽

V. Walker ◽

O. Lairez ◽

...

Keyword(s):

Breast Cancer ◽

Coronary Artery ◽

Predictive Value ◽

Cancer Radiotherapy ◽

Heart Dose ◽

Breast Cancer Radiotherapy ◽

Mean Heart Dose

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Treatment planning comparison of volumetric modulated arc therapy with the trilogy and the Halcyon for bilateral breast cancer

Radiation Oncology ◽

10.1186/s13014-021-01763-z ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Tao Sun ◽

Xiutong Lin ◽

Guifang Zhang ◽

Qingtao Qiu ◽

Chengqiang Li ◽

...

Keyword(s):

Breast Cancer ◽

Treatment Planning ◽

Volumetric Modulated Arc Therapy ◽

Bilateral Breast Cancer ◽

Planning System ◽

Skin Dose ◽

Delivery Time ◽

Dose Volume ◽

Arc Therapy ◽

The Mean

Abstract Background The Halcyon is a new machine from the Varian company. The purpose of this study was to evaluate the dosimetry of the Halcyon in treatment of bilateral breast cancer with volumetric modulated arc therapy. Methods On CT images of 10 patients with bilateral breast cancer, four Halcyon plans with different setup fields were generated, and dosimetric comparisons using Bonferroni’s multiple comparisons test were conducted among the four plans. Whole and partial arc plans on the Trilogy and the Halcyon, referred to as T-4arc, T-8arc, H-4arc and H-8arc, were designed. The prescription dose was 50 Gy in 2-Gy fractions. All plans were designed with the Eclipse version 15.5 treatment planning system. The dosimetric differences between whole and partial arc plans in the same accelerator were compared using the Mann–Whitney U test. The better Halcyon plan was selected for the further dosimetric comparison of the plan quality and delivery efficiency between the Trilogy and the Halcyon. Results Halcyon plans with high‐quality megavoltage cone beam CT setup fields increased the Dmean, D2 and V107 of the planning target volume (PTV) and the V5 and Dmean of the heart, left ventricle (LV) and lungs compared with other Halcyon setup plans. The mean dose and low dose volume of the heart, lungs and liver were significantly decreased in T-8arc plans compared to T-4arc plans. In terms of the V5, V20, V30, V40 and Dmean of the heart, the V20, V30, V40 and Dmean of the LV, the V30, V40, Dmax and Dmean of the left anterior descending artery (LAD), and the V5 and V40 of lungs, H-8arc was significantly higher than H-4arc (p < 0.05). Compared with the Trilogy’s plans, the Halcyon’s plans reduced the high-dose volume of the heart and LV but increased the mean dose of the heart. For the dose of the LAD and the V20 and V30 of lungs, there was no significant difference between the two accelerators. Compared with the Trilogy, plans on the Halcyon significantly increased the skin dose but also significantly reduced the delivery time. Conclusion For the Halcyon, the whole-arc plans have more dosimetric advantages than partial-arc plans in bilateral breast cancer radiotherapy. Although the mean dose of the heart and the skin dose are increased, the doses of the cardiac substructure and other OARs are comparable to the Trilogy, and the delivery time is significantly reduced.

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Cardiac dose evaluation in patients undergoing breast radiotherapy in the modern era.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.26_suppl.78 ◽

2014 ◽

Vol 32 (26_suppl) ◽

pp. 78-78

Author(s):

Christopher A. Peters ◽

Andrew Kaleda ◽

Anthony Manfredo ◽

Elizabeth Tapen ◽

Lawrence Koutcher

Keyword(s):

Breast Cancer ◽

Multivariate Analysis ◽

Critical Role ◽

Univariate Analysis ◽

Metastatic Breast ◽

Planning System ◽

Treatment Planning System ◽

Breast Radiotherapy ◽

Heart Dose ◽

Mean Heart Dose

78 Background: Breast radiotherapy (RT) after conservative surgery improves overall survival and minimizes locoregional recurrence. The therapeutic ratio of adjuvant RT continues to improve with time. Cardiac toxicity from breast cancer treatment remains a concern, and can result from chemotherapy, biologic therapy, or RT in a dose-dependent fashion. Dose to avoidance structures can be minimized as technological improvements in radiotherapy evolve. We sought to investigate heart and coronary artery dose using modern RT techniques. Methods: We reviewed 164 consecutive non-metastatic breast cancer patients treated with adjuvant breast RT, from 3/2011 to 12/2013. 8 patients were excluded because they did not complete the prescribed dose. Patients were treated on 3 different machines, at 2 centers. Data was extracted using both the treatment planning system and electronic medical records. Univariate analysis was done using t-test and one way ANOVA for variables predicting higher mean heart dose (MHD). Multivariate analysis was performed using multiple linear regression. p values ≤0.05 were considered significant. Results: The median age of our cohort was 63 (range 33-85), and 90% had ≤ stage 2 disease. 53% had left sided RT, 45% right, and 2% had bilateral RT. 18% had breast/chest wall and nodal RT, with 2% dedicated IMN targeting. 22% of patients were treated prone. The median dose, including boost, was 60.4 Gy (range 42.4-66.4). 35% received cytotoxic chemotherapy and 10% received trastuzumab. Mean heart dose was 1.4Gy (SD 2.2), and mean LAD dose was 4.9Gy (SD 4.4). MHD were lower in the prone position compared to supine, but did not reach statistical significance p=0.3. Advanced AJCC stage grouping, left sided or bilateral treatment, breast/nodal target volume, and helical treatment were associated with significantly higher MHD on univariate analysis. On multivariate analysis, only breast/nodal volume and helical technique remained significant, both p<0.001. Conclusions: Modern techniques result in low heart and LAD doses in our series. Because adjuvant breast RT plays a critical role in the definitive management of breast cancer, these data are reassuring to patients, physicians, and payers.

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