Modern Radiation Therapy for Left-Sided Breast Cancer: An Analysis of Mean Heart Dose Within Diverse Practice Settings

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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Mean Heart Dose and Distribution of Coronary Artery Stenosis in Breast Cancer Patients Treated With CT-Based Radiation Therapy

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/j.ijrobp.2017.06.700 ◽

2017 ◽

Vol 99 (2) ◽

pp. E45-E46

Author(s):

C.A. Schonewolf ◽

J. Vogel ◽

M.J. LaRiviere ◽

J.D. Kolker ◽

S. Nagda ◽

...

Keyword(s):

Breast Cancer ◽

Radiation Therapy ◽

Coronary Artery ◽

Cancer Patients ◽

Coronary Artery Stenosis ◽

Artery Stenosis ◽

Breast Cancer Patients ◽

Heart Dose ◽

Mean Heart Dose

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Mean Heart Dose Is an Inadequate Surrogate for Left Anterior Descending Coronary Artery Dose and the Risk of Major Adverse Cardiac Events in Lung Cancer Radiation Therapy

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/j.ijrobp.2021.03.005 ◽

2021 ◽

Author(s):

Katelyn M. Atkins ◽

Danielle S. Bitterman ◽

Tafadzwa L. Chaunzwa ◽

David E. Kozono ◽

Elizabeth H. Baldini ◽

...

Keyword(s):

Lung Cancer ◽

Radiation Therapy ◽

Coronary Artery ◽

Major Adverse Cardiac Events ◽

Cardiac Events ◽

Heart Dose ◽

Adverse Cardiac Events ◽

Mean Heart Dose

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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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An update on the dosimetric analysis of concurrent radiation therapy and trastuzumab on early cardiac events.

Journal of Clinical Oncology ◽

10.1200/jco.2011.29.27_suppl.121 ◽

2011 ◽

Vol 29 (27_suppl) ◽

pp. 121-121

Author(s):

K. S. Keene ◽

L. C. Klepczyk ◽

R. Meredith ◽

A. Forero-Torres ◽

J. T. Carpenter ◽

...

Keyword(s):

Radiation Therapy ◽

Heart Disease ◽

Breath Hold ◽

Cardiac Events ◽

Cardiac Morbidity ◽

Heart Dose ◽

Dosimetric Analysis ◽

Mean Heart Dose ◽

The Impact

121 Background: The impact of radiation therapy (RT) with concurrent trastuzumab on early cardiac morbidity is relatively unknown. Trastuzumab’s radiosensitizing properties may augment both early and late effects of RT. This retrospective review update provides an analysis of cardiac event (CE) development in patients treated with concurrent RT and trastuzumab with a focus on RT heart dose. Methods: Sixty-five patients treated with concurrent RT (30 left, 33 right, 2 bilateral) and trastuzumab at the University of Alabama at Birmingham were identified. Patient data for pre-existing heart disease, cardiac risk factors, drug regimen, and CEs were recorded. Dosimetric parameters of maximum heart dose, mean heart dose, heart volume receiving 5, 10, 15, 20 and 30Gy (V5, V10, V15, V20, V30) were also analyzed. Endpoints include the occurrence of CEs at any time in relation to RT and those specifically after the start of RT. Results: In addition to receiving trastuzumab, 80% of patients received doxorubicin. 15.4% had preexisting heart disease. The mean heart dose for all patients was 248cGy. With a median follow-up of 24.5 months, six patients developed CEs (9.2%), and three of these cases occurred after RT initiation (4, 4, and 0.5 months post-RT). All six CEs occurred during treatment with trastuzumab and consisted of congestive heart failure. Analysis of the heart dose maximum, mean, V5, V10, V15, and V20, V30 were similar in patients with and without CEs, and small differences between groups did not reach statistical significance. CE incidence was significantly associated with smoking (p=0.0037) but not hypertension, diabetes or pre-existing heart disease. Conclusions: This updated retrospective dosimetric analysis did not find a correlation between concurrent trastuzumab and RT on the development of early cardiac events. Modern era RT with 3D conformal planning, the use of heart blocks, and breath hold techniques will continue to decrease the dose to the heart. Longer follow-up will be needed for analysis of the impact of modern technologic advances and late cardiac morbidity.

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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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Proton Therapy for Primary Breast Cancer

Breast Care ◽

10.1159/000489893 ◽

2018 ◽

Vol 13 (3) ◽

pp. 168-172 ◽

Cited By ~ 8

Author(s):

Eugen B. Hug

Keyword(s):

Breast Cancer ◽

Proton Therapy ◽

Cardiac Complications ◽

Heart Dose ◽

Normal Tissues ◽

Long Term Follow Up ◽

Mean Heart Dose ◽

Dose Deposition

Proton therapy reduces the integral dose received by normal tissues due to its physical properties of dose deposition in the Bragg peak. In a small but significant percentage of patients requiring adjuvant radiotherapy (RT) for left-sided breast cancer, photon-based RT can lead to cardiac complications during long-term follow-up. The risk of cardiac complications is correlated with the dose to the coronary arteries and to the general ‘mean heart dose'. Dosimetric comparison analysis has identified advantages of proton therapy in accomplishing sparing of the heart with increasing target complexity while permitting uncompromised target coverage of the chest wall ± breast plus draining lymphatics. Early clinical data indicate good clinical tolerance to proton therapy without unexpected complications. Several clinical trials are presently ongoing to prospectively confirm a clinical benefit and to identify the subgroup of patients benefitting most from proton therapy for breast cancer.

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