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

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.

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

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.

scholarly journals Dosimetric Considerations in Respiratory-Gated Deep Inspiration Breath-Hold for Left Breast Irradiation

2016 ◽  
Vol 16 (1) ◽  
pp. 22-32 ◽  
Author(s):  
Steve Walston ◽  
Allison M. Quick ◽  
Karla Kuhn ◽  
Yi Rong
Keyword(s):  
Chest Wall ◽  
Lung Volume ◽  
Left Lung ◽  
Free Breathing ◽  
Left Breast ◽  
Breath Hold ◽  
Deep Inspiration ◽  
Lung Dose ◽  
Deep Inspiration Breath Hold ◽  
Heart Dose

Purpose: To present our clinical workflow of incorporating AlignRT for left breast deep inspiration breath-hold treatments and the dosimetric considerations with the deep inspiration breath-hold protocol. Material and Methods: Patients with stage I to III left-sided breast cancer who underwent lumpectomy or mastectomy were considered candidates for deep inspiration breath-hold technique for their external beam radiation therapy. Treatment plans were created on both free-breathing and deep inspiration breath-hold computed tomography for each patient to determine whether deep inspiration breath-hold was beneficial based on dosimetric comparison. The AlignRT system was used for patient setup and monitoring. Dosimetric measurements and their correlation with chest wall excursion and increase in left lung volume were studied for free-breathing and deep inspiration breath-hold plans. Results: Deep inspiration breath-hold plans had significantly increased chest wall excursion when compared with free breathing. This change in geometry resulted in reduced mean and maximum heart dose but did not impact lung V20 or mean dose. The correlation between chest wall excursion and absolute reduction in heart or lung dose was found to be nonsignificant, but correlation between left lung volume and heart dose showed a linear association. It was also identified that higher levels of chest wall excursion may paradoxically increase heart or lung dose. Conclusion: Reduction in heart dose can be achieved for many left-sided breast and chest wall patients using deep inspiration breath-hold. Chest wall excursion as well as left lung volume did not correlate with reduction in heart dose, and it remains to be determined what metric will provide the most optimal and reliable dosimetric advantage.

Mean radiation dose to the heart in patients with left breast cancer with and without breath-hold technique.

2014 ◽  
Vol 32 (26_suppl) ◽  
pp. 85-85 ◽  
Author(s):  
Geraldine M. Jacobson ◽  
Christopher Nicholas Watson ◽  
Jianjun Zhang ◽  
Sijin Wen ◽  
Nicole Helen Bunda-Randall
Keyword(s):  
Breast Cancer ◽  
Radiation Treatment ◽  
Left Breast ◽  
Breath Hold ◽  
Exact Test ◽  
Heart Dose ◽  
Treatment Regimens ◽  
Treatment Plans ◽  
Mean Heart Dose ◽  
Standard Fractionation

85 Background: Mean heart dose (MHD) from breast irradiation has been correlated with late risk of ischemic heart disease. We previously reported using 3-D conformal radiation with field-in-field forward planning and heart blocking; MHD is substantially lower than described for patients treated before 2001. To further reduce MHD, we treated eligible patients with left breast cancer with breath hold technique. We compared the MHD with and without breath hold technique. Methods: We reviewed 45 radiation treatment plans of patients treated to the left breast from 5/2013-5/2014. All patients were evaluated for breath hold technique. Criteria were ability to hold the breath for 20 seconds and a stable chest position. 18 patients were treated with breath hold (BH), 27 patients with non-breath hold (NBH). All treatment plans were CT-based, 3-D conformal with field-in- field forward planning and heart blocking. Two treatment regimens were used: hypofractionation (HF) (16 x 2.66 Gy, no boost) or standard fractionation (SF) (46.8-50.4 Gy, +/- 10 Gy boost). Fisher's exact test and t-test were used to assess the data between MHD with breath hold (BH) and without (NBH). Results: Average MHD was 1.03 Gy (0.59-1.7) in BH patients, in comparison to 1.57 Gy (0.89-2.50) in NBH patients p<0.0001). MHD was associated with total breast dose (p=0.01) and BH patients were younger, average age 55.78 years (21.41-48.37) vs NBH, average 62.78 years (38-82). There was no association between breath hold and BMI. BH BMI average 34.12 (21.41-48.37), NBH average BMI 32.6 (20.58-44.71) p=0.46. Conclusions: Patients treated with radiation to the left breast with breath hold technique had significantly lower MHD than those treated with non-breath hold. (p=0.0001) Breath hold eligible patients tended to be younger; there was no relation between breath hold eligibility and BMI.

scholarly journals Dose Volume Relationship in Estimating Cardiac Doses in Breast Cancer Radiotherapy

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.

Deep inspiration breath hold (DIBH) with electromagnetic surface transponder confirmation of chest wall (CW) position during radiation for left breast cancer.

2014 ◽  
Vol 32 (26_suppl) ◽  
pp. 126-126
Author(s):  
Madeera Kathpal ◽  
Kelly Sun ◽  
Cynthia Malmer ◽  
Stephanie Ninneman ◽  
Stacie Wendt ◽  
...  
Keyword(s):  
Free Breathing ◽  
Left Breast ◽  
Breath Hold ◽  
Breast Cancers ◽  
Deep Inspiration Breath Hold ◽  
Heart Dose ◽  
Real Time Tracking ◽  
The Mean ◽  
The Difference ◽  
Ischemic Events

126 Background: DIBH during radiation of left breast cancers reduces heart dose, potentially reducing late cardiac ischemic events, but requires a treatment CW position significantly different from a free-breathing (FB) position. We sought to improve the accuracy of radiation therapy during DIBH by using electromagnetic surface transponders to track the position of the CW during treatment. We examined the benefit of this technique in reducing dose to the heart and consistently reproducing the DIBH position. We also evaluated the difference between FB and DIBH CW position and compared CW movement within the plateau of each DIBH to within beam-on time. Methods: 15 patients participated in this IRB-approved study. Patients were planned and treated using DIBH. We fused treatment-position FB CT scans to DIBH scans to compare mean heart (MH) and left anterior descending coronary artery (LAD) dose. We used surface transponder tracking reports to determine CW motion at the time of daily port films, during FB, the plateau of each DIBH, and beam-on time. We summed anterior and superior motion using the Pythagorean Theorem and report our results in this combined axis. Paired t-test was used to compare heart dose with vs. without DIBH and CW motion during plateau DIBH vs. beam-on. Results: DIBH significantly reduced MH and LAD dose vs. FB plans (MH 1.26 ± 0.51 Gy v 2.84 ± 1.55 Gy, p < 0.01), (LAD 5.49 ± 4.02 Gy v 18.15 ± 8.78 Gy, p < 0.01). DIBH CW position was a mean of 13.9 ± 5.3 mm anterior and superior to FB position. The mean difference in CW position at the time of daily port film vs. beam-on was -1.0 ± 2.5 mm. Plateau DIBH CW motion was 2.8 ± 2.3 mm, significantly increased from CW motion during beam-on (1.1 ± 1.2 mm, p < 0.01). Treatment was paused in 23% of fractions to adjust for suboptimal breath hold or CW position. Conclusions: DIBH reduced the MH and LAD dose by at least 50%. Real-time tracking with electromagnetic transponders allowed us to limit treatment to the most stable portion of the DIBH plateau, significantly reducing intra-fraction motion. Electromagnetic confirmation of CW position allowed verification of breath-hold reproducibility.

The Advantages of Active Breathing Coordinator Device During Left-Sided Breast Cancer Radiation Therapy: A Dosimetric Comparison Study

2020 ◽  
Author(s):  
Nadia Pasinetti ◽  
Lilia Bardoscia ◽  
Luigi Spiazzi ◽  
Barbara Ghedi ◽  
Sara Pedretti ◽  
...  
Keyword(s):  
Breast Cancer ◽  
At Risk ◽  
Side Effects ◽  
Organs At Risk ◽  
Left Lung ◽  
Normal Tissue Complication Probability ◽  
Left Breast ◽  
Breath Hold ◽  
Deep Inspiration Breath Hold ◽  
Dose Volume Histograms

Abstract Background: Radiotherapy (RT) improves local control and survival in breast cancer (BC) patients. However, risk of heart and lung side effects after post-operative left breast RT for breast cancer remain despite technological and technical RT advances. In a retrospective cohort we investigated if Active Breathing Coordinator (ABC) device can reduce risk of cardiopulmonary morbidity.Methods: we performed two different dosimetric analyses by Normal Tissue Complication Probability (NTCP) and Bio-Dose-Volume Histograms (Bio-DVH) in order to determine whether left breast RT using moderating deep inspiration breath-hold (mDIBH) with the Active Breathing Coordinator (ABC) device, may significantly reduce heart, left anterior descending coronary artery (LADCA) and lung radiation exposure during left breast RT performed with 3d-CRT technique.Results: Several dosimetric parameters were used in the present study to compare the treatment plans generated by FB and mDIBH images of sixty-nine consecutive patients treated between May 2012 and April 2016 at the Istituto del Radio Radiation Oncology Dept. All data derived by Bio-DVH and the heart NTCP calculation showed that ABC led to significant sparing of organs at risk compared with FB, expecially for the heart and LADCA. We also showed that the mDIBH technique significantly reduced left lung dose: in fact, through inflation, only low density lung tissue remains within the tangential field, thus avoiding its deterioration.Conclusions: Use of mDIBH gives a real advantage on breast cancer RT by reducing the radiation to the organs at risk (OARs) and consequently, the risk of cardiac and pulmonary late side effects.

Dosimetric evaluation of 3 and/or 4 field radiation therapy of breast cancers: clinical experience

2020 ◽  
pp. 1-15
Author(s):  
Ernest Osei ◽  
Susan Dang ◽  
Johnson Darko ◽  
Katrina Fleming ◽  
Ramana Rachakonda
Keyword(s):  
Breast Cancer ◽  
Radiation Therapy ◽  
High Risk ◽  
Chest Wall ◽  
Treatment Plan ◽  
Breath Hold ◽  
Adjuvant Radiation ◽  
Node Positive ◽  
Treatment Plans ◽  
The Mean

Abstract Background: Breast cancer is the most commonly diagnosed cancer among women and the second leading cause of cancer-related death in Canadian women. Surgery is often the first line of treatment for low-risk early stage patients, followed by adjuvant radiation therapy to reduce the risk of local recurrence and prevent metastasis after lumpectomy or mastectomy. For high-risk patients with node positive disease or are at greater risk of nodal metastasis, radiation therapy will involve treatment of the intact breast or chest-wall as well as the regional lymph nodes. Materials and methods: We retrospectively evaluated the treatment plans of 354 patients with breast cancer with nodes positive or were at high risk of nodal involvement treated at our cancer centre. All patients were treated with a prescription dose of 50 Gy in 25 fractions to the intact breast or chest-wall and 50 Gy in 25 fractions to the supraclavicular region and, based on patient suitability and tolerance, were treated either using the deep inspiration breath hold (DIBH) or free-breathing (FB) techniques. Results: Based on patient suitability and tolerance, 130 (36·7%) patients were treated with DIBH and 224 (63·3%) with FB techniques. There were 169 (47·7%) patients treated with intact breast, whereas 185 (52·3%) were treated for post-mastectomy chest-wall. The mean PTV_eval V92%, V95%, V100% and V105% for all patients are 99·4 ± 0·7, 97·6 ± 1·6, 74·8 ± 7·9 and 1·5 ± 3·2%, respectively. The mean ipsilateral lung V10Gy, V20Gy and V30Gy are 30·0 ± 5·3, 22·4 ± 4·7 and 18·4 ± 4·3% for intact breast and 30·9 ± 5·8, 23·5 ± 5·4 and 19·4 ± 5·0% for post-mastectomy patients with FB, respectively. The corresponding values for patients treated using DIBH are 26·3 ± 5·9, 18·9 ± 5·0 and 15·6 ± 4·7% for intact breast and 27·5 ± 6·5, 20·6 ± 5·7 and 17·1 ± 5·2% for post-mastectomy patients, respectively. The mean heart V10Gy, V20Gy, is 1·8 ± 1·7, 0·9 ± 1·0 for intact breast and 3·1 ± 2·2, 1·7 ± 1·6 for post-mastectomy patients with FB, respectively. The corresponding values with the DIBH are 0·5 ± 0·7, 0·1 ± 0·4 for intact breast and 1·1 ± 1·4, 0·4 ± 0·7 for post-mastectomy patients, respectively. Conclusion: The use of 3 and/or 4 field hybrid intensity-modulated radiation therapy technique for radiation therapy of high-risk node positive breast cancer patients provides an efficient and reliable method for achieving superior dose uniformity, conformity and homogeneity in the breast or post-mastectomy chest-wall volume with minimal doses to the organs at risk. The development and implementation of a consistent treatment plan acceptability criteria in radiotherapy programmes would establish an evaluation process to define a consistent, standardised and transparent treatment path for all patients that would reduce significant variations in the acceptability of treatment plans.

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