Hypofractionated Breast and Chest Wall Irradiation Using Simultaneous in-field Boost IMRT Delivered via Helical Tomotherapy

Although helical tomotherapy has been described as a means of administering accelerated partial breast irradiation, its practicality in routine whole breast irradiation as part of breast conserving therapy or chest wall irradiation has been questioned. In this technical note we describe our method of whole breast or chest wall irradiation using helical tomotherapy based image-guided, hypofractionated, simultaneous in-field boost intensity modulated radiation therapy. We have observed that excellent dose-distributions can be achieved with helical tomotherapy through a careful selection of treatment planning parameters. Dose homogeneity to the whole breast and simultaneously targeted lumpectomy region appears superior to conventional “tangents” with minimal hot or cold spots. Dose-volume histogram analysis documents effective reduction of high dose to critical sensitive structures (heart and lung) although a greater volume of these non-target organs receives low dose compared to what is typical with tangential beams. Treatment planning is efficient and is usually completed within one to two hours, although physician contouring requires more time and attention than non-IMRT approaches. Pretreatment megavoltage CT (MVCT) imaging has proved invaluable in aiding set-up and engenders greater confidence that the planned IMRT dose distributions are truly being delivered. In some situations, MVCT can provide visual feedback when a seroma or overall breast volume has changed significantly since simulation, thereby identifying cases where replanning might be prudent. Treatment is brief, typically completed in 6 to 9 minutes. Initial clinical application has confirmed the feasibility and practicality of helical tomotherapy as an efficient means of administering radiation therapy for routine breast-conserving therapy and post-mastectomy chest wall irradiation. A simultaneous in-field boost technique reduces the length of the overall course by about a week thereby adding convenience and reducing costs. Further refinements of our technique are being explored and formal prospective clinical evaluation is underway.