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Published online: 2024-05-29

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Impact of deep inspiration breath hold irradiation on dose reduction to the heart and left coronary artery in breast cancer

Piotr Winczura1, Julianna Wejs-Maternik1, Andrzej Blukis1, Monika Antonowicz-Szydłowska2, Patrycja Urbanowicz3, Agnieszka Rakowiecka1, Marcin Urbanowicz4, Matteo Pepa5, Samantha Dicuonzo5, Barbara A. Jereczek-Fossa56, Andrzej Badzio2

Abstract

Objectives. Deep inspiration breath-hold (DIBH) is an effective and feasible approach to reducing the radiation dose to the heart in left-sided breast cancer radiotherapy (RT). This study aimed to assess the impact of DIBH on dose reduction to the heart and the left anterior descending coronary artery (LAD) in left-sided early breast cancer patients with intact breasts. 

Material and methods. We compared RT plans of 42 patients from computed tomography datasets acquired for free breathing (FB) and DIBH techniques with 6 MeV photon tangential fields. The prescribed dose was 50 Gy in 25 fractions. 

Results. DIBH enabled significant dose reduction to the heart and the LAD. A significantly lower mean heart dose (MHD) was observed in DIBH compared to FB planning (2.9 vs. 6.0 Gy, respectively; p < 0.0001). The considered LAD parameters, namely Dmax 0.2 cm3, mean dose, and V45Gy, were all significantly reduced in DIBH compared to FB planning (33.3 vs. 47 Gy; p < 0.0001, 16.7 vs. 30.1 Gy; p < 0.0001 and 0.5 vs 1.7 cm3; p < 0.0001, respectively). Reduction in any of the LAD dose parameters was not correlated with MHD reduction. The LAD parameters were found to be significantly reduced in the group of patients with modest MHD reduction defined as < 2.8 Gy (31.2 vs. 46.9 Gy; p = 0.0001, 15 vs. 26.9 Gy; p < 0.00001, and 0.5 vs. 1.6 Gy; p = 0.0005, respectively). 

Conclusions. DIBH has a pronounced impact on dose reduction to the LAD. This influence is not correlated with the MHD and is present even in patients with modest MHD reduction with DIBH. 

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References

  1. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013; 368(11): 987–998.
  2. van den Bogaard VAB, Ta BDP, van der Schaaf A, et al. Validation and Modification of a Prediction Model for Acute Cardiac Events in Patients With Breast Cancer Treated With Radiotherapy Based on Three-Dimensional Dose Distributions to Cardiac Substructures. J Clin Oncol. 2017; 35(11): 1171–1178.
  3. Smyth LM, Knight KA, Aarons YK, et al. The cardiac dose-sparing benefits of deep inspiration breath-hold in left breast irradiation: a systematic review. J Med Radiat Sci. 2015; 62(1): 66–73.
  4. Shah C, Badiyan S, Berry S, et al. Cardiac dose sparing and avoidance techniques in breast cancer radiotherapy. Radiother Oncol. 2014; 112(1): 9–16.
  5. Gaál S, Kahán Z, Paczona V, et al. Deep-inspirational breath-hold (DIBH) technique in left-sided breast cancer: various aspects of clinical utility. Radiat Oncol. 2021; 16(1): 89.
  6. Sixel KE, Aznar MC, Ung YC. Deep inspiration breath hold to reduce irradiated heart volume in breast cancer patients. Int J Radiat Oncol Biol Phys. 2001; 49(1): 199–204.
  7. Stranzl H, Zurl B. Postoperative irradiation of left-sided breast cancer patients and cardiac toxicity. Does deep inspiration breath-hold (DIBH) technique protect the heart? Strahlenther Onkol. 2008; 184(7): 354–358.
  8. Swanson T, Grills IS, Ye H, et al. Six-year experience routinely using moderate deep inspiration breath-hold for the reduction of cardiac dose in left-sided breast irradiation for patients with early-stage or locally advanced breast cancer. Am J Clin Oncol. 2013; 36(1): 24–30.
  9. Wang W, Purdie TG, Rahman M, et al. Rapid automated treatment planning process to select breast cancer patients for active breathing control to achieve cardiac dose reduction. Int J Radiat Oncol Biol Phys. 2012; 82(1): 386–393.
  10. Vikström J, Hjelstuen MHB, Mjaaland I, et al. Cardiac and pulmonary dose reduction for tangentially irradiated breast cancer, utilizing deep inspiration breath-hold with audio-visual guidance, without compromising target coverage. Acta Oncol. 2011; 50(1): 42–50.
  11. Nissen HD, Appelt AL. Improved heart, lung and target dose with deep inspiration breath hold in a large clinical series of breast cancer patients. Radiother Oncol. 2013; 106(1): 28–32.
  12. Borst GR, Sonke JJ, den Hollander S, et al. Clinical results of image-guided deep inspiration breath hold breast irradiation. Int J Radiat Oncol Biol Phys. 2010; 78(5): 1345–1351.
  13. Hayden AJ, Rains M, Tiver K. Deep inspiration breath hold technique reduces heart dose from radiotherapy for left-sided breast cancer. J Med Imaging Radiat Oncol. 2012; 56(4): 464–472.
  14. Lee HaY, Chang JS, Lee IkJ, et al. The deep inspiration breath hold technique using Abches reduces cardiac dose in patients undergoing left-sided breast irradiation. Radiat Oncol J. 2013; 31(4): 239–246.
  15. Dincoglan F, Beyzadeoglu M, Sager O, et al. Dosimetric evaluation of critical organs at risk in mastectomized left-sided breast cancer radiotherapy using breath-hold technique. Tumori. 2013; 99(1): 76–82.
  16. Mast ME, van Kempen-Harteveld L, Heijenbrok MW, et al. Left-sided breast cancer radiotherapy with and without breath-hold: does IMRT reduce the cardiac dose even further? Radiother Oncol. 2013; 108(2): 248–253.
  17. Reardon KA, Read PW, Morris MM, et al. A comparative analysis of 3D conformal deep inspiratory-breath hold and free-breathing intensity-modulated radiation therapy for left-sided breast cancer. Med Dosim. 2013; 38(2): 190–195.
  18. Korreman SS, Pedersen AN, Josipović M, et al. Cardiac and pulmonary complication probabilities for breast cancer patients after routine end-inspiration gated radiotherapy. Radiother Oncol. 2006; 80(2): 257–262.
  19. Duane F, Aznar MC, Bartlett F, et al. A cardiac contouring atlas for radiotherapy. Radiother Oncol. 2017; 122(3): 416–422.
  20. Taylor C, Correa C, Duane FK, et al. Early Breast Cancer Trialists’ Collaborative Group. Estimating the Risks of Breast Cancer Radiotherapy: Evidence From Modern Radiation Doses to the Lungs and Heart and From Previous Randomized Trials. J Clin Oncol. 2017; 35(15): 1641–1649.
  21. White JTA, Arthur D, et al. Breast cancer atlas for radiation therapy planning: consenus definitions. http://www.nrgoncology.org/Portals/0/Resources/Atlases/BreastCancerAtlas.pdf.
  22. Gayed IW, Liu HH, Yusuf SW, et al. The prevalence of myocardial ischemia after concurrent chemoradiation therapy as detected by gated myocardial perfusion imaging in patients with esophageal cancer. J Nucl Med. 2006; 47(11): 1756–1762.
  23. Clarke M, Collins R, Darby S, et al. Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005; 366(9503): 2087–2106.
  24. Piroth MD, Baumann R, Budach W, et al. Heart toxicity from breast cancer radiotherapy : Current findings, assessment, and prevention. Strahlenther Onkol. 2019; 195(1): 1–12.
  25. Cuzick J, Stewart H, Rutqvist L, et al. Cause-specific mortality in long-term survivors of breast cancer who participated in trials of radiotherapy. J Clin Oncol. 1994; 12(3): 447–453.
  26. Wolf J, Stoller S, Lübke J, et al. Deep inspiration breath-hold radiation therapy in left-sided breast cancer patients: a single-institution retrospective dosimetric analysis of organs at risk doses. Strahlenther Onkol. 2023; 199(4): 379–388.
  27. Vijeh L, Ahmed Y, Lee L, et al. Impact on Lung Dose in Left Breast Radiation Therapy Patients With Deep Inspiration Breath Hold Versus Free Breathing Technique. Int J Radiat Oncol Biol Phys. 2016; 96(2): E52.
  28. Sripathi LK, Ahlawat P, Simson DK, et al. Cardiac Dose Reduction with Deep-Inspiratory Breath Hold Technique of Radiotherapy for Left-Sided Breast Cancer. J Med Phys. 2017; 42(3): 123–127.