Dosimetric comparison of normal breathing and deep inspiration breath hold technique for synchronous bilateral breast cancer using 6MV flattened beam and flattening filter free beam
Abstract
Background: The present study was to investigate the usefulness of deep inspiration breath hold (DIBH) in bilateral breast patients using 6MV flattened beam (FB) and flattening filter free beam (FFFB).
Materials and methods: Twenty bilateral breast cancer patients were simulated, using left breast patients treated with DIBH technique. CT scans were performed in the normal breathing (NB) and DIBH method. Three-dimensional conformal radiotherapy (3DCRT) and volumetric arc therapy (VMAT) plans were generated.
Results: In our study the best organ at risk (OAR) sparing is achieved in the 3DCRT DIBH plan with adequate PTV coverage (V95 ≥ 47.5 Gy) as compared to 6MV FB and FFFB VMAT DIBH plans. The DIBH scan plan reduces the heart mean dose significantly at the rate of 49% in 3DCRT (p = 0.00) and 22% in VMAT (p = 0.010). Similarly, the DIBH scan plan produces lesser common lung mean dose of 18% in 3DCRT (p = 0.011) and 8% in VMAT (0.007) as compared to the NB scan. The conformity index is much better in VMAT FB (1.04 ± 0.04 vs. 1.04 ± 0.05), p =1.00 and VMAT FFFB (1.04 ± 0.05 vs. 1 ± 0.24, p = 0.345) plans as compared to 3DCRT (1.63 ± 0.2 vs. 1.47 ± 0.28, p = 0.002). The homogeneity index of all the plans is less than 0.15. The global dmax is more in VMAT FFFB DIBH plan (113.7%). The maximum MU noted in the NB scan plan (478 vs. 477MU, 1366 vs. 1299 MU and 1853 vs. 1788 MU for 3DCRT, VMAT FB and VMAT FFFB technique as compared to DIBH scan.
Conclusion: We recommend that the use of DIBH techniques for bilateral breast cancer patients significantly reduces the radiation doses to OARs in both 3DCRT and VMAT plans.
Keywords: deep inspiration breath holdfree breething
References
- Kheirelseid EAH, Jumustafa H, Miller N, et al. Bilateral breast cancer: analysis of incidence, outcome, survival and disease characteristics. Breast Cancer Res Treat. 2011; 126(1): 131–140.
- Schubert LK, Gondi V, Sengbusch E, et al. Dosimetric comparison of left-sided whole breast irradiation with 3DCRT, forward-planned IMRT, inverse-planned IMRT, helical tomotherapy, and topotherapy. Radiother Oncol. 2011; 100(2): 241–246.
- Thilmann C, Zabel A, Kuhn S, et al. [Inversely planned intensity modulated radiotherapy for irradiation of a woman with breast cancer and funnel chest]. Strahlenther Onkol. 2002; 178(11): 637–643.
- Teoh M, Clark CH, Wood K, et al. Volumetric modulated arc therapy: a review of current literature and clinical use in practice. Br J Radiol. 2011; 84(1007): 967–996.
- Otto K. Volumetric modulated arc therapy: IMRT in a single gantry arc. Med Phys. 2008; 35(1): 310–317.
- Lind P, Wennberg B, Gagliardi G, et al. Pulmonary complications following different radiotherapy techniques for breast cancer, and the association to irradiated lung volume and dose. Breast Cancer Res Treat. 2001; 68(3): 199–210.
- 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.
- Tanguturi SK, Lyatskaya Y, Chen Y, et al. Prospective assessment of deep inspiration breath-hold using 3-dimensional surface tracking for irradiation of left-sided breast cancer. Pract Radiat Oncol. 2015; 5(6): 358–365.
- Parkes MJ, Green S, Stevens AM, et al. Safely prolonging single breath-holds to >5 min in patients with cancer; feasibility and applications for radiotherapy. Br J Radiol. 2016; 89(1063): 20160194.
- Parkes MJ, Green S, Kilby W, et al. The feasibility, safety and optimization of multiple prolonged breath-holds for radiotherapy. Radiother Oncol. 2019; 141: 296–303.
- Osman SOS, Hol S, Poortmans PM, et al. Volumetric modulated arc therapy and breath-hold in image-guided locoregional left-sided breast irradiation. Radiother Oncol. 2014; 112(1): 17–22.
- Georg D, Knöös T, McClean B. Current status and future perspective of flattening filter free photon beams. Med Phys. 2011; 38(3): 1280–1293.
- Hodapp N. [The ICRU Report 83: prescribing, recording and reporting photon-beam intensity-modulated radiation therapy (IMRT)]. Strahlenther Onkol. 2012; 188(1): 97–99.
- Paddick I, Lippitz B. A simple dose gradient measurement tool to complement the conformity index. J Neurosurg. 2006; 105 Suppl: 194–201.
- Kalef-Ezra J, Karantanas A, Tsekeris P. CT measurement of lung density. Acta Radiol. 1999; 40(3): 333–337.
- Rotstein S, Lax I, Svane G. Influence of radiation therapy on the lung-tissue in breast cancer patients: CT-assessed density changes and associated symptoms. Int J Radiat Oncol Biol Phys . 1990; 18(1): 173–180.
- Fogliata A, Nicolini G, Vanetti E, et al. The impact of photon dose calculation algorithms on expected dose distributions in lungs under different respiratory phases. Phys Med Biol. 2008; 53(9): 2375–2390.
- Oechsner M, Düsberg M, Borm KJ, et al. Deep inspiration breath-hold for left-sided breast irradiation: Analysis of dose-mass histograms and the impact of lung expansion. Radiat Oncol. 2019; 14(1): 109.
- Kim SJ, Lee MiJo, Youn SM. Radiation therapy of synchronous bilateral breast carcinoma (SBBC) using multiple techniques. Med Dosim. 2018; 43(1): 55–68.
- Cho Y, Cho YJ, Chang WS, et al. Evaluation of optimal treatment planning for radiotherapy of synchronous bilateral breast cancer including regional lymph node irradiation. Radiat Oncol. 2019; 14(1): 56.
- Tamilarasu S, Saminathan M, Sharma SK, et al. Treatment Planning With Unflattened as Compared to Flattened Beams for Bilateral Carcinoma of the Breast. Asian Pac J Cancer Prev. 2017; 18(5): 1377–1381.
- Gagliardi G, Constine LS, Moiseenko V, et al. Radiation dose-volume effects in the heart. Int J Radiat Oncol Biol Phys. 2010; 76(3 Suppl): S77–S85.
- Sun T, Lin X, Tong Y, et al. Heart and Cardiac Substructure Dose Sparing in Synchronous Bilateral Breast Radiotherapy: A Dosimetric Study of Proton and Photon Radiation Therapy. Front Oncol. 2019; 9: 1456.
- Haji G, Nabizade U, Kazimov K, et al. Liver dose reduction by deep inspiration breath hold technique in right-sided breast irradiation. Radiat Oncol J. 2019; 37(4): 254–258.
- Rice L, Harris S, Green MML, et al. Deep inspiration breath-hold (DIBH) technique applied in right breast radiotherapy to minimize liver radiation. BJR Case Rep. 2015; 1(2): 20150038.
- Huang JH, Wu XX, Lin X, et al. Evaluation of fixed-jaw IMRT and tangential partial-VMAT radiotherapy plans for synchronous bilateral breast cancer irradiation based on a dosimetric study. J Appl Clin Med Phys. 2019; 20(9): 31–41.
- Shaitelman SF, Grills IS, Liang J, et al. A Comprehensive Dose-volume Analysis of Predictors of Pneumonitis and Esophagitis following Radiotherapy for Non–small Cell Lung Cancer (NSCLC). Int J Radiat Oncol Biol Phys. 2009; 75(3): S468.
- Graham M, Purdy J, Emami B, et al. Clinical dose–volume histogram analysis for pneumonitis after 3D treatment for non-small cell lung cancer (NSCLC). Int J Radiat Oncol Biol Phys . 1999; 45(2): 323–329.
- Grantzau T, Thomsen MS, Væth M, et al. Risk of second primary lung cancer in women after radiotherapy for breast cancer. Radiother Oncol. 2014; 111(3): 366–373.
- Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 2018; 8(3): 145–152.
- Kry SF, Bednarz B, Howell RM, et al. AAPM TG 158: Measurement and calculation of doses outside the treated volume from external-beam radiation therapy. Med Phys. 2017; 44(10): e391–e429.