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Ahmad I, Chufal KS, Miller AA, Bajpai R, Umesh P, Sokhal BS, Bhatia K, Pati S, Gairola M. Identification of variables and development of a prediction model for DIBH eligibility in left-sided breast cancer radiotherapy: a prospective cohort study with temporal validation. Radiat Oncol 2024; 19:115. [PMID: 39210454 PMCID: PMC11363400 DOI: 10.1186/s13014-024-02512-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024] Open
Abstract
OBJECTIVE To identify variables associated with a patients' ability to reproducibly hold their breath for deep-inspiration breath-hold (DIBH) radiotherapy (RT) and to develop a predictive model for DIBH eligibility. METHODS This prospective, single-institution, IRB-approved observational study included women with left-sided breast cancer treated between January 2023 and March 2024. Patients underwent multiple breath-hold sessions over 2-3 consecutive days. DIBH waveform metrics and clinical factors were recorded and analysed. Logistic mixed modelling was used to predict DIBH eligibility, and a temporal validation cohort was used to assess model performance. RESULTS In total, 253 patients were included, with 206 in the model development cohort and 47 in the temporal validation cohort. The final logistic mixed model identified increasing average breath-hold duration (OR, 95% CI: 0.308, 0.104-0.910. p = 0.033) and lower amplitude (OR, 95% CI: 0.737, 0.641-0.848. p < 0.001) as significant predictors of DIBH eligibility. Increasing age was associated with higher odds of being ineligible for DIBH (OR, 95% CI: 1.040, 1.001-1.081. p = 0.044). The model demonstrated good discriminative performance in the validation cohort with an AUC of 80.9% (95% CI: 73.0-88.8). CONCLUSION The identification of variables associated with DIBH eligibility and development of a predictive model has the potential to serve as a decision-support tool. Further external validation is required before its integration into routine clinical practice.
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Affiliation(s)
- Irfan Ahmad
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Sector 5, Rohini, New Delhi, India.
| | - Kundan Singh Chufal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Sector 5, Rohini, New Delhi, India
| | - Alexis Andrew Miller
- Department of Radiation Oncology, Illawarra Cancer Care Centre, Wollongong, NSW, Australia
| | - Ram Bajpai
- School of Medicine, Keele University, Staffordshire, UK
| | - Preetha Umesh
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Sector 5, Rohini, New Delhi, India
| | | | - Kratika Bhatia
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Sector 5, Rohini, New Delhi, India
| | - Shilpa Pati
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Sector 5, Rohini, New Delhi, India
| | - Munish Gairola
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Sector 5, Rohini, New Delhi, India
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Birch S, Otton J. Cardio-oncology and radiation oncology: How collaboration between cardiologists and oncologists can be realised in radiation oncology. J Med Imaging Radiat Oncol 2024. [PMID: 38874328 DOI: 10.1111/1754-9485.13724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/02/2024] [Indexed: 06/15/2024]
Abstract
Increased survivorship, improvements in cancer treatments, and the potential for cardiac side effects from cancer treatments have resulted in increased collaboration between oncologists and cardiologists and the development of cardio-oncology clinics. This collaboration is important given its role in ensuring greater patient satisfaction, aiding teams of clinicians in making complex treatment decision, and ensuring cardiac complications are diagnosed at an early stage. The particularities of implementing this collaboration in the field of radiation oncology and how this setting is different from other areas of cardio-oncology have not been well detailed in the literature. This paper will discuss what is currently understood about the need for and role of cardio-oncology and what a cardio-oncology services involves, with a particular emphasis on patient and clinician needs in the field of radiation oncology. The literature and recent guidelines do advocate for a detailed baseline assessment of cancer patients undergoing radiotherapy, especially patients with treatment or patient risk factors that increase their risk of cancer-therapy related cardiotoxicity. Advancements in cardiac imaging techniques will be discussed as these may help to diagnose cardiac side effects of certain cancer treatments, including radiotherapy, at an early stage. A multi-disciplinary and collaborative approach is well received by patients and such an approach, guided by the aim of maintaining a patient's cancer treatment wherever possible, should be the cornerstone of cardio-oncology clinics regardless of the patient's treatment regime.
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Affiliation(s)
- Samuel Birch
- Cardiology Department, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - James Otton
- Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
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Huijskens S, Granton P, Fremeijer K, van Wanrooij C, Offereins-van Harten K, Schouwenaars-van den Beemd S, Hoogeman MS, Sattler MGA, Penninkhof J. Clinical practicality and patient performance for surface-guided automated VMAT gating for DIBH breast cancer radiotherapy. Radiother Oncol 2024; 195:110229. [PMID: 38492672 DOI: 10.1016/j.radonc.2024.110229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND AND PURPOSE To evaluate the performance of automated surface-guided gating for left-sided breast cancer with DIBH and VMAT. MATERIALS AND METHODS Patients treated in the first year after introduction of DIBH with VMAT were retrospectively considered for analysis. With automated surface-guided gating the beam automatically switches on/off, if the surface region of interest moved in/out the gating tolerance (±3 mm, ±3°). Patients were coached to hold their breath as long as comfortably possible. Depending on the patient's preference, patients received audio instructions during treatment delivery. Real-time positional variations of the breast/chest wall surface with respect to the reference surface were collected, for all three orthogonal directions. The durations and number of DIBHs needed to complete dose delivery, and DIBH position variations were determined. To evaluate an optimal gating window threshold, smaller tolerances of ±2.5 mm, ±2.0 mm, and ±1.5 mm were simulated. RESULTS 525 fractions from 33 patients showed that median DIBH duration was 51 s (range: 30-121 s), and median 4 DIBHs per fraction were needed to complete VMAT dose delivery. Median intra-DIBH stability and intrafractional DIBH reproducibility approximated 1.0 mm in each direction. No large differences were found between patients who preferred to perform the DIBH procedure with (n = 21) and without audio-coaching (n = 12). Simulations demonstrated that gating window tolerances could be reduced from ±3.0 mm to ±2.0 mm, without affecting beam-on status. CONCLUSION Independent of the use of audio-coaching, this study demonstrates that automated surface-guided gating with DIBH and VMAT proved highly efficient. Patients' DIBH performance far exceeded our expectations compared to earlier experiences and literature. Furthermore, gating window tolerances could be reduced.
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Affiliation(s)
- Sophie Huijskens
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands.
| | - Patrick Granton
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Kimm Fremeijer
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Cynthia van Wanrooij
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Kirsten Offereins-van Harten
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | | | - Mischa S Hoogeman
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Margriet G A Sattler
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Joan Penninkhof
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
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Portillo EGD, Hernández-Rodríguez JH, Tenllado-Baena E, Fernández-Lara Á, Alonso-Rodríguez O, Matías-Pérez Á, Cigarral-García C, García-Álvarez G, Pérez-Romasanta LA. Cardiac segments dosimetric benefit from deep inspiration breath hold technique for left-sided breast cancer radiotherapy. Rep Pract Oncol Radiother 2024; 29:21-29. [PMID: 39165592 PMCID: PMC11333077 DOI: 10.5603/rpor.99024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/22/2024] [Indexed: 08/22/2024] Open
Abstract
Background The objective was to compare dosimetry in left-sided breast cancer (LSBC) patients receiving deep inspiration breath hold (DIBH) radiotherapy (RT) with free-breathing (FB) treatment plans. Materials and methods Voluntary DIBH with a spirometer-based video-assisted system and CT-simulation were performed under FB and DIBH conditions on 40 LSBC patients, segmented according Duane's atlas. IMRT plans kept the same dosimetric goals on FB and DIBH conditions. Target, lungs and heart volumes were measured. Planning target volume (PTV) dose distribution, organs at risk (OARs) dose/volume parameters, including cardiac substructures, were calculated. Results Lungs and left-lung volumes increased in DIBH conditions (ΔV = 1637.8 ml ± 555.3 and 783.5 ml ± 286.4, respectively). Heart volume slightly decreased in apnea (p = 0.04), but target volumes, CTV and PTV were similar in FB or DIBH plans. PTV dose coverage was similar irrespective of respiratory conditions (median D50% = 41.1 Gy vs 41.0 Gy, p = 0.665; V95% = 96.9% vs. 97%). Mean dose for the whole heart (MHD), left ventricle (LV), and LV segments were significantly reduced in DIBH plans. V20 values for heart subvolumes were significantly different only for those that received considerable doses (apical and anterior). DIBH plans provided significantly smaller doses (Dmax, D2%, and V20) to the LAD artery. Conclusion Important dosimetric improvements can be achieved with DIBH technique for LSBC patients, reducing the dose to the LAD artery and heart, particularly to the segments closer to the chest wall. Apical/anterior LV segments, should be considered as separate organ at risk in breast RT.
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Affiliation(s)
| | | | | | | | | | - Ángela Matías-Pérez
- Department of Radiation Oncology, Salamanca University Hospital, Salamanca, Spain
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Piao Y, Chen H, Yuan F, Fan J, Wu S, Li X, Yang D. Active Breathing Coordinator reduces radiation dose to the stomach in patients with left breast cancer. Acta Oncol 2023; 62:1873-1879. [PMID: 37909907 DOI: 10.1080/0284186x.2023.2275288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/22/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND/PURPOSE Gastric dose parameters comparison for deep inspiration breath-hold (DIBH) or free breathing (FB) mode during radiotherapy (RT) for left-sided breast cancer patients (LSBCPs) has not been investigated before. This study aimed to analyze the impact of Active Breath Coordinator (ABC)-DIBH technique on the dose received by the stomach during RT for LSBCPs and to provide organ-specific dosimetric parameters. MATERIALS AND METHODS The study included 73 LSBCPs. The dosimetric parameters of the stomach were compared between FB and DIBH mode. The correlation between the stomach volume and dosimetric parameters was analyzed. RESULTS Compared to FB mode, statistically significant reductions were observed in gastric dose parameters in ABC-DIBH mode, including Dmax (46.60 vs 17.25, p < 0.001), D1cc (38.42 vs 9.60, p < 0.001), Dmean (4.10 vs 0.80, p < 0.001), V40Gy (0.50 vs 0.00, p < 0.001), V30Gy (6.30 vs 0.00, p < 0.001), V20Gy (20.80 vs 0.00, p < 0.001), V10Gy (51.10 vs 0.77, p < 0.001), and V5Gy (93.20 vs 9.60, p < 0.001). ABC-DIBH increased the distance between the stomach and the breast PTV when compared to FB, from 1.3 cm to 2.8 cm (p < 0.001). Physiologic decrease in stomach volume was not found from FB to ABC-DIBH (415.54 cm3 vs 411.61 cm3, p = 0.260). The stomach volume showed a positive correlation with V40Gy (r2 = 0.289; p < 0.05), V30Gy (r2 = 0.287; p < 0.05), V20Gy (r2 = 0.343; p < 0.05), V10Gy (r2 = 0.039; p < 0.001), V5Gy (r2 = 0.439; p < 0.001), Dmax (r2 = 0.269; p < 0.05) and D1cc (r2 = 0.278; p < 0.05) in FB mode. While in ABC-DIBH mode, most stomach dosimetric parameters were not correlated with gastric volume. CONCLUSIONS The implementation of ABC-DIBH in LSBCPs radiotherapy resulted in lower irradiation of the stomach. Larger stomach volume was associated with statistically significantly higher dose irradiation in FB mode. To reduce radiotherapy related side effects in FB mode, patients should be fast for at least 2 hours before the CT simulation and treatment.
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Affiliation(s)
- Ying Piao
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Hongtao Chen
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Fengshun Yuan
- Sichuan Provincial Center for Disease Control and Prevention, Center for AIDS/STD Control and Prevention, Chengdu, Sichuan, People's Republic of China
| | - Juan Fan
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Shihai Wu
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Xianming Li
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Dong Yang
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
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Kirli Bolukbas M, Karaca S, Coskun V, Kocak Uzel E. Cardiac protective techniques in left breast radiotherapy: rapid selection criteria for routine clinical decision making. Eur J Med Res 2023; 28:504. [PMID: 37941070 PMCID: PMC10633921 DOI: 10.1186/s40001-023-01470-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVE In left breast radiotherapy (RT) desired heart doses may be achieved without heart-sparing RT techniques in some patients. We aimed to examine the existence of predictive factors and cutoff points to determine which patients are the main candidates for heart-sparing RT techniques. MATERIAL AND METHOD Dosimetric data for left breast cancer was examined. RT plans were made at conventional doses to the breast and peripheral lymph nodes. Statistical analyses were performed using SPSS 22.0 (SPSS Inc., IBM Corp., Armonk, NY). RESULT 114 cases were evaluated by ROC (Receiver operating characteristic) analysis in the breast-conserving surgery (BCS) and mastectomy groups. While only left lung volume (AUC: 0.74, 95% CI 0.61-0.87, p = 0.002) was significant in BCS cases, in cases with mastectomy, left lung volume (AUC: 0.81, 95% CI 0.69-0.94, p = 0.002) and lung/heart volume ratio (AUC: 0.83, 95% CI 0.70-0.96, p = 0.001) had a significant relationship with the relevance of heart doses. The cutoff point of 1.92 was selected for the lung/heart volume ratio for the mastectomized patients. Moreover, the cutoff point 1154 cc and 1208 cc was determined for the left lung volume for the BCS and mastectomized patients, respectively. CONCLUSION Various cutoff points in left breast RT can be used to predict whether RT plans will meet QUANTEC (Quantitative Analysis of Normal Tissue Effects in the Clinic) heart dose limits. Evaluating only these few cutoff points before planning makes it possible to eliminate 70% of patients with BCS and 40% of patients with mastectomy from respiratory-controlled methods, which require time and effort. Patients with lung volume and lung/heart volume ratio smaller than the cutoff values can be considered primary candidates for heart-sparing techniques.
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Affiliation(s)
- Meltem Kirli Bolukbas
- Department of Radiation Oncology, Health Sciences University Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Tevfik Saglam Street, Bakirkoy, 34140, Istanbul, Turkey.
| | - Sibel Karaca
- Department of Radiation Oncology, Akdeniz University, Dumlupinar Boulevard, Pınarbası Konyaalti, Antalya, Turkey
| | - Volkan Coskun
- Department of Radiation Oncology, Health Sciences University Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Tevfik Saglam Street, Bakirkoy, 34140, Istanbul, Turkey
| | - Esengul Kocak Uzel
- Department of Radiation Oncology, Health Sciences University Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Tevfik Saglam Street, Bakirkoy, 34140, Istanbul, Turkey
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Zeverino M, Piccolo C, Wuethrich D, Jeanneret-Sozzi W, Marguet M, Bourhis J, Bochud F, Moeckli R. Clinical implementation of deep learning-based automated left breast simultaneous integrated boost radiotherapy treatment planning. Phys Imaging Radiat Oncol 2023; 28:100492. [PMID: 37780177 PMCID: PMC10534254 DOI: 10.1016/j.phro.2023.100492] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 10/03/2023] Open
Abstract
Background and purpose Automation in radiotherapy treatment planning aims to improve both the quality and the efficiency of the process. The aim of this study was to report on a clinical implementation of a Deep Learning (DL) auto-planning model for left-sided breast cancer. Materials and methods The DL model was developed for left-sided breast simultaneous integrated boost treatments under deep-inspiration breath-hold. Eighty manual dose distributions were revised and used for training. Ten patients were used for model validation. The model was then used to design 17 clinical auto-plans. Manual and auto-plans were scored on a list of clinical goals for both targets and organs-at-risk (OARs). For validation, predicted and mimicked dose (PD and MD, respectively) percent error (PE) was calculated with respect to manual dose. Clinical and validation cohorts were compared in terms of MD only. Results Median values of both PD and MD validation plans fulfilled the evaluation criteria. PE was < 1% for targets for both PD and MD. PD was well aligned to manual dose while MD left lung mean dose was significantly less (median:5.1 Gy vs 6.1 Gy). The left-anterior-descending artery maximum dose was found out of requirements (median values:+5.9 Gy and + 2.9 Gy, for PD and MD respectively) in three validation cases, while it was reduced for clinical cases (median:-1.9 Gy). No other clinically significant differences were observed between clinical and validation cohorts. Conclusion Small OAR differences observed during the model validation were not found clinically relevant. The clinical implementation outcomes confirmed the robustness of the model.
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Affiliation(s)
- Michele Zeverino
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Consiglia Piccolo
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Diana Wuethrich
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Wendy Jeanneret-Sozzi
- Radiation Oncology Department, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Maud Marguet
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean Bourhis
- Radiation Oncology Department, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Francois Bochud
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Raphael Moeckli
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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Sasaki M, Matsushita N, Fujimoto T, Nakata M, Ono Y, Yoshimura M, Mizowaki T. New patient setup procedure using surface-guided imaging to reduce body touch and skin marks in whole-breast irradiation during the COVID-19 pandemic. Radiol Phys Technol 2023; 16:422-429. [PMID: 37474738 DOI: 10.1007/s12194-023-00735-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/14/2023] [Accepted: 07/15/2023] [Indexed: 07/22/2023]
Abstract
This study aimed to assess the effectiveness of a new patient-setup procedure using surface-guided imaging during the coronavirus disease 2019 (COVID-19) pandemic for left-sided whole-breast irradiation with deep inspiration breath-hold. Two setup procedures were compared regarding patient positioning accuracy for the first 22 patients. The first was a traditional setup (T-setup) procedure that used a surface-guided system after patient setup with traditional skin marks and lasers. The second procedure involved a new setup (N-setup) that used only a surface-guided system. The positioning accuracy of the remaining 23 patients was assessed using a setup that combined marker reduction and the N-setup procedure. No significant difference was observed in positioning accuracy between the two setups. The positioning accuracy of the marker-reduction setup was within 3 mm in all directions. The N-setup procedure may be a useful strategy for preventing infection during or after the COVID-19 pandemic.
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Affiliation(s)
- Makoto Sasaki
- Division of Clinical Radiology Service, Kyoto University Hospital, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, Kyoto, 606-8507, Japan.
| | - Norimasa Matsushita
- Division of Clinical Radiology Service, Kyoto University Hospital, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, Kyoto, 606-8507, Japan
| | - Takahiro Fujimoto
- Division of Clinical Radiology Service, Kyoto University Hospital, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, Kyoto, 606-8507, Japan
| | - Manabu Nakata
- Division of Clinical Radiology Service, Kyoto University Hospital, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, Kyoto, 606-8507, Japan
| | - Yuka Ono
- Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Michio Yoshimura
- Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Mizowaki
- Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Trampetti I, Cuenin M, Gérard K, Salleron J, Peiffert D, Charra-Brunaud C. Can we predict the cardiac benefit of deep inspiration breath hold for left breast and regional nodal irradiation? Cancer Radiother 2023; 27:407-412. [PMID: 37541798 DOI: 10.1016/j.canrad.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 06/13/2023] [Indexed: 08/06/2023]
Abstract
PURPOSE Deep inspiration breath hold (DIBH) is used to decrease the dose of radiotherapy delivered to the heart. There is a need to define criteria to select patients with the potential to derive a real clinical benefit from DIBH treatment. Our study's main goal was to investigate whether two CT-scan cardiac anatomical parameters, cardiac contact distance in the parasagittal plane (CCDps) and lateral heart-to-chest distance (HCD), were predictive of unmet dosimetric cardiac constraints for left breast and regional nodal irradiation (RNI). MATERIALS AND METHODS This retrospective single-institution dosimetric study included 62 planning CT scans of women with left-sided breast cancer (BC) from 2016 to 2021. Two independent radiation oncologists measured HCD and CCDps twice to assess inter- and intra-observer reproducibility. Dosimetric constraints to be respected were defined, and dosimetric parameters of interest were collected for each patient. RESULTS Mean heart dose was 7.9Gy. Inter-rater reproducibility between the two readers was considered excellent. The mean heart dose constraint<8Gy was not achieved in 25 patients (40%) and was achieved in 37 patients (60%). There was a significant correlation between mean heart dose and HCD (rs=-0.25, P=0.050) and between mean heart dose and CCDps (rs=0.25, P=0.047). The correlation between HCD and CCDps and unmet cardiac dosimetric constraints was not statistically significant. CONCLUSION Our dosimetric analysis did not find that the cardiac anatomical parameters HCD and CCDps were predictive of unmet dosimetric cardiac constraints, nor that they were good predictors for cardiac exposure in left-sided BC radiotherapy comprising RNI.
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Affiliation(s)
- I Trampetti
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France; Faculté de médecine de Nancy, université de Lorraine, 9, avenue de la Forêt de Haye, 54505 Vandoeuvre-lès-Nancy, France.
| | - M Cuenin
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
| | - K Gérard
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
| | - J Salleron
- Unité de biostatistiques, institut de cancérologie de Lorraine, 54519 Vandoeuvre-lès-Nancy, France
| | - D Peiffert
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
| | - C Charra-Brunaud
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
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10
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Lu Y, Ma Y, Yang D, Li Y, Yuan W, Tang F, Xu L, Zhou L, Lin H, Li B, Chen R, He C, Zhao D. Cardiorespiratory dose comparison among six radiotherapy regimens for patients with left-sided breast cancer. Sci Rep 2023; 13:13339. [PMID: 37587214 PMCID: PMC10432504 DOI: 10.1038/s41598-023-40577-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 08/13/2023] [Indexed: 08/18/2023] Open
Abstract
There is uncertainty regarding the benefits and drawbacks of various radiation protocols for the treatment of left-sided breast cancer. To address this issue, we conducted a Bayesian network analysis. First, we searched several electronic databases for eligible literature. Next, we pooled the data from twelve studies concerning three-dimensional conformal radiation therapy (3D-CRT), intensity modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT), combined with either deep inspiratory breath-holding (DIBH) or free-breathing (FB) modalities. The integrated cardiac and pulmonary dosimetric indexes for all included treatments were compared using Bayesian networks. A direct meta-analysis indicated that for the two methods of 3D-CRT and IMRT, DIBH technology was more effective than FB in reducing the radiation dose to the heart and lungs. Additionally, according to the network results, DIBH was superior to FB in all six treatment options, regardless of whether the plan was 3D-CRT, IMRT, or VMAT. Besides, the combined data indicated that the FB-3D-CRT regimen had the weakest dosimetric advantage of all the treatments. Excluding FB-3D-CRT, each of the other five treatments had its own specific benefits. This is the first Bayesian study of several radiotherapy regimens for breast cancer patients on the left side, and the findings can be used to select appropriate radiotherapy programs for breast cancer patients.
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Affiliation(s)
- Yongkai Lu
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No.277, Yanta West Road, Xi'an, 710061, Shaanxi, China.
| | - Yanfang Ma
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No.277, Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Di Yang
- Department of Radiation Oncology, Shaanxi Provincial Tumor Hospital, Affiliated Hospital of Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yi Li
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No.277, Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Wei Yuan
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No.277, Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Fengwen Tang
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No.277, Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Lei Xu
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No.277, Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Luping Zhou
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No.277, Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Hao Lin
- Department of Thoracic Surgery, Xi'an Central Hospital, Xi'an, China
| | - Binglin Li
- Department of Thoracic Surgery, Xi'an Central Hospital, Xi'an, China
| | - Ruijuan Chen
- Department of Thoracic Surgery, Xi'an Central Hospital, Xi'an, China.
| | - Chenchen He
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No.277, Yanta West Road, Xi'an, 710061, Shaanxi, China.
| | - Dongli Zhao
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No.277, Yanta West Road, Xi'an, 710061, Shaanxi, China.
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Salim N, Popodko A, Tumanova K, Stolbovoy A, Lagkueva I, Ragimov V. Cardiac dose in the treatment of synchronous bilateral breast cancer patients between three different radiotherapy techniques (VMAT, IMRT, and 3D CRT). Discov Oncol 2023; 14:29. [PMID: 36862205 PMCID: PMC9981832 DOI: 10.1007/s12672-023-00636-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
PURPOSE Synchronous bilateral irradiation of both mammary glands and chest wall is a challenging task due to technical difficulties and limited evidence supporting an optimal technique to improve treatment outcomes. We studied and compared the dosimetry data of three radiotherapy techniques to select the most optimal one. METHODS We compared three-dimensional conformal radiation treatment (3D CRT), intensity-modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT) during irradiation of synchronous bilateral breast cancer in nine patients followed by examination of dose distribution to the cardiac conduction system (SA node, AV node and Bundle of His), myocardium, lungs, left anterior descending artery (LADA) and right coronary artery (RCA) . RESULTS VMAT is the most sparing technique for SBBC treatment. Even though doses to the SA node, AV node and Bundle of His were higher with VMAT (Dmean were 3.75 ± 0.62, 2.58 ± 0.83 and 3.03 ± 1.18 Gy respectively) compared with 3D CRT (Dmean were 2.61 ± 0.66, 1.52 ± 0.38 and 1.88 ± 0.70 Gy respectively), this difference is statistically insignificant. Doses to the right and left lung (average Dmean = 12.65 ± 3.20 Gy, V20Gy = 24.12 ± 6.25%), myocardium (Dmean = 5.33 ± 1.51 Gy, V10Gy = 9.80 ± 3.83%, V20Gy = 7.19 ± 3.15%, V25Gy = 6.20 ± 2.93%), and LADA (Dmean = 10.04 ± 4.92 Gy, V20Gy = 18.17 ± 13.24% and V25Gy = 15.41 ± 12.19%) were highest with 3D CRT. The highest Dmean in the cardiac conduction system (5.30 ± 2.23, 3.15 ± 1.61 and 3.89 ± 1.85 Gy respectively) was observed with IMRT, and a similar effect was noted in RCA (Dmean = 7.48 ± 2.11 Gy). CONCLUSION VMAT is the optimal and satisfactory radiation therapy technique for sparing organs at risk (OARs). With VMAT, a lower Dmean value was noted in the myocardium, LADA, and lungs. The use of 3D CRT significantly increases the dose of radiation reaching the lungs, myocardium, and LADA, which can subsequently cause cardiovascular and lung complications, but not in the cardiac conduction system.
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Affiliation(s)
- Nidal Salim
- Department of Radiation Oncology, European Medical Center, Moscow, Russia
- Department of Radiation Oncology, Russian Medical Academy of Continuous Medical Education of the Ministry of Health, Moscow, Russia
| | - Alexey Popodko
- Department of Radiation Oncology, European Medical Center, Moscow, Russia
| | - Kristina Tumanova
- Department of Radiation Oncology, European Medical Center, Moscow, Russia.
| | - Alexandr Stolbovoy
- Department of Radiation Oncology, European Medical Center, Moscow, Russia
- Department of Radiation Oncology, Russian Medical Academy of Continuous Medical Education of the Ministry of Health, Moscow, Russia
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12
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Abdollahi S, Hadizadeh Yazdi MH, Mowlavi AA, Ceberg S, Aznar MC, Tabrizi FV, Salek R, Ghodsi A, Shams A. A dose planning study for cardiac and lung dose sparing techniques in left breast cancer radiotherapy: Can free breathing helical tomotherapy be considered as an alternative for deep inspiration breath hold? Tech Innov Patient Support Radiat Oncol 2023; 25:100201. [PMID: 36798947 PMCID: PMC9926227 DOI: 10.1016/j.tipsro.2023.100201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/29/2022] [Accepted: 01/17/2023] [Indexed: 01/27/2023] Open
Abstract
Purpose To investigate the possibility to be able to offer left sided breast cancer patients, not suitable for DIBH, an organ at risk saving treatment. Materials and Methods Twenty patients receiving radiotherapy for left breast cancer in DIBH were enrolled in the study. Planning CT scans were acquired in the same supine treatment position in FB and DIBH. 3DCRT_DIBH plans were designed and optimized using two parallel opposed tangent beams (with some additional segments) for the breast and chest wall and anterior-posterior fields for regional lymph nodes irradiation. Additionally, FB helical tomotherapy plans were optimized to minimize heart and lung dose. All forty plans were optimized with at least 95% of the total CTV covered by the 95% of prescribed dose of 50 Gy in 25 fractions. Results HT_FB plans showed significantly better dose homogeneity and conformity compared to the 3DCRT_DIBH specially for regional nodal irradiation. The heart mean dose was almost comparable in 3DCRT_DIBH and HT_FB while the volume (%) of the heart receiving 25 Gy had a statistically significant reduction from 7.90 ± 3.33 in 3DCRT_DIBH to 0.88 ± 0.66 in HT_FB. HT_FB was also more effective in left descending artery (LAD) mean dose reduction about 100% from 30.83 ± 9.2 Gy to 9.7 ± 3.1. The ipsilateral lung volume receiving 20 Gy has a further reduction of 43 % in HT_FB compared with 3DCRT_DIBH. For low dose comparison, 3DCRT_DIBH was superior for contralateral organ sparing compared to the HT_FB due to the limited angle for dose delivery. Conclusion For patients who cannot be a candidate for DIBH for any reason, HT in free breathing may be a good alternative and provides heart and ipsilateral lung dose sparing, however with the cost of increased dose to contralateral breast and lung.
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Affiliation(s)
- Sara Abdollahi
- Physics Department, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran,Medical Physics Department, Reza Radiotherapy and Oncology Center, Mashhad, Iran
| | | | - Ali Asghar Mowlavi
- Physics Department, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran,Corresponding author at: Physics Department, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Sofie Ceberg
- Medical Radiation Physics, Lund University, Lund, Sweden
| | - Marianne Camille Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | | | - Roham Salek
- Radiotherapy and Oncology Department, Reza Radiotherapy and Oncology Center, Mashhad, Iran,Radiotherapy and Oncology Department, Mashhad University of Medical Science, Mashhad, Iran
| | - Alireza Ghodsi
- Department of Statistics, Hakim Sabzevari University, Sabzevar, Iran
| | - Ali Shams
- Medical Physics Department, Seyed-al-Shohada Hospital, Isfahan, Iran
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13
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Oshima M, Shikama N, Usui K, Nojiri S, Isobe A, Muramoto Y, Kawamoto T, Yamaguchi N, Kosugi Y, Sasai K. Development of deep-inspiration breath-hold system that monitors the position of the chest wall using infrared rangefinder. JOURNAL OF RADIATION RESEARCH 2023; 64:171-179. [PMID: 36527722 PMCID: PMC9855317 DOI: 10.1093/jrr/rrac083] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/17/2022] [Indexed: 06/17/2023]
Abstract
We conducted a prospective study to quantitatively evaluate the movement of the chest wall to establish the simple and reproducible deep-inspiration breath-hold (DIBH) method. The left nipple position was monitored to confirm the inspiratory state. Planning computed tomography (CT) was performed under DIBH and free-breath. We conducted radiation plans with DIBH and free-breath CT and evaluated organ at risk (OAR) and target doses according to two different plans. The relationship between positioning errors of the chest wall and patient factors was evaluated using univariate analysis and fixed-effects models. Twenty-three patients aged ≤ 60 years were enrolled during January-August 2021; 358 daily radiation treatments were evaluated. The median time of treatment room occupancy was 16 minutes (interquartile range, 14-20). The area of the planning target volume (PTV) surrounded by the 95% isodose line was more extensive in DIBH than in free breathing (71.6% vs 69.5%, P < 0.01), whereas the cardiac and left anterior descending (LAD) artery doses were lower (both P < 0.01). In the fixed-effects model analysis, the occupation time of the treatment room was correlated with positioning error. The difference between the planned and irradiated dose was the largest in the LAD branch of the coronary artery (-2.5 Gy), although the OAR dose decreased owing to positional error. The current DIBH method, wherein a single point on the chest wall is monitored to confirm that the patient is in an inspiratory state, allows radiation to be performed in a short time with a small dose error.
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Affiliation(s)
- Masaki Oshima
- Corresponding author. 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan. Tel: +81-3-3813-3111; Fax: +81-3-3813-3622; E-mail:
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Keisuke Usui
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
- Department of Radiological Technology, Juntendo University, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Shuko Nojiri
- Medical Technology Innovation Center, Juntendo University, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Akira Isobe
- Department of Radiology, Juntendo University Hospital, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Yoichi Muramoto
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Terufumi Kawamoto
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Nanae Yamaguchi
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Yasuo Kosugi
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, 21-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
- Misugikai Satou Hospital, Department of Radiation Oncology, 65-1 Yabuhigashimachi, Hirakata-shi, Osaka 573-1124, Japan
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Abdollahi S, Yazdi MHH, Mowlavi AA, Ceberg S, Aznar MC, Tabrizi FV, Salek R, Ghodsi A, Jamali F. Surface guided 3DCRT in deep-inspiration breath-hold for left sided breast cancer radiotherapy: implementation and first clinical experience in Iran. Rep Pract Oncol Radiother 2022; 27:881-896. [PMID: 36523810 PMCID: PMC9746649 DOI: 10.5603/rpor.a2022.0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/16/2022] [Indexed: 12/12/2022] Open
Abstract
Background The aim of the study is to evaluate the overall accuracy of the surface-guided radiotherapy (SGRT) workflow through a comprehensive commissioning and quality assurance procedures and assess the potential benefits of deep-inspiration breath-hold (DIBH) radiotherapy as a cardiac and lung dose reduction approach for left-sided breast cancer irradiation. Materials and methods Accuracy and reproducibility of the optical surface scanner used for DIBH treatment were evaluated using different phantoms. Patient positioning accuracy and reproducibility of DIBH treatment were evaluated. Twenty patients were studied for treatment plan quality in target dose coverage and healthy organ sparing for the two different treatment techniques. Results Reproducibility tests for the surface scanner showed good stability within 1 mm in all directions. The maximum position variation between applied shifts on the couch and the scanner measured offsets is 1 mm in all directions. The clinical study of 200 fractions showed good agreement between the surface scanner and portal imaging with the isocenter position deviation of less than 3 mm in each lateral, longitudinal, and vertical direction. The standard deviation of the DIBH level showed a value of < 2 mm during all evaluated DIBHs. Compared to the free breathing (FB) technique, DIBH showed significant reduction of 48% for heart mean dose, 43% for heart V25, and 20% for ipsilateral lung V20. Conclusion Surface-guided radiotherapy can be regarded as an accurate tool for patient positioning and monitoring in breast radiotherapy. DIBH treatment are considered to be effective techniques in heart and ipsilateral lung dose reductions for left breast radiotherapy.
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Affiliation(s)
- Sara Abdollahi
- Physics Department, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran
- Medical Physics Department, Reza Radiotherapy and Oncology Center, Mashhad, Iran
| | | | - Ali Asghar Mowlavi
- Physics Department, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Sofie Ceberg
- Department of Medical Radiation Physics, Lund University, Lund, Sweden
| | - Marianne Camille Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | | | - Roham Salek
- Radiotherapy and Oncology Department, Reza Radiotherapy and Oncology Center, Mashhad, Iran
- Radiotherapy and Oncology Department, Mashhad University of Medical Science, Mashhad, Iran
| | - Alireza Ghodsi
- Department of Statistics, Hakim Sabzevari University, Sabzevar, Iran
| | - Farideh Jamali
- Medical Physics Department, Reza Radiotherapy and Oncology Center, Mashhad, Iran
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15
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Badescu MC, Badulescu OV, Scripcariu DV, Butnariu LI, Bararu-Bojan I, Popescu D, Ciocoiu M, Gorduza EV, Costache II, Rezus E, Rezus C. Myocardial Ischemia Related to Common Cancer Therapy-Prevention Insights. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071034. [PMID: 35888122 PMCID: PMC9325217 DOI: 10.3390/life12071034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/08/2022] [Accepted: 07/10/2022] [Indexed: 12/18/2022]
Abstract
Modern antineoplastic therapy improves survival and quality of life in cancer patients, but its indisputable benefits are accompanied by multiple and major side effects, such as cardiovascular ones. Endothelial dysfunction, arterial spasm, intravascular thrombosis, and accelerated atherosclerosis affect the coronary arteries, leading to acute and chronic coronary syndromes that negatively interfere with the oncologic treatment. The cardiac toxicity of antineoplastic agents may be mitigated by using adequate prophylactic measures. In the absence of dedicated guidelines, our work provides the most comprehensive, systematized, structured, and up-to-date analyses of the available literature focusing on measures aiming to protect the coronary arteries from the toxicity of cancer therapy. Our work facilitates the implementation of these measures in daily practice. The ultimate goal is to offer clinicians the necessary data for a personalized therapeutic approach for cancer patients receiving evidence-based oncology treatments with potential cardiovascular toxicity.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (I.I.C.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (I.B.-B.); (M.C.)
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
- Correspondence: (O.V.B.); (D.V.S.); (L.I.B.)
| | - Dragos Viorel Scripcariu
- Surgery Department, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- 1st Surgical Oncology Unit, Regional Institute of Oncology, 2-4 General Henri Mathias Berthelot Street, 700483 Iasi, Romania
- Correspondence: (O.V.B.); (D.V.S.); (L.I.B.)
| | - Lăcrămioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
- Correspondence: (O.V.B.); (D.V.S.); (L.I.B.)
| | - Iris Bararu-Bojan
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (I.B.-B.); (M.C.)
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (I.I.C.); (C.R.)
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (I.B.-B.); (M.C.)
| | - Eusebiu Vlad Gorduza
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Irina Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (I.I.C.); (C.R.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (I.I.C.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
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Upshaw JN, Mohanty S, Rastogi A. Cardioprotection of High-Risk Individuals. Heart Fail Clin 2022; 18:385-402. [PMID: 35718414 PMCID: PMC10984350 DOI: 10.1016/j.hfc.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Targeting cardioprotective strategies to patients at the highest risk for cardiac events can help maximize therapeutic benefits. Dexrazoxane, liposomal formulations, continuous infusions, and neurohormonal antagonists may be useful for cardioprotection for anthracycline-treated patients at the highest risk for heart failure. Prevalent cardiovascular disease is a risk factor for cardiac events with many cancer therapies, including anthracyclines, anti-human-epidermal growth factor receptor-2 therapy, radiation, and BCR-Abl tyrosine kinase inhibitors, and may be a risk factor for cardiac events with other therapies. Although evidence for cardioprotective strategies is sparse for nonanthracycline therapies, optimizing cardiac risk factors and prevalent cardiovascular disease may improve outcomes.
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Affiliation(s)
- Jenica N Upshaw
- Division of Cardiology, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA.
| | - Sharanya Mohanty
- Division of Cardiology, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Akash Rastogi
- Division of Cardiology, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
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Chen CP, Lin CY, Kuo CC, Chen TH, Lin SC, Tseng KH, Cheng HW, Chao HL, Yen SH, Lin RY, Feng CJ, Lu LS, Chiou JF, Hsu SM. Skin Surface Dose for Whole Breast Radiotherapy Using Personalized Breast Holder: Comparison with Various Radiotherapy Techniques and Clinical Experiences. Cancers (Basel) 2022; 14:cancers14133205. [PMID: 35804977 PMCID: PMC9264904 DOI: 10.3390/cancers14133205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023] Open
Abstract
Purpose: Breast immobilization with personalized breast holder (PERSBRA) is a promising approach for normal organ protection during whole breast radiotherapy. The aim of this study is to evaluate the skin surface dose for breast radiotherapy with PERSBRA using different radiotherapy techniques. Materials and methods: We designed PERSBRA with three different mesh sizes (large, fine and solid) and applied them on an anthropomorphic(Rando) phantom. Treatment planning was generated using hybrid, intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) techniques to deliver a prescribed dose of 5000 cGy in 25 fractions accordingly. Dose measurement with EBT3 film and TLD were taken on Rando phantom without PERSBRA, large mesh, fine mesh and solid PERSBRA for (a) tumor doses, (b) surface doses for medial field and lateral field irradiation undergoing hybrid, IMRT, VMAT techniques. Results: The tumor dose deviation was less than five percent between the measured doses of the EBT3 film and the TLD among the different techniques. The application of a PERSBRA was associated with a higher dose of the skin surface. A large mesh size of PERSBRA was associated with a lower surface dose. The findings were consistent among hybrid, IMRT, or VMAT techniques. Conclusions: Breast immobilization with PERSBRA can reduce heart toxicity but leads to a build-up of skin surface doses, which can be improved with a larger mesh design for common radiotherapy techniques.
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Affiliation(s)
- Chiu-Ping Chen
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; (C.-P.C.); (C.-Y.L.); (C.-C.K.); (H.-L.C.); (S.-H.Y.)
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (R.-Y.L.); (C.-J.F.)
| | - Chi-Yeh Lin
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; (C.-P.C.); (C.-Y.L.); (C.-C.K.); (H.-L.C.); (S.-H.Y.)
| | - Chia-Chun Kuo
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; (C.-P.C.); (C.-Y.L.); (C.-C.K.); (H.-L.C.); (S.-H.Y.)
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei Medical University, Taipei 110, Taiwan; (T.-H.C.); (L.-S.L.)
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei 110, Taiwan
- Ph.D. Program for Cancer Molecular Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University and Academia Sinica, Taipei 110, Taiwan
| | - Tung-Ho Chen
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei Medical University, Taipei 110, Taiwan; (T.-H.C.); (L.-S.L.)
| | - Shao-Chen Lin
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan;
| | - Kuo-Hsiung Tseng
- Department of Electrical Engineering, National Taipei University of Technology, Taipei 10608, Taiwan;
| | - Hao-Wen Cheng
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, Taipei 11031, Taiwan;
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
| | - Hsing-Lung Chao
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; (C.-P.C.); (C.-Y.L.); (C.-C.K.); (H.-L.C.); (S.-H.Y.)
- Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Sang-Hue Yen
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; (C.-P.C.); (C.-Y.L.); (C.-C.K.); (H.-L.C.); (S.-H.Y.)
| | - Ruo-Yu Lin
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (R.-Y.L.); (C.-J.F.)
| | - Chen-Ju Feng
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (R.-Y.L.); (C.-J.F.)
| | - Long-Sheng Lu
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei Medical University, Taipei 110, Taiwan; (T.-H.C.); (L.-S.L.)
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan;
- TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei 110, Taiwan
- International Ph.D. Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan
- International Ph.D. Program for Cell Therapy and Regenerative Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Jeng-Fong Chiou
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei Medical University, Taipei 110, Taiwan; (T.-H.C.); (L.-S.L.)
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Correspondence: (J.-F.C.); (S.-M.H.)
| | - Shih-Ming Hsu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (R.-Y.L.); (C.-J.F.)
- Correspondence: (J.-F.C.); (S.-M.H.)
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TROG 14.04: Multicentre Study of Feasibility and Impact on Anxiety of DIBH in Breast Cancer Patients. Clin Oncol (R Coll Radiol) 2022; 34:e410-e419. [PMID: 35717318 DOI: 10.1016/j.clon.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/13/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022]
Abstract
AIMS The aim of TROG 14.04 was to assess the feasibility of deep inspiration breath hold (DIBH) and its impact on radiation dose to the heart in patients with left-sided breast cancer undergoing radiotherapy. Secondary end points pertained to patient anxiety and cost of delivering a DIBH programme. MATERIALS AND METHODS The study comprised two groups - left-sided breast cancer patients engaging DIBH and right-sided breast cancer patients using free breathing through radiotherapy. The primary end point was the feasibility of DIBH, defined as left-sided breast cancer patients' ability to breath hold for 15 s, decrease in heart dose in DIBH compared with the free breathing treatment plan and reproducibility of radiotherapy delivery using mid-lung distance (MLD) assessed on electronic portal imaging as the surrogate. The time required for treatment delivery, patient-reported outcomes and resource requirement were compared between the groups. RESULTS Between February and November 2018, 32 left-sided and 30 right-sided breast cancer patients from six radiotherapy centres were enrolled. Two left-sided breast cancer patients did not undergo DIBH (one treated in free breathing as per investigator choice, one withdrawn). The mean heart dose was reduced from 2.8 Gy (free breathing) to 1.5 Gy (DIBH). Set-up reproducibility in the first week of treatment assessed by MLD was 1.88 ± 1.04 mm (average ± 1 standard deviation) for DIBH and 1.59 ± 0.93 mm for free breathing patients. Using a reproducibility cut-off for MLD of 2 mm (1 standard deviation) as per study protocol, DIBH was feasible for 67% of DIBH patients. Radiotherapy delivery using DIBH took about 2 min longer than for free breathing. Anxiety was not significantly different in DIBH patients and decreased over the course of treatment in both groups. CONCLUSION Although DIBH was shown to require about 2 min longer per treatment slot, it has the potential to reduce heart dose in left-sided breast cancer patients by nearly a half, provided careful assessment of breath hold reproducibility is carried out.
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Ng AC, Dong X, Sharma H, Barnard A, Brown E, Beaton NR, Browne P, Hargrave C, Watson S, Harvey J, Mai T, Lehman M. Deep Inspiration Breath Hold and Global Longitudinal Strain in Women Undergoing Left-Sided Breast Irradiation. JACC CardioOncol 2022; 4:136-138. [PMID: 35492827 PMCID: PMC9040094 DOI: 10.1016/j.jaccao.2022.01.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Omland T, Heck SL, Gulati G. The Role of Cardioprotection in Cancer Therapy Cardiotoxicity: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:19-37. [PMID: 35492815 PMCID: PMC9040117 DOI: 10.1016/j.jaccao.2022.01.101] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 12/11/2022] Open
Abstract
Cardiotoxicity is a relatively frequent and potentially serious side effect of traditional and targeted cancer therapies. Both general measures and specific pharmacologic cardioprotective interventions as well as imaging- and biomarker-based surveillance strategies to identify patients at high risk have been tested in randomized controlled trials to prevent or attenuate cancer therapy-related cardiotoxic effects. Although meta-analyses including early trials suggest an overall beneficial effect, there is substantial heterogeneity in results. Recent randomized controlled trials of neurohormonal inhibitors in patients receiving anthracyclines and/or human epidermal growth factor receptor 2-targeted therapies have shown a lower rate of cancer therapy-related cardiac dysfunction than previously reported and a modest or no sustained effect of the interventions. Data on preventive cardioprotective strategies for novel cancer drugs are lacking. Larger, prospective multicenter randomized clinical trials testing traditional and novel interventions are required to more accurately define the benefit of different cardioprotective strategies and to refine risk prediction and identify patients who are likely to benefit.
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Key Words
- ACE, angiotensin-converting enzyme
- ADT, androgen deprivation therapy
- ARB, angiotensin receptor blocker
- CMR, cardiovascular magnetic resonance
- CTRCD, cancer therapy–related cardiac dysfunction
- GLS, global longitudinal strain
- GnRH, gonadotropin-releasing hormone
- HER2 therapy
- HER2, human epidermal growth factor receptor 2
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- MRA, mineralocorticoid receptor antagonist
- RR, risk ratio
- anthracycline
- cardiomyopathy
- prevention
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Affiliation(s)
- Torbjørn Omland
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Siri Lagethon Heck
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Geeta Gulati
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
- Department of Cardiology, Division of Medicine, Oslo University Hospital, Ullevål, Oslo, Norway
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Evaluation of image-guided and surface-guided radiotherapy for breast cancer patients treated in deep inspiration breath-hold: A single institution experience. Tech Innov Patient Support Radiat Oncol 2022; 21:51-57. [PMID: 35243045 PMCID: PMC8861395 DOI: 10.1016/j.tipsro.2022.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Nowadays, deep inspiratory breath-hold is a common technique to reduce heart dose in left-sided breast radiotherapy. This study evaluates the evolution of the breath-hold technique in our institute, from portal imaging during dose delivery to continuous monitoring with surface-guided radiotherapy (SGRT). MATERIALS AND METHODS Setup data and portal imaging results were analyzed for 98 patients treated before 2014, and SGRT data for 228 patients treated between 2018 and 2020. For the pre-SGRT group, systematic and random setup errors were calculated for different correction protocols. Residual errors and reproducibility of breath-holds were evaluated for both groups. The benefit of using SGRT for initial positioning was evaluated for another cohort of 47 patients. RESULTS Online correction reduced the population mean error from 3.9 mm (no corrections) to 1.4 mm. Despite online setup correction, deviations greater than 3 mm were observed in about 10% and 20% of the treatment beams in ventral-dorsal and cranial-caudal directions, respectively. However, these percentages were much smaller than with offline protocols or no corrections. Mean absolute differences between breath-holds within a fraction were smaller in the SGRT-group (1.69 mm) than in the pre-SGRT-group (2.10 mm), and further improved with addition of visual feedback (1.30 mm). SGRT for positioning did not improve setup accuracy, but slightly reduced the time for imaging and setup correction, allowing completion within 3.5 min for 95% of fractions. CONCLUSION For accurate radiotherapy breast treatments using deep inspiration breath-hold, daily imaging and correction is required. SGRT provides accurate information on patient positioning during treatment and improves patient compliance with visual feedback.
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Key Words
- (U, V), ventral-dorsal and cranial-caudal direction in the tangential beam, respectively
- Breast
- Breath-hold
- CBCT, cone-beam CT
- CT, computer tomography
- DIBH
- DIBH, Deep inspiratory breath-hold
- DRRs, digitally reconstructed radiographs
- LAT, medio-lateral direction
- LNG, cranial-caudal direction
- NAL, no-action-level setup correction protocol
- OTM, online treatment monitor
- SGRT, surface-guided radiotherapy
- Surface-guided radiotherapy
- VRT, anterior-posterior direction
- eNAL, extended NAL setup correction protocol
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Yang D, Piao Y, Yuan F, Chen H, Zhang D, Li X. Gastric side effects and the stomach dosimetric analysis in left-sided breast cancer radiotherapy in free-breathing and deep inspiration breath-hold technique. Radiat Oncol 2022; 17:2. [PMID: 34980180 PMCID: PMC8722150 DOI: 10.1186/s13014-021-01963-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/03/2021] [Indexed: 12/25/2022] Open
Abstract
Background Adjuvant radiotherapy following surgery reduces the local recurrence and improves the prognosis. However, a considerable part of patients developed digestive reaction in daily treatment. In order to explore the correlation between breast radiotherapy and gastric toxicity, we investigated the clinic symptoms and stomach dose during DIBH or FB mode while left-sided breast cancer patients (LSBCP) receiving radiotherapy. Methods In the study, 124 LSBCP received adjuvant radiotherapy after surgery at our department were analyzed clinical characteristics and enquired about gastrointestinal side effects after treatment. Moreover, dosimetric parameters were assessed. Results There was no statistically significant difference between the two groups in age, T staging, N staging, hormone receptors, human epidermal receptor-2 (HER2), surgical methods, fractionated regimen, and chemotherapy conditions. However, larger stomach volumes and higher fractionated dose (Dmax/F) were associated with a statistically significantly greater risk for acute radiotherapy toxicity. In addition, the use of the DIBH gating technique (FB/DIBH) reduced the incidence of digestive reactions. Conclusion In order to cut down gastric side effects after breast radiotherapy, large meals should be avoided before treatment. DIBH treatment should be implemented in centers where conditions are satisfied to reduce radiotherapy side effects. Furthermore, dose limitation in stomach should be considered when the radiotherapy plan was formulated, especially for the patients treated with hypofractionated radiotherapy.
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Affiliation(s)
- Dong Yang
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Dongmenbei Road 1017, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Ying Piao
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Dongmenbei Road 1017, Shenzhen, 518000, Guangdong, People's Republic of China.
| | - Fengshun Yuan
- Center for AIDS/STD Control and Prevention, Sichuan Center for Disease Control and Prevention, Zhongxue Road 6, Chengdu, 610051, Sichuan, People's Republic of China
| | - Hongtao Chen
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Dongmenbei Road 1017, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Ding Zhang
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Dongmenbei Road 1017, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Xianming Li
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Dongmenbei Road 1017, Shenzhen, 518000, Guangdong, People's Republic of China.
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Tang L, Ishikawa Y, Ito K, Yamamoto T, Umezawa R, Jingu K. Evaluation of DIBH and VMAT in Hypofractionated Radiotherapy for Left-Sided Breast Cancers After Breast-Conserving Surgery: A Planning Study. Technol Cancer Res Treat 2021; 20:15330338211048706. [PMID: 34657495 PMCID: PMC8521420 DOI: 10.1177/15330338211048706] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Dosimetric parameters of the planning target volume (PTV) and organs at risk (OARs) were compared among 3 different radiotherapy (RT) modalities in left breast cancer patients after breast-conserving surgery (BCS). Methods: Eleven patients with left breast cancer after BCS were enrolled and underwent CT simulation in the free breathing (FB) and deep inspiration breath-hold (DIBH) position. Three-dimensional conformal RT (3DCRT) and volumetric modulated arc therapy (VMAT) plans were generated for each patient in the DIBH positions. A 3DCRT plan was also created in the FB position. A dose-volume histogram (DVH) was used to analyze each evaluation index of PTV and OARs. The principal outcomes were PTV dose, heart dose, right breast dose, left anterior descending coronary artery (LADCA) dose, and left lung dose. Results: For 3DCRT plans, significant dose reductions were demonstrated in all evaluation parameters of the heart, LADCA, and left lung doses in the DIBH position compared with those in the FB position (P < 0.05). In the DIBH position, significant dose reductions were found in the heart and LADCA in VMAT plans compared to those in 3DCRT plans (P < 0.05). For the right breast, VMAT reduced Dmean significantly (0.32 Gy vs 0.08 Gy, P < 0.01). There were no significant differences between 3DCRT and VMAT plans for the left lung dose in the DIBH position. The indicators of PTV had no significant difference between the 3 plans. Conclusion: DIBH and VMAT could reduce dosimetric parameters of the OARs in left breast cancer patients after BCS. RT plans for left breast cancer after BCS can be optimized by DIBH and VMAT techniques to minimize radiation-induced toxicity.
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Affiliation(s)
- Liuwei Tang
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yojiro Ishikawa
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kengo Ito
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaya Yamamoto
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Rei Umezawa
- Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Jingu
- Tohoku University Graduate School of Medicine, Sendai, Japan
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Kuo CC, Chang CC, Cheng HW, Lin JC, Tsai JT. Impact of respiratory motion in dosimetric and clinical advantages for adjuvant left-sided breast radiotherapy. JOURNAL OF RADIATION RESEARCH 2021:rrab087. [PMID: 34611714 DOI: 10.1093/jrr/rrab087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/05/2021] [Indexed: 06/13/2023]
Abstract
We investigated the organ-sparing effect of the deep inspiration breath hold (DIBH) technique among different levels of lung expansion for left-side breast radiotherapy. This retrospective study enrolled 30 patients who received adjuvant left breast radiotherapy after breast-conserving surgery (BCS). Simulation scans of both DIBH and deep breathing four-dimensional computed tomography (4DCT) were acquired, and three treatment plans were generated for each patient. One plan was based on the DIBH images, and the other two plans were based on the mid-lung expansion (ME) and initial lung expansion (IE) phases retrieved from 4DCT data sets. Dosimetric comparisons and normal tissue complication probability (NTCP) models were conducted. We used image registration for displacement analysis and sought potential factors related to the dose benefit of DIBH. The DIBH plans resulted significantly lower doses to the heart, left ventricle (LV) and left anterior descending coronary artery (LAD), including the high- to low-dose areas, followed by the ME plans and IE plans (p < 0.05). DIBH reduced the risk of long-term cardiac mortality by 40% and radiation pneumonitis of the left lung by 37.96% compared with the IE plans (p < 0.001). The reduction in the mean dose to the heart and LV significantly correlated with anterior displacement of the left lung. The DIBH technique is a feasible tool to provide dosimetric and clinical advantages for adjuvant left-sided breast radiotherapy. Breathing pattern and the level of lung expansion seem to play an important role.
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Affiliation(s)
- Chia-Chuan Kuo
- Department of Radiation Oncology, Taipei Medical University-Shuang Ho Hospital, New Taipei City 235, Taiwan
| | - Chin-Chieh Chang
- Department of Radiation Oncology, Taipei Medical University-Shuang Ho Hospital, New Taipei City 235, Taiwan
| | - Hao-Wen Cheng
- Department of Radiation Oncology, Taipei Medical University-Shuang Ho Hospital, New Taipei City 235, Taiwan
| | - Jang-Chun Lin
- Department of Radiation Oncology, Taipei Medical University-Shuang Ho Hospital, New Taipei City 235, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City 110, Taiwan
| | - Jo-Ting Tsai
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City 110, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei City 110, Taiwan
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Lai J, Zhong F, Deng J, Hu S, Shen R, Luo H, Luo Y. Prone position versus supine position in postoperative radiotherapy for breast cancer: A meta-analysis. Medicine (Baltimore) 2021; 100:e26000. [PMID: 34011096 PMCID: PMC8136988 DOI: 10.1097/md.0000000000026000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 04/23/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND This meta-analysis evaluates the difference of sparing organs at risk (OAR) in different position (Prone position and Supine position) with different breathing patterns (Free breathing, FB/Deep inspiration breath hold, DIBH) for breast cancer patients receiving postoperative radiotherapy and provides a useful reference for clinical practice. METHOD The relevant controlled trials of prone position versus supine position in postoperative radiotherapy for breast cancer were retrieved from the sources of PubMed, Cochrane Library, Embase, Web of Science and ClinicalTrails.gov. The principal outcome of interest was OAR doses (heart dose, left anterior descending coronary artery dose and ipsilateral lung dose) and target coverage. We mainly compared the effects of P-FB (Prone position FB) and S-FB (Supine position FB) and discussed the effects of DIBH combined with different positions on OAR dose in postoperative radiotherapy. We calculated summary standardized mean difference (SMD) and 95% confidence intervals (CI). The meta-analysis was performed using RevMan 5.4 software. RESULTS The analysis included 751 patients from 19 observational studies. Compared with the S-FB, the P-FB can have lower heart dose, left anterior descending coronary artery (LADCA) dose, and ipsilateral lung dose (ILL) more effectively, and the difference was statistically significant (heart dose, SMD = - 0.51, 95% CI - 0.66 ∼ - 0.36, P < .00001. LADCA dose, SMD = - 0.58, 95% CI - 0.85 ∼ - 0.31, P < .0001. ILL dose, SMD = - 2.84, 95% CI - 3.2 ∼ - 2.48, P < .00001). And there was no significant difference in target coverage between the S-FB and P-FB groups (SMD = - 0.1, 95% CI - 0.57 ∼ 0.36, P = .66). Moreover, through descriptive analysis, we found that P-DIBH (Prone position DIBH) has better sparing OAR than P-FB and S-DIBH (Supine position DIBH). CONCLUSION By this meta-analysis, compared with the S-FB we found that implementation of P-FB in postoperative radiotherapy for breast cancer can reduce irradiation of heart dose, LADCA dose and ILL dose, without compromising mean dose of target coverage. Moreover, P-DIBH might become the most promising way for breast cancer patients to undergo radiotherapy.
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Affiliation(s)
- Junming Lai
- Department of Radiation Oncology, Yiwu Central Hospital, The Affiliated Yiwu Hospital of Wenzhou Medical University, Yiwu, Zhejiang
| | - Fangyan Zhong
- Department of oncology, The First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi
| | - Jianxiong Deng
- Department of oncology, The First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi
| | - Shuang Hu
- Department of General Medicine, Yiwu Central Hospital, The Affiliated Yiwu Hospital of Wenzhou Medical University, Yiwu, Zhejiang
| | - Ruoyan Shen
- Department of Second Institute of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, P.R. China
| | - Hui Luo
- Department of oncology, The First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi
| | - Yongbiao Luo
- Department of Radiation Oncology, Yiwu Central Hospital, The Affiliated Yiwu Hospital of Wenzhou Medical University, Yiwu, Zhejiang
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Gaál S, Kahán Z, Paczona V, Kószó R, Drencsényi R, Szabó J, Rónai R, Antal T, Deák B, Varga Z. Deep-inspirational breath-hold (DIBH) technique in left-sided breast cancer: various aspects of clinical utility. Radiat Oncol 2021; 16:89. [PMID: 33985547 PMCID: PMC8117634 DOI: 10.1186/s13014-021-01816-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background Studying the clinical utility of deep-inspirational breath-hold (DIBH) in left breast cancer radiotherapy (RT) was aimed at focusing on dosimetry and feasibility aspects. Methods In this prospective trial all enrolled patients went through planning CT in supine position under both DIBH and free breathing (FB); in whole breast irradiation (WBI) cases prone CT was also taken. In 3-dimensional conformal radiotherapy (3DCRT) plans heart, left anterior descending coronary artery (LAD), ipsilateral lung and contralateral breast doses were analyzed. The acceptance of DIBH technique as reported by the patients and the staff was analyzed; post-RT side-effects including radiation lung changes (visual scores and lung density measurements) were collected. Results Among 130 enrolled patients 26 were not suitable for the technique while in 16, heart or LAD dose constraints were not met in the DIBH plans. Among 54 and 34 patients receiving WBI and postmastectomy/nodal RT, respectively with DIBH, mean heart dose (MHD) was reduced to < 50%, the heart V25 Gy to < 20%, the LAD mean dose to < 40% and the LAD maximum dose to about 50% as compared to that under FB; the magnitude of benefit was related to the relative increase of the ipsilateral lung volume at DIBH. Nevertheless, heart and LAD dose differences (DIBH vs. FB) individually varied. Among the WBI cases at least one heart/LAD dose parameter was more favorable in the prone or in the supine FB plan in 15 and 4 cases, respectively; differences were numerically small. All DIBH patients completed the RT, inter-fraction repositioning accuracy and radiation side-effects were similar to that of other breast RT techniques. Both the patients and radiographers were satisfied with the technique. Conclusions DIBH is an excellent heart sparing technique in breast RT, but about one-third of the patients do not benefit from that otherwise laborious procedure or benefit less than from an alternative method. Trial registration: retrospectively registered under ISRCTN14360721 (February 12, 2021) Supplementary information The online version contains supplementary material available at 10.1186/s13014-021-01816-3.
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Affiliation(s)
- Szilvia Gaál
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Zsuzsanna Kahán
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Viktor Paczona
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Renáta Kószó
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Rita Drencsényi
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Judit Szabó
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Ramóna Rónai
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Tímea Antal
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Bence Deák
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Zoltán Varga
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary.
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Pathomechanisms and therapeutic opportunities in radiation-induced heart disease: from bench to bedside. Clin Res Cardiol 2021; 110:507-531. [PMID: 33591377 PMCID: PMC8055626 DOI: 10.1007/s00392-021-01809-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/16/2021] [Indexed: 12/14/2022]
Abstract
Cancer management has undergone significant improvements, which led to increased long-term survival rates among cancer patients. Radiotherapy (RT) has an important role in the treatment of thoracic tumors, including breast, lung, and esophageal cancer, or Hodgkin's lymphoma. RT aims to kill tumor cells; however, it may have deleterious side effects on the surrounding normal tissues. The syndrome of unwanted cardiovascular adverse effects of thoracic RT is termed radiation-induced heart disease (RIHD), and the risk of developing RIHD is a critical concern in current oncology practice. Premature ischemic heart disease, cardiomyopathy, heart failure, valve abnormalities, and electrical conduct defects are common forms of RIHD. The underlying mechanisms of RIHD are still not entirely clear, and specific therapeutic interventions are missing. In this review, we focus on the molecular pathomechanisms of acute and chronic RIHD and propose preventive measures and possible pharmacological strategies to minimize the burden of RIHD.
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Xin X, Li J, Zhao Y, Wang P, Tang B, Yao X, Liao X, Ma J, Orlandini LC. Retrospective Study on Left-Sided Breast Radiotherapy: Dosimetric Results and Correlation with Physical Factors for Free Breathing and Breath Hold Irradiation Techniques. Technol Cancer Res Treat 2021; 20:15330338211062429. [PMID: 34855575 PMCID: PMC8646776 DOI: 10.1177/15330338211062429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/12/2021] [Accepted: 10/25/2021] [Indexed: 12/25/2022] Open
Abstract
Objectives: In breast radiotherapy, the proximity of the target to sensitive structures together with the uncertainty introduced by respiratory movement, make this treatment one of the most studied to increase its effectiveness. Dosimetric and physical variables play an important role and the study of their correlation and impact on treatment is fundamental. This retrospective study aims to highlight the dosimetric differences of 2 different clinical data sets of patients receiving left-sided breast irradiation in free breathing (FB) or breath hold (BH). Methods: A total of 155 left breast carcinoma patients receiving whole-breast irradiation in FB (73 patients) and BH (82 patients) were enrolled in this study. The dosimetric parameters of the target, heart, left and right lung and right breast were evaluated and compared, and possible correlations were studied in both groups. Results: No significant difference (P > .05) was found in the target dosimetry; a clear advantage in BH for both high and low doses received by the heart, with reductions of the dosimetric parameters between 27.1% and 100% (P < .003); for the left lung reductions decreased with increasing dose (-22.4% and -13.4% for doses of 5 and 20 Gy, respectively, P < .003). Conclusion: Significant correlations for BH treatments were registered between the volumes of the target and left lung, and the dosimetric parameters of the heart and left lung. BH treatment brings significant dosimetric advantages to organs at risk for a wide range of patients with different anatomy, target volumes and lung capacity, with additional benefits for small-sized breasts and important lung capacity.
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Affiliation(s)
- Xin Xin
- Sichuan Cancer Hospital & Research Institute, Chengdu, China
- UESTC University of Electronic Science and Technology of China, Chengdu, China
| | - Jie Li
- Sichuan Cancer Hospital & Research Institute, Chengdu, China
- UESTC University of Electronic Science and Technology of China, Chengdu, China
| | - Yanqun Zhao
- Sichuan Cancer Hospital & Research Institute, Chengdu, China
- UESTC University of Electronic Science and Technology of China, Chengdu, China
| | - Pei Wang
- Sichuan Cancer Hospital & Research Institute, Chengdu, China
- UESTC University of Electronic Science and Technology of China, Chengdu, China
| | - Bin Tang
- Sichuan Cancer Hospital & Research Institute, Chengdu, China
- UESTC University of Electronic Science and Technology of China, Chengdu, China
| | - Xinghong Yao
- Sichuan Cancer Hospital & Research Institute, Chengdu, China
- UESTC University of Electronic Science and Technology of China, Chengdu, China
| | - Xiongfei Liao
- Sichuan Cancer Hospital & Research Institute, Chengdu, China
- UESTC University of Electronic Science and Technology of China, Chengdu, China
| | - Jiabao Ma
- Sichuan Cancer Hospital & Research Institute, Chengdu, China
- UESTC University of Electronic Science and Technology of China, Chengdu, China
| | - Lucia Clara Orlandini
- Sichuan Cancer Hospital & Research Institute, Chengdu, China
- UESTC University of Electronic Science and Technology of China, Chengdu, China
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Sakyanun P, Saksornchai K, Nantavithya C, Chakkabat C, Shotelersuk K. The effect of deep inspiration breath-hold technique on left anterior descending coronary artery and heart dose in left breast irradiation. Radiat Oncol J 2020; 38:181-188. [PMID: 33012146 PMCID: PMC7533398 DOI: 10.3857/roj.2020.00094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 08/07/2020] [Indexed: 11/13/2022] Open
Abstract
Purpose To determine the effect of the deep inspiration breath-hold (DIBH) technique on left anterior descending coronary artery (LAD) region and heart dose in left breast cancer irradiation. Materials and Methods Twenty-five left breast cancer patients who previously received breast-conserving surgery underwent computed tomography (CT) simulation with both free-breathing (FB) and DIBH techniques and four radiation treatment plans. The plan comprised the following with both the FB and DIBH techniques: whole breast (WB), and WB with internal mammary lymph nodes (WB+IMNs). The prescription dose was 50 Gy in 25 fractions. The doses to the LAD region, heart and lungs were compared. Moreover, in-field maximum heart distance (maxHD) and breast volume were analyzed for correlations with the mean heart dose (MHD). Results In the WB plan with DIBH vs. FB techniques, the mean radiation doses to the LAD region, MHD, and the left lung V20 were 11.48 Gy vs. 19.84 Gy (p < 0.0001), 2.95 Gy vs. 5.38 Gy (p < 0.0001), and 19.72% vs. 22.73% (p = 0.0045), respectively. In the WB+IMNs plan, the corresponding values were 23.88 Gy vs. 31.98 Gy (p < 0.0001), 6.43 Gy vs. 10.24 Gy (p < 0.0001), and 29.31% vs. 32.1% (p = 0.0009), respectively. MHD correlated with maxHD (r = 0.925) and breast volume (r = 0.6). Conclusion The use of the DIBH technique in left breast cancer irradiation effectively reduces the radiation doses to the LAD region, heart and lungs. MHD is associated with maxHD and breast size.
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Affiliation(s)
- Pitchaya Sakyanun
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Kitwadee Saksornchai
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chonnipa Nantavithya
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chakkapong Chakkabat
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Kanjana Shotelersuk
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Upshaw JN. Cardioprotective Strategies to Prevent Cancer Treatment-Related Cardiovascular Toxicity: a Review. Curr Oncol Rep 2020; 22:72. [DOI: 10.1007/s11912-020-00923-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Arslan A, Aktas E, Sengul B, Tekin B. Dosimetric evaluation of left ventricle and left anterior descending artery in left breast radiotherapy. Radiol Med 2020; 126:14-21. [PMID: 32356249 DOI: 10.1007/s11547-020-01201-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION We evaluated the dosimetric results of the identification of the left ventricle (LV) and left anterior descending artery (LAD) as organs at risk (OARs) in adjuvant radiotherapy (RT) after breast-conserving surgery (BCS). MATERIALS AND METHODS Twenty-two patients who had previously received RT in our center were evaluated retrospectively. All patients had undergone BCS operation for left breast cancer. LV and LAD were contoured as OARs on the same simulation CTs for these patients whose treatment was previously completed in which LV and LAD were not defined as OARs. Complying with the initial plans, intensity-modulated RT plans with 7-9 fields were made on the computer. Planning target volume (PTV), homogeneity index (HI), conformity index (CI), monitor unit (MU) values, and doses of OARs were compared using the Wilcoxon signed-rank test (p < 0.05). RESULTS There were no significant differences in PTV 50 (D 50% and D 98%), PTV 60 (D 2% and D 50%), HI, CI, and MU values when treatment plans and control plans were compared (p > 0.05). While it was possible to protect the heart, LAD, and LV better, LAD and LV were not contoured in the treatment plans, and they received higher doses compared to the control plans (p < 0.05). There was no significant difference in the other OARs. CONCLUSION In conclusion, it is essential to define the lower anatomical regions of the heart as OARs. Otherwise, the doses taken by these regions are ignored and may be maintained less than possible. In our study, it was shown that LV and LAD doses were significantly reduced even in the same center and planning by the same team.
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Affiliation(s)
- Alaettin Arslan
- Clinic of Radiation Oncology, Kayseri City Hospital, Turkey, Kayseri, Turkey.
| | - Elif Aktas
- Clinic of Radiology, Kayseri City Hospital, Turkey, Kayseri, Turkey
| | - Burak Sengul
- Clinic of Radiation Oncology, Kayseri City Hospital, Turkey, Kayseri, Turkey
| | - Burcu Tekin
- Clinic of Radiation Oncology, Kayseri City Hospital, Turkey, Kayseri, Turkey
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