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Duma MN, Baumann R, Budach W, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Krug D, Piroth MD, Sedlmayer F, Souchon R, Sauer R. Heart-sparing radiotherapy techniques in breast cancer patients: a recommendation of the breast cancer expert panel of the German society of radiation oncology (DEGRO). Strahlenther Onkol 2019; 195:861-871. [PMID: 31321461 DOI: 10.1007/s00066-019-01495-w] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/27/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this review was to analyze the respective efficacy of various heart-sparing radiotherapy techniques. MATERIAL AND METHODS Heart-sparing can be performed in three different ways in breast cancer radiotherapy: by seeking to keep the heart out of treated volumes (i.e. by prone position or specific breathing techniques such as deep inspiration breath-hold [DIBH] and/or gating), by solely irradiating a small volume around the lumpectomy cavity (partial breast irradiation, PBI), or by using modern radiation techniques like intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT) or protons. This overview presents the available data on these three approaches. RESULTS Studies on prone position are heterogeneous and most trials only refer to patients with large breasts; therefore, no definitive conclusion can be drawn for clinical routine. Nonetheless, there seems to be a trend toward better sparing of the left anterior descending artery in supine position even for these selected patients. The data on the use of DIBH for heart-sparing in breast cancer patients is consistent and the benefit compared to free-breathing is supported by several studies. In comparison with whole breast irradiation (WBI), PBI has an advantage in reducing the heart dose. Of note, DIBH and PBI with multicatheter brachytherapy are similar with regard to the dose reduction to heart structures. WBI by IMRT/VMAT techniques without DIBH is not an effective strategy for heart-sparing in breast cancer patients with "standard" anatomy. A combination of DIBH and IMRT may be used for internal mammary radiotherapy. CONCLUSION Based on the available findings, the DEGRO breast cancer expert panel recommends the use of DIBH as the best heart-sparing technique. Nonetheless, depending on the treatment volume and localization, other techniques may be employed or combined with DIBH when appropriate.
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Affiliation(s)
- Marciana-Nona Duma
- Department of Radiotherapy and Radiation Oncology, University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07745, Jena, Germany.
| | | | - Wilfried Budach
- Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jürgen Dunst
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Petra Feyer
- Vivantes Hospital Neukoelln, Berlin, Germany
| | | | - Wulf Haase
- St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | | | - Thomas Hehr
- Marienhospital Stuttgart, Stuttgart, Germany
| | - David Krug
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Marc D Piroth
- Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Felix Sedlmayer
- Paracelsus Medical University Hospital Salzburg, Salzburg, Austria
| | | | - Rolf Sauer
- University Hospital Erlangen, Erlangen, Germany
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Radiation dose to the left anterior descending coronary artery during interstitial pulsed-dose-rate brachytherapy used as a boost in breast cancer patients undergoing organ-sparing treatment. J Contemp Brachytherapy 2017; 9:7-13. [PMID: 28344598 PMCID: PMC5346609 DOI: 10.5114/jcb.2017.66043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/11/2017] [Indexed: 12/25/2022] Open
Abstract
Purpose To assess dose received by the left anterior descending (LAD) coronary artery during interstitial pulsed-dose-rate brachytherapy (PDR-BT) boost for left-sided breast cancer patients undergoing organ-sparing treatment. Material and methods Thirty consecutive pT1-3N0-1M0 breast cancer patients boosted between 2014 and 2015 with 10 Gy/10 pulses/hour PDR-BT following a computed tomography (CT) simulation with the multi-catheter implant were included. The most common localization of primary tumor were upper quadrants. Patients were implanted with rigid tubes following breast conserving surgery and whole breast external beam irradiation (40 Gy/15 or 50 Gy/25 fractions). Computed tomography scans were retrospectively reviewed and LADs were contoured without and with margin of 5 mm (LAD5mm). Standard treatment plan encompassed tumor bed determined by the surgical clips with margin of 2 cm. Dosimetric parameters were extracted from the dose-volume histograms. Results The mean D90 and V100 were 10.3 Gy (range: 6.6-13.3), and 42.0 cc (range: 15.3-109.3), respectively. The median dose non-uniformity ratio (DNR) was 0.50 (range: 0.27-0.82). The mean doses to LAD and LAD5mm were 1.0 Gy and 0.96 Gy, and maximal doses were 1.57 Gy and 1.99 Gy, respectively. Dose to the 0.1 cc of the LAD and LAD5mm were 1.42 Gy and 1.85 Gy (range: 0.01-4.98 Gy and 0.1-6.89 Gy), respectively. Conclusions Interstitial multi-catheter PDR-BT used as a boost for left-sided breast cancer is generally associated with low dose to the LAD. However, higher dose in individual cases may require alternative approaches.
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Wollschläger D, Merzenich H, Schwentner L, Janni W, Wiegel T, Bartkowiak D, Wöckel A, Schmidt M, Schmidberger H, Blettner M. Self-reported long-term cardiac morbidity in breast cancer patients: a retrospective cohort study in Germany (PASSOS Heart Study). Breast Cancer Res Treat 2017; 163:595-604. [DOI: 10.1007/s10549-017-4215-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
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Holliday EB, Kirsner SM, Thames HD, Mason BE, Nelson CL, Bloom ES. Lower mean heart dose with deep inspiration breath hold-whole breast irradiation compared with brachytherapy-based accelerated partial breast irradiation for women with left-sided tumors. Pract Radiat Oncol 2016; 7:80-85. [PMID: 28274398 DOI: 10.1016/j.prro.2016.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 07/21/2016] [Accepted: 07/25/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE For left-sided breast cancer, radiation to the heart is a concern. We present a comparison of mean heart and coronary artery biologically effective dose (BED) between accelerated partial breast irradiation (APBI) and whole breast irradiation with deep inspiration breath-hold technique (DIBH-WBI). METHODS AND MATERIALS A total of 100 patients with left-sided, early-stage breast cancer were identified. Fifty underwent single-entry catheter-based APBI and 50 underwent DIBH-WBI. The heart, left anterior descending/interventricular branch, left main, and right coronary artery were delineated. BEDs were calculated from APBI treatment plans (34 Gy in 3.4 Gy twice daily fractions) and for 4 separate plans generated for each DIBH-WBI patient: 50 Gy in 25 fractions (50/25), 50/25 + 10/5 boost, 40/15, and 40/15 + 10/5 boost. RESULTS BED to the heart and coronary vessels were statistically significantly higher with APBI than with any of the DIBH-WBI dose/fractionation schedules. CONCLUSIONS For women with left-sided early-stage breast cancer, DIBH-WBI resulted in statistically significantly lower mean BED to the heart and coronary vessels compared with APBI. This is likely due to increased physical separation between the heart and tumor bed afforded by the DIBH-WBI technique. Long-term assessment of late effects in these tissues will be required to determine whether these differences are clinically significant.
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Affiliation(s)
- Emma B Holliday
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steve M Kirsner
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Howard D Thames
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bryan E Mason
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher L Nelson
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth S Bloom
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Niglas M, McCann C, Keller BM, Makhani N, Presutti J, Vesprini D, Rakovitch E, Elzibak A, Mashouf S, Lee J. A dosimetric study of cardiac dose sparing using the reverse semi-decubitus technique for left breast and internal mammary chain irradiation. Radiother Oncol 2016; 118:187-93. [DOI: 10.1016/j.radonc.2015.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 10/07/2015] [Accepted: 12/05/2015] [Indexed: 12/25/2022]
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Trombetta M, Julian TB, Hannoun-Levi JM. Breast Brachytherapy: Brachytherapy in the Management of Ipsilateral Breast Tumor Recurrence. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Beck RE, Kim L, Yue NJ, Haffty BG, Khan AJ, Goyal S. Treatment techniques to reduce cardiac irradiation for breast cancer patients treated with breast-conserving surgery and radiation therapy: a review. Front Oncol 2014; 4:327. [PMID: 25452938 PMCID: PMC4231838 DOI: 10.3389/fonc.2014.00327] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 10/30/2014] [Indexed: 12/25/2022] Open
Abstract
Thousands of women diagnosed with breast cancer each year receive breast-conserving surgery followed by adjuvant radiation therapy. For women with left-sided breast cancer, there is risk of potential cardiotoxicity from the radiation therapy. As data have become available to quantify the risk of cardiotoxicity from radiation, strategies have also developed to reduce the dose of radiation to the heart without compromising radiation dose to the breast. Several broad categories of techniques to reduce cardiac radiation doses include breath hold techniques, prone positioning, intensity-modulated radiation therapy, and accelerated partial breast irradiation, as well as many small techniques to improve traditional three-dimensional conformal radiation therapy. This review summarizes the published scientific literature on the various techniques to decrease cardiac irradiation in women treated to the left breast for breast cancer after breast-conserving surgery.
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Affiliation(s)
- Robert E Beck
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Leonard Kim
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Ning J Yue
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Atif J Khan
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Sharad Goyal
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
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Merino Lara TR, Fleury E, Mashouf S, Helou J, McCann C, Ruschin M, Kim A, Makhani N, Ravi A, Pignol JP. Measurement of mean cardiac dose for various breast irradiation techniques and corresponding risk of major cardiovascular event. Front Oncol 2014; 4:284. [PMID: 25374841 PMCID: PMC4205812 DOI: 10.3389/fonc.2014.00284] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/30/2014] [Indexed: 12/04/2022] Open
Abstract
After breast conserving surgery, early stage breast cancer patients are currently treated with a wide range of radiation techniques including whole breast irradiation (WBI), accelerated partial breast irradiation (APBI) using high-dose rate (HDR) brachytherapy, or 3D-conformal radiotherapy (3D-CRT). This study compares the mean heart’s doses for a left breast irradiated with different breast techniques. An anthropomorphic Rando phantom was modified with gelatin-based breast of different sizes and tumors located medially or laterally. The breasts were treated with WBI, 3D-CRT, or HDR APBI. The heart’s mean doses were measured with Gafchromic films and controlled with optically stimulated luminescent dosimeters. Following the model reported by Darby (1), major cardiac were estimated assuming a linear risk increase with the mean dose to the heart of 7.4% per gray. WBI lead to the highest mean heart dose (2.99 Gy) compared to 3D-CRT APBI (0.51 Gy), multicatheter (1.58 Gy), and balloon HDR (2.17 Gy) for a medially located tumor. This translated into long-term coronary event increases of 22, 3.8, 11.7, and 16% respectively. The sensitivity analysis showed that the tumor location had almost no effect on the mean heart dose for 3D-CRT APBI and a minimal impact for HDR APBI. In case of WBI large breast size and set-up errors lead to sharp increases of the mean heart dose. Its value reached 10.79 Gy for women with large breast and a set-up error of 1.5 cm. Such a high value could increase the risk of having long-term coronary events by 80%. Comparison among different irradiation techniques demonstrates that 3D-CRT APBI appears to be the safest one with less probability of having cardiovascular events in the future. A sensitivity analysis showed that WBI is the most challenging technique for patients with large breasts or when significant set-up errors are anticipated. In those cases, additional heart shielding techniques are required.
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Affiliation(s)
- Tomas Rodrigo Merino Lara
- Radiotherapy Unit, School of Medicine, Pontificia Universidad Católica de Chile , Santiago , Chile ; Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Emmanuelle Fleury
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Shahram Mashouf
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Joelle Helou
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Claire McCann
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Anthony Kim
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Nadiya Makhani
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Ananth Ravi
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Jean-Philippe Pignol
- Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada ; Department of Radiation Oncology, Erasmus MC , Rotterdam , Netherlands
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Eyre K, Whitney D, Mukesh M, Wilson C, Coles C. Optimization and comparison of balloon-based partial breast brachytherapy using a single source, a standard plan line source, and both forward and inverse planned multilumen techniques. Brachytherapy 2013; 12:107-13. [DOI: 10.1016/j.brachy.2012.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 03/16/2012] [Accepted: 03/20/2012] [Indexed: 10/28/2022]
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