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Völk F, Borm KJ, Düsberg M, Combs SE, Knippen S, Duma MN. Regional nodal irradiation in breast cancer patients: Effects of deep inspiration breath hold on the internal mammary chain location. Med Dosim 2023; 48:299-303. [PMID: 37648622 DOI: 10.1016/j.meddos.2023.08.002] [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: 10/22/2022] [Revised: 07/11/2023] [Accepted: 08/08/2023] [Indexed: 09/01/2023]
Abstract
The purpose of this study was to investigate the impact of deep inspiration breath hold (DIBH) on the positioning of thoracic structures and provide treatment planning recommendations for internal mammary chain (IMC) irradiation in breast cancer patients. Thirty-two breast cancer patients from our database underwent both DIBH and free breathing (FB) treatment planning. Contouring of the axillary lymph node clinical target volumes (CTVs: level I, II, III, IV, and IMC according to ESTRO), the internal mammary artery (IMA), the heart, and the left anterior descending artery (LAD) was performed. The following were then analyzed: the distance between the IMA and the heart, the craniocaudal distance in which IMC-CTV and heart coexist, the craniocaudal distance between the lower end of the of level III and IV and the upper end of the heart. Several significant geometric differences were observed between DIBH and FB that explain the efficacy of the DIBH for regional nodal irradiation. In >80% of patients the cranial origin of the LAD lies below the lower edge of the IMC-CTV in DIBH. In addition the slices in which the heart/LAD and IMC-CTV coexist decrease during DIBH. The IMA-heart distance is significantly larger in DIBH. Also the craniocaudal distance between the lower border of the CTV level III and IV and the upper border of the heart is larger in DIBH. The observed mechanisms during DIBH contribute significantly to the dose reduction in regional nodal irradiation. To further enhance the benefits of DIBH for the irradiation of the IMC-CTV, it is recommended to implement steep dose gradients in the caudal plane.
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Affiliation(s)
- Felix Völk
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany
| | - Kai Joachim Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany
| | - Mathias Düsberg
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany; Institute of Radiation Medicine, Helmholtz Zentrum München, Neuherberg, Germany; Deutsches Konsortium für Translationale Krebsforschung, DKTK Partner Site Munich, Munich, Germany
| | - Stefan Knippen
- Department for Human Medicine, MSH Medical School Hamburg, Hamburg, Germany; Department of Radiation Oncology, Helios Hospitals Schwerin, Schwerin, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany; Department for Human Medicine, MSH Medical School Hamburg, Hamburg, Germany; Department of Radiation Oncology, Helios Hospitals Schwerin, Schwerin, Germany.
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Costin IC, Marcu LG. Factors impacting on patient setup analysis and error management during breast cancer radiotherapy. Crit Rev Oncol Hematol 2022; 178:103798. [PMID: 36031175 DOI: 10.1016/j.critrevonc.2022.103798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/28/2022] [Accepted: 08/21/2022] [Indexed: 12/24/2022] Open
Abstract
Radiotherapy is required to deliver an accurate dose to the tumor while protecting surrounding normal tissues. Breast cancer radiotherapy involves a number of factors that can influence patient setup and error management, including the immobilization device used, the verification system and the patient's treatment position. The aim of this review is to compile and discuss the setup errors that occur due to the above-mentioned factors. In view of this, a systematic search of the scientific literature in the Medline/PubMed databases was performed over the 1990-2021 time period, with 93 articles found to be relevant for the study. To be accessible to all, this study not only aims to identify factors impacting on patient setup analysis, but also seeks to evaluate the role of each verification device, board immobilization and position in influencing these errors.
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Affiliation(s)
- Ioana-Claudia Costin
- West University of Timisoara, Faculty of Physics, Timisoara, Romania; "Dr. Gavril Curteanu" County Hospital, Oradea 410469, Romania
| | - Loredana G Marcu
- West University of Timisoara, Faculty of Physics, Timisoara, Romania; Faculty of Informatics & Science, University of Oradea, Oradea 410087, Romania; Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia.
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Cilla S, Macchia G, Romano C, Morabito VE, Boccardi M, Picardi V, Valentini V, Morganti AG, Deodato F. Challenges in lung and heart avoidance for postmastectomy breast cancer radiotherapy: Is automated planning the answer? Med Dosim 2021; 46:295-303. [PMID: 33836910 DOI: 10.1016/j.meddos.2021.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 11/18/2022]
Abstract
Postmastectomy radiotherapy (PMRT) has been shown to improve the overall survival for invasive breast cancer patients. However, it represents a challenging treatment geometry and individualized planning strategies with complex field arrangements are usually adopted to decrease radiotoxicity to heart and lungs. Automated treatment planning has the potential to improve plan quality consistency and planning efficiency. Herein, we describe the application of the Pinnacle3 Autoplanning engine as a valuable technological resource able to allow the treatment of challenging patients theoretically unfit for radiotherapy for major cardiac and pulmonary comorbidities. Treatment was planned for three left-sided chest wall and regional lymph-nodes postmastectomy breast cancer patients. A deep inspiration breath-hold (DIBH) technique was used aiming to reduce the OARs irradiation. Three manually generated plans (hybrid-IMRT (HMRT), hybrid-VMAT (HVMAT) and full VMAT (MP-VMAT) and a fully automated plan created by the Autoplanning engine (AP-VMAT) were optimized in order to ensure a safe radiation therapy to the patients. The plans were evaluated based on planning target volumes (PTVs) coverage, dose homogeneity index (HI), conformity index (CN), dose to organs at risk (OARs) and normal tissue complication probabilities (NTCPs) of pericarditis, long term mortality and pneumonitis. Despite the use of deep moderated breath-hold, all human-driven plans failed to reach the stringent dose objectives for OARs. All plans provided an optimal coverage for chest wall and lymph-nodal area. AP-VMAT delivered the lowest mean dose to the heart (3.4 to 4.9 Gy) and ipsilateral lung (7.5 to 12.5 Gy) reporting the lowest NTCP for pneumonitis (<1%), confirming the only chance to comply the dose objectives. Moreover, AP-VMAT reported a decrease of the integral dose, which was lower by about 4-8% with respect to manual plans. AP-VMAT plan resulted in up to 58% increase of MUs with respect to manual plans, suggesting a more pronounced fluence modulation and plan complexity. A major difference was found for the planning time which was reduced to less than 30 minutes by using the Auto-Planning module. With improved planning quality and efficiency, Auto-planning is an effective tool to enable high-quality plans in challenging postmastectomy breast cancer radiotherapy.
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Affiliation(s)
- Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy.
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Carmela Romano
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | | | - Mariangela Boccardi
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Picardi
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Valentini
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy; Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy; DIMES, Alma Mater Studiorum, Bologna University, Bologna, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy; Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
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