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Kil WJ, Smith W, Herndon C, Shipe W. Continuous Positive Airway Pressure-Assisted Breathing With Supine Tangential Left Breast Radiation Therapy When Deep Inspiration Breath-Hold Radiation Therapy Was Ineffective or Unsuitable: Clinical Implications for an Affordable Heart-Sparing Breast Radiation Therapy to Reduce the Health Care Disparities in Low-Resource Settings. Adv Radiat Oncol 2024; 9:101472. [PMID: 38681888 PMCID: PMC11043812 DOI: 10.1016/j.adro.2024.101472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/04/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose To report continuous positive airway pressure (CPAP)-assisted breathing with supine tangential left breast radiation therapy (CPAP-RT) when deep inspiration breath-hold RT (DIBH-RT) was ineffective or unsuitable. Methods and Materials Ten patients with left breast cancer underwent computed tomography simulation scan (CT-sim) under DIBH followed by CPAP-assisted breathing (15 cm H2O) to create CPAP-RT plans in authors' institute. Reasons for CPAP-RT include inability to reproduce DIBH (n = 5), DIBH-RT plan exceeded dose limits to the heart (n = 2), and unable to proceed with planned DIBH-RT due to mechanical issues (n = 3). Radiation target volumes and organs at risk were contoured according to published atlas data. For dosimetric comparison, supine tangential fields for breast only RT (Breast-RT) and wide-tangential fields for breast + internal mammary nodal RT (Breast + IMN-RT) were used with prescription of 40 Gy in 15 fractions on each patients' CT-sim with free-breathing (FB), DIBH, and CPAP-assisted breathing, respectively. Results Planning target volume (PTV) coverage was acceptable and comparable in all RT plans. Compared with FB, both DIBH and CPAP-assisted breathing inflated the thorax and increased left lung volume on average by 46% and 51%, respectively (FB: 1230 vs DIBH: 1802 vs CPAP-assisted breathing:1860 cc, P < .01), and increased the shortest distance between PTVeval-Breast to the heart by 5.6 ± 3.0 and 11.9 ± 3.6 mm (P < .01) and to LAD by 4.9 ± 2.9 and 10.8 ± 4.3 mm, respectively (P < .01). Compared with FB, both DIBH and CPAP significantly reduced radiation dose to the heart and LAD. A mean dose to the heart (HeartDmean) was FB: 2.3 ± 0.9, DIBH: 1.2 ± 0.7, and CPAP: 0.9 ± 0.4 Gy in Breast-RT (P < .01); FB: 3.2 ± 1.7, DIBH: 1.7 ± 0.8, and CPAP: 1.3 ± 0.5 Gy in Breast + IMN-RT (P < .01). LADDmean was FB: 11 ± 4.5, DIBH: 5.4 ± 3.2, and CPAP: 2.4 ± 0.9 Gy in Breast-RT (P < .01); FB: 15.5 ± 7.8, DIBH: 7.4 ± 4.1, and CPAP: 3.5 ± 1.4 Gy in Breast + IMN-RT (P < .01). A maximum dose to LAD (LADDmax) was FB: 35.8 ± 8.7, DIBH: 22.4 ± 15.4, and CPAP: 7.8 ± 5.3 Gy in Breast-RT (P < .01); FB: 38.7 ± 5.0, DIBH: 25.3 ± 15.2, and CPAP: 10.2 ± 6.8 Gy in Breast + IMN-RT (P < .01). All patients successfully completed CPAP-RT. Conclusions CPAP-RT provides efficient and practical heart and LAD sparing RT using simple supine tangential fields for Breast-RT or wide-tangential fields for Breast + IMN-RT when DIBH-RT was ineffective or unsuitable. With its easy accessibility and low infrastructural requirement, CPAP-RT can provide affordable heart-sparing left breast RT to reduce the health care disparities in low-resource settings.
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Affiliation(s)
- Whoon Jong Kil
- Radiation Oncology, UPMC Hillman Cancer Center, Williamsport, Pennsylvania
- Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Wyatt Smith
- Radiation Oncology, UPMC Hillman Cancer Center, Williamsport, Pennsylvania
| | - Craig Herndon
- Radiation Oncology, UPMC Hillman Cancer Center, Williamsport, Pennsylvania
| | - Warren Shipe
- Radiation Oncology, UPMC Hillman Cancer Center, Williamsport, Pennsylvania
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Lu W, Hong LX, Yamada N, Berry SL, Song Y, Choi W, Cerviño LI, Tang X, Mechalakos JG, Romesser PB, Powell S, Li G. Comparison of setup accuracy of optical surface image versus orthogonal x-ray images for VMAT of the left breast using deep-inspiration breath-hold. J Appl Clin Med Phys 2023; 24:e14117. [PMID: 37535396 PMCID: PMC10691624 DOI: 10.1002/acm2.14117] [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: 04/05/2023] [Revised: 05/25/2023] [Accepted: 07/18/2023] [Indexed: 08/04/2023] Open
Abstract
To compare the setup accuracy of optical surface image (OSI) versus orthogonal x-ray images (2DkV) using cone beam computed tomography (CBCT) as ground truth for radiotherapy of left breast cancer in deep-inspiration breath-hold (DIBH). Ten left breast DIBH patients treated with volumetric modulated arc therapy (VMAT) were studied retrospectively. OSI, 2DkV, and CBCT were acquired weekly at treatment setup. OSI, 2DkV, and CBCT were registered to planning CT or planning DRR based on a breast surface region of interest (ROI), bony anatomy (chestwall and sternum), and both bony anatomy and breast surface, respectively. These registrations provided couch shifts for each imaging system. The setup errors, or the difference in couch shifts between OSI and CBCT were compared to those between 2DkV and CBCT. A second OSI was acquired during last beam delivery to evaluate intrafraction motion. The median absolute setup errors were (0.21, 0.27, 0.23 cm, 0.6°, 1.3°, 1.0°) for OSI, and (0.26, 0.24, 0.18 cm, 0.9°, 1.0°, 0.6°) for 2DkV in vertical, longitudinal and lateral translations, and in rotation, roll and pitch, respectively. None of the setup errors was significantly different between OSI and 2DkV. For both systems, the systematic and random setup errors were ≤0.6 cm and ≤1.5° in all directions. Nevertheless, larger setup errors were observed in some sessions in both systems. There was no correlation between OSI and CBCT whereas there was modest correlation between 2DkV and CBCT. The intrafraction motion in DIBH detected by OSI was small with median absolute translations <0.2 cm, and rotations ≤0.4°. Though OSI showed comparable and small setup errors as 2DkV, it showed no correlation with CBCT. We concluded that to achieve accurate setup for both bony anatomy and breast surface, daily 2DkV can't be omitted following OSI for left breast patients treated with DIBH VMAT.
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Affiliation(s)
- Wei Lu
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Linda X. Hong
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Nelson Yamada
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Sean L. Berry
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Yulin Song
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Wookjin Choi
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Laura I. Cerviño
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Xiaoli Tang
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - James G. Mechalakos
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Paul B. Romesser
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Simon Powell
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Guang Li
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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Lai TY, Hu YW, Wang TH, Chen JP, Shiau CY, Huang PI, Lai IC, Tseng LM, Huang N, Liu CJ. Association of radiation dose to cardiac substructures with major ischaemic events following breast cancer radiotherapy. Eur Heart J 2023; 44:4796-4807. [PMID: 37585426 DOI: 10.1093/eurheartj/ehad462] [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] [Received: 12/08/2022] [Revised: 05/18/2023] [Accepted: 07/13/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND AND AIMS Patients with left-sided breast cancer receive a higher mean heart dose (MHD) after radiotherapy, with subsequent risk of ischaemic heart disease. However, the optimum dosimetric predictor among cardiac substructures has not yet been determined. METHODS AND RESULTS This study retrospectively reviewed 2158 women with breast cancer receiving adjuvant radiotherapy. The primary endpoint was a major ischaemic event. The dose-volume parameters of each delineated cardiac substructure were calculated. The risk factors for major ischaemic events and the association between MHD and major ischaemic events were analysed by Cox regression. The optimum dose-volume predictors among cardiac substructures were explored in multivariable models by comparing performance metrics of each model. At a median follow-up of 7.9 years (interquartile range 5.6-10.8 years), 89 patients developed major ischaemic events. The cumulative incidence rate of major ischaemic events was significantly higher in left-sided disease (P = 0.044). Overall, MHD increased the risk of major ischaemic events by 6.2% per Gy (hazard ratio 1.062, 95% confidence interval 1.01-1.12; P = 0.012). The model containing the volume of the left ventricle receiving 25 Gy (LV V25) with the cut-point of 4% presented with the best goodness of fit and discrimination performance in left-sided breast cancer. Age, chronic kidney disease, and hyperlipidaemia were also significant risk factors. CONCLUSION Risk of major ischaemic events exist in the era of modern radiotherapy. LV V25 ≥ 4% appeared to be the optimum parameter and was superior to MHD in predicting major ischaemic events. This dose constraint could aid in achieving better heart protection in breast cancer radiotherapy, though a further validation study is warranted.
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Affiliation(s)
- Tzu-Yu Lai
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - Yu-Wen Hu
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - Ti-Hao Wang
- Department of Radiation Oncology, China Medical University Hospital, 404327 Taichung, Taiwan
- Department of Medicine, China Medical University, 404333 Taichung, Taiwan
- Everfortune.AI, 403020 Taichung, Taiwan
| | - Jui-Pin Chen
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
| | - Cheng-Ying Shiau
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
| | - Pin-I Huang
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - I Chun Lai
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - Ling-Ming Tseng
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Comprehensive Breast Health Center & Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - Chia-Jen Liu
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 112201 Taipei, Taiwan
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Wu HG, Zhang GW, Liu JF, Yang JG, Su XH. Correlation between maximum heart distance and thoracic diameter changes and diaphragmatic descent in left-sided breast cancer patients during deep inspiration breath-hold (DIBH). Radiol Oncol 2023; 57:530-537. [PMID: 38038420 PMCID: PMC10690744 DOI: 10.2478/raon-2023-0053] [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: 04/13/2023] [Accepted: 08/28/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Cardioprotection is valued in radiotherapy for patients with left-sided breast cancer. Deep inspiration breath-hold (DIBH) technique can achieve cardioprotection well. However, during DIBH, the extent to which the heart enters the radiation field is affected by the movement of the thorax and diaphragm. The aim of this study was to analyze the correlation between the maximum distance of the heart entering the field (maximum heart distance, MHD) and thoracic diameter changes and diaphragmatic descent in left-sided breast cancer patients during DIBH. PATIENTS AND METHODS Ninety-eight patients with left-sided breast cancer were included in this retrospective study. They performed simulation in Sentinel-guided DIBH, and two sets of CT images were collected under both free breathing (FB) and DIBH, and diaphragm positions, anteroposterior thoracic diameter (ATD), transverse thoracic diameter (TTD), gating window level (GWL), and MHD were measured, and the change (Δ) of each parameter in DIBH relative to that in FB were calculated. Pearson or Spearman test were used to analyze the correlation between ΔMHD and the changes in other parameters. RESULTS For all patients with DIBH, the average of ΔMHD was -8.3 mm, and the average of ΔATD and ΔTTD were 11.0 and 8.6 mm, and the median of both left diaphragmatic descent (LDD) and right diaphragmatic descent (RDD) were 35.0 mm, and the median of GWL was 11.1 mm. The correlation coefficients between MHD decrease (ΔMHD) and LDD, RDD, and ΔTTD were -0.430 (p = 0.000), -0.592 (p = 0.000) and 0.208 (p = 0.040), respectively, but not significantly correlated with ΔATD or GWL. CONCLUSIONS The MHD decrease showed a moderate correlation with diaphragmatic descent In Sentinel-guided DIBH for patients with left-sided breast cancer, while there was a weak or no correlation with thoracic diameter changes or GWL. Abdominal breathing can lower diaphragm more and may be more beneficial to the heart stay away from tangential field.
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Affiliation(s)
- He-Gou Wu
- Department of Radiation Oncology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, People's Republic of China
| | - Guang-Wei Zhang
- Department of Radiation Oncology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, People's Republic of China
| | - Jian-Feng Liu
- Department of Radiation Oncology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, People's Republic of China
| | - Jun-Guo Yang
- Department of Radiation Oncology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, People's Republic of China
| | - Xiao-Hui Su
- Department of Radiation Oncology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, People's Republic of China
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Stuart SR, Poço JG, Rodrigues MVS, Abe RY, Carvalho HA. Can we predict who will benefit from the deep inspiration breath hold (DIBH) technique for breast cancer irradiation? Rep Pract Oncol Radiother 2023; 28:582-591. [PMID: 38179291 PMCID: PMC10764047 DOI: 10.5603/rpor.96867] [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: 02/14/2023] [Accepted: 07/28/2023] [Indexed: 01/06/2024] Open
Abstract
Background The objective was to explore the clinical use of an "in-house" prototype developed to monitor respiratory motion to implement the deep inspiration breath hold technique (DIBH), compare dosimetric differences, and assess whether simple anatomic metrics measured on free breathing (FB) computed tomography scan (CT) can help in selecting patients that would benefit the most from the technique. Materials and methods A prospective study was conducted on patients with left breast cancer with an indication of adjuvant radiotherapy for breast only. Treatment simulation consisted of four series of CTs: the first during FB and three in DIBH to assess the reproducibility and stability of apnea. Contouring was based on the RTOG atlas, and planning was done in both FB and DIBH. Dosimetric and geometric parameters were assessed and compared between FB and DIBH. Results From June 2020 to December 2021, 30 patients with left breast cancer were recruited. Overall, the DIBH technique presented a mean dose reduction of 24% in the heart and 30% in the left anterior descendent coronary artery (LAD) (p < 0.05). The only geometric parameter correlated to a 30% dose reduction in the mean heart dose and LAD doses was the anterolateral distance from the heart to the chest wall of at least 1.5 cm measured on FB (p < 0.0001). Conclusion The prototype enabled the use of the DIBH technique with dose reductions in the heart and LAD. The benefit of the DIBH technique can be predicted on FB CT by measuring the distance between the heart and chest wall at the treatment isocenter.
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Affiliation(s)
| | - Joao Guilherme Poço
- Radiotherapy, Instituto de Radiologia, Universidade de São Paulo, Sao Paulo, Brazil
| | | | - Ricardo Y. Abe
- Estatistica, Instituto de Matematica e Estatistica, Universidade de Sao Paulo Sao Paulo, Brazil
| | - Heloisa A. Carvalho
- Radiotherapy, Instituto de Radiologia, Universidade de São Paulo, Sao Paulo, Brazil
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Wang S, Tsai W, Lin K, Yu C, Yang S, Shueng P, Wu Y, Hsu C, Wu T. Integrating subvolume dose and myocardial perfusion imaging parameters to assess the impact of radiation therapy on heart function in breast cancer patients: A comparative analysis between left- and right-sided breast cancer. Thorac Cancer 2023; 14:2696-2706. [PMID: 37553772 PMCID: PMC10493477 DOI: 10.1111/1759-7714.15056] [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: 04/14/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND This study aimed to utilize an innovative method of integrating the 20 subvolume dose of left ventricle and the Tl-201 single photon emission computed tomography (SPECT) with myocardial perfusion imaging (MPI) parameters in patients with left- and right-sided breast cancer after radiation therapy. METHODS Female patients with breast cancer underwent SPECT MPI before commencing radiotherapy and 12 months later were enrolled from January 2014 to December 2018. The images of CT simulation and SPECT MPI were integrated into the treatment planning system. The differences of doses and parameters of MPI in all cardiac subvolumes between left- and right-sided breast cancer patients were analyzed. RESULTS Patients with left-sided breast cancer (n = 61) received a higher radiation dose to the heart, left ventricular, and its territories and subvolumes, compared to patients with right-sided breast cancer (n = 19). The 20-segment analysis also showed statistically significant disparities in the average radiation doses received by the two groups. In different coronary artery territories, the end-diastolic perfusion and end-systolic perfusion showed a decrease in both sides, with no significant differences. However, the wall motion and wall thickening showed a significant decline in subregions within the left- and right-sided coronary artery territories. CONCLUSION This study demonstrates an innovative integrated method combining the left ventricular 20 regional doses with SPECT MPI which shows that left-sided breast cancer patients receive a higher subvolume dose than right-sided breast cancer patients. Further research is needed to confirm the potential impact on heart function after radiotherapy on both sides.
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Affiliation(s)
- Shan‐Ying Wang
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Department of Nuclear MedicineFar Eastern Memorial HospitalNew Taipei CityTaiwan
| | - Wei‐Ta Tsai
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Department of Radiation Oncology, Dalin Tzu Chi HospitalBuddhist Tzu Chi Medical FoundationChiayiTaiwan
| | - Kuan‐Heng Lin
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Division of Radiation Oncology, Department of RadiologyFar Eastern Memorial HospitalNew Taipei CityTaiwan
- Industrial Ph.D. Program of Biomedical Science and EngineeringNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Chih‐Wei Yu
- Department of Radiation OncologyChina Medical University Hsinchu HospitalZhubei CityTaiwan
- Institute of Nuclear Engineering and ScienceNational Tsing Hua UniversityHsinchu CityTaiwan
| | - Shu‐Ya Yang
- Department of Nuclear MedicineCheng Hsin General HospitalTaipeiTaiwan
| | - Pei‐Wei Shueng
- Division of Radiation Oncology, Department of RadiologyFar Eastern Memorial HospitalNew Taipei CityTaiwan
- School of Medicine, College of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Yen‐Wen Wu
- Department of Nuclear MedicineFar Eastern Memorial HospitalNew Taipei CityTaiwan
- School of Medicine, College of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Division of Cardiology, Cardiovascular Medical CenterFar Eastern Memorial HospitalNew Taipei CityTaiwan
| | - Chen‐Xiong Hsu
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Division of Radiation Oncology, Department of RadiologyFar Eastern Memorial HospitalNew Taipei CityTaiwan
| | - Tung‐Hsin Wu
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
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Comparison of fulfilling the criteria for critical organs in irradiation of patients with breast cancer using the deep inspiration breath-hold and free breathing techniques. POLISH JOURNAL OF MEDICAL PHYSICS AND ENGINEERING 2022. [DOI: 10.2478/pjmpe-2022-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Introduction: The aim of the study was to evaluate organ-at-risk dose sparing in treatment plans for patients with left-sided breast cancer irradiated with Deep Inspiration Breath Hold (DIBH) and Free Breathing (FB) techniques.
Material and methods: Twenty patients with left-sided breast cancer were analyzed and divided into two groups. Group A included 10 patients with non-metastatic breast cancer, while group B involved 10 patients with metastatic breast cancer spreading to regional lymph nodes. All patients went through the DIBH coaching. For planning purposes, CT scans were obtained in both DIBH and FB. Mean heart dose (Dmean,heart), mean heart volume receiving 50% of the prescribed dose (V50), V20 (V20L.lung), V10 (V10L.lung) and V5 for left lung (V5L.lung), the volume of the PTV receiving a dose greater than or equal to 95% of the prescribed dose (V95 [%]), the maximum point dose (Dmax), and the volume of PTV receiving 107% of the prescribed dose were reported.
Results: In all 20 analyzed pairs of plans, a reduction by more than half in the mean heart dose in DIBH technique plans was achieved, as well as a significant reduction was found in DIBH plans for the heart V50. In 19 patients, the use of the DIBH technique also reduced the volume of the left lung receiving doses of 20 Gy, 10 Gy, and 5 Gy compared to the FB technique.
Conclusions: Dosimetric analysis showed that the free breathing plans don’t fulfill the criteria for a mean heart dose (group B) and the left lung receiving a 20 Gy dose (group A) compared to the DIBH plans. Radiation therapy of left breast cancer with the use of the DIBH technique results in a significant dose reduction in the heart and also reduces the dose in the left lung in the majority of patients, compared to the FB procedure.
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Lu W, Li G, Hong L, Yorke E, Tang X, Mechalakos JG, Zhang P, Cerviño LI, Powell S, Berry SL. Reproducibility of chestwall and heart position using surface-guided versus RPM-guided DIBH radiotherapy for left breast cancer. J Appl Clin Med Phys 2022; 24:e13755. [PMID: 35993318 PMCID: PMC9859984 DOI: 10.1002/acm2.13755] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/27/2022] [Accepted: 08/26/2021] [Indexed: 01/27/2023] Open
Abstract
This study compared the reproducibility of chestwall and heart position using surface-guided versus RPM (real-time position management)-guided deep inspiration breath hold (DIBH) radiotherapy for left sided breast cancer. Forty DIBH patients under either surface-guided radiotherapy (SGRT) or RPM guidance were studied. For patients treated with tangential fields, reproducibility was measured as the displacements in central lung distance (CLD) and heart shadow to field edge distance (HFD) between pretreatment MV (megavoltage) images and planning DRRs (digitally reconstructed radiographs). For patients treated with volumetric modulated arc therapy (VMAT), sternum to isocenter (ISO) distance (StID), spine to rib edge distance (SpRD), and heart shadow to central axis (CAX) distance (HCD) between pretreatment kV images and planning DRRs were measured. These displacements were compared between SGRT and RPM-guided DIBH. In tangential patients, the mean absolute displacements of SGRT versus RPM guidance were 0.19 versus 0.23 cm in CLD, and 0.33 versus 0.62 cm in HFD. With respect to planning DRR, heart appeared closer to the field edge by 0.04 cm with surface imaging versus 0.62 cm with RPM. In VMAT patients, the displacements of surface imaging versus RPM guidance were 0.21 versus 0.15 cm in StID, 0.24 versus 0.19 cm in SpRD, and 0.72 versus 0.41 cm in HCD. Heart appeared 0.41 cm further away from CAX with surface imaging, whereas 0.10 cm closer to field CAX with RPM. None of the differences between surface imaging and RPM guidance was statistically significant. In conclusion, the displacements of chestwall were small and were comparable with SGRT- or RPM-guided DIBH. The position deviations of heart were larger than those of chestwall with SGRT or RPM. Although none of the differences between SGRT and RPM guidance were statistically significant, there was a trend that the position deviations of heart were smaller and more favorable with SGRT than with RPM guidance in tangential patients.
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Affiliation(s)
- Wei Lu
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Guang Li
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Linda Hong
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Ellen Yorke
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Xiaoli Tang
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - James G. Mechalakos
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Pengpeng Zhang
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Laura I. Cerviño
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Simon Powell
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Sean L. Berry
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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Li G. Advances and potential of optical surface imaging in radiotherapy. Phys Med Biol 2022; 67:10.1088/1361-6560/ac838f. [PMID: 35868290 PMCID: PMC10958463 DOI: 10.1088/1361-6560/ac838f] [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: 12/08/2021] [Accepted: 07/22/2022] [Indexed: 11/12/2022]
Abstract
This article reviews the recent advancements and future potential of optical surface imaging (OSI) in clinical applications as a four-dimensional (4D) imaging modality for surface-guided radiotherapy (SGRT), including OSI systems, clinical SGRT applications, and OSI-based clinical research. The OSI is a non-ionizing radiation imaging modality, offering real-time 3D surface imaging with a large field of view (FOV), suitable for in-room interactive patient setup, and real-time motion monitoring at any couch rotation during radiotherapy. So far, most clinical SGRT applications have focused on treating superficial breast cancer or deep-seated brain cancer in rigid anatomy, because the skin surface can serve as tumor surrogates in these two clinical scenarios, and the procedures for breast treatments in free-breathing (FB) or at deep-inspiration breath-hold (DIBH), and for cranial stereotactic radiosurgery (SRS) and radiotherapy (SRT) are well developed. When using the skin surface as a body-position surrogate, SGRT promises to replace the traditional tattoo/laser-based setup. However, this requires new SGRT procedures for all anatomical sites and new workflows from treatment simulation to delivery. SGRT studies in other anatomical sites have shown slightly higher accuracy and better performance than a tattoo/laser-based setup. In addition, radiographical image-guided radiotherapy (IGRT) is still necessary, especially for stereotactic body radiotherapy (SBRT). To go beyond the external body surface and infer an internal tumor motion, recent studies have shown the clinical potential of OSI-based spirometry to measure dynamic tidal volume as a tumor motion surrogate, and Cherenkov surface imaging to guide and assess treatment delivery. As OSI provides complete datasets of body position, deformation, and motion, it offers an opportunity to replace fiducial-based optical tracking systems. After all, SGRT has great potential for further clinical applications. In this review, OSI technology, applications, and potential are discussed since its first introduction to radiotherapy in 2005, including technical characterization, different commercial systems, and major clinical applications, including conventional SGRT on top of tattoo/laser-based alignment and new SGRT techniques attempting to replace tattoo/laser-based setup. The clinical research for OSI-based tumor tracking is reviewed, including OSI-based spirometry and OSI-guided tumor tracking models. Ongoing clinical research has created more SGRT opportunities for clinical applications beyond the current scope.
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Affiliation(s)
- Guang Li
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, United States of America
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10
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A Critical Overview of Predictors of Heart Sparing by Deep-Inspiration-Breath-Hold Irradiation in Left-Sided Breast Cancer Patients. Cancers (Basel) 2022; 14:cancers14143477. [PMID: 35884538 PMCID: PMC9319386 DOI: 10.3390/cancers14143477] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 07/11/2022] [Accepted: 07/15/2022] [Indexed: 01/21/2023] Open
Abstract
Simple Summary Adjuvant radiotherapy could damage the heart in left-sided breast cancer patients. The deep-inspiration-breath-hold technique may limit the heart exposure to radiation. As non-beneficiaries exist, there is some need to do an upfront cost-effective selection. Some easy-to-use anatomical predictors may help insiders in the treatment decision. The awareness of such findings may improve the efficiency of practitioners’ workflows. Abstract Radiotherapy represents an essential part of the therapeutic algorithm for breast cancer patients after conservative surgery. The treatment of left-sided tumors has been associated with a non-negligible risk of developing late-onset cardiovascular disease. The cardiac risk perception has especially increased over the last years due to the prolongation of patients’ survival owing to the advent of new drugs and an ever earlier cancer detection through screening programs. Improvements in radiation delivery techniques could reduce the treatment-related heart toxicity. The deep-inspiration-breath-hold (DIBH) irradiation is one of the most advanced treatment approaches, which requires specific technical equipment and uses inspiration to displace the heart from the tangential radiation fields. However, not all patients benefit from its use. Moreover, DIBH irradiation needs patient compliance and accurate training. Therefore, such a technique may be unjustifiably cumbersome and time-consuming as well as unnecessarily expensive from a mere healthcare cost point of view. Hence the need to early select only the true beneficiaries while tailoring more effective heart-sparing techniques for the others and streamlining the workflow, especially in high-volume radiation oncology departments. In this literature overview, we collected some possible predictors of cardiac dose sparing in DIBH irradiation for left breast treatment in an effort to provide an easy-to-consult summary of simple instruments to insiders for identifying patients actually benefitting from this technique. We critically reviewed the reliability and weaknesses of each retrieved finding, aiming to inspire new insights and discussions on this much-debated topic.
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11
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Stowe HB, Andruska ND, Reynoso F, Thomas M, Bergom C. Heart Sparing Radiotherapy Techniques in Breast Cancer: A Focus on Deep Inspiration Breath Hold. BREAST CANCER: TARGETS AND THERAPY 2022; 14:175-186. [PMID: 35899145 PMCID: PMC9309321 DOI: 10.2147/bctt.s282799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/04/2022] [Indexed: 11/23/2022]
Abstract
Adjuvant radiation therapy is a critical component of breast cancer management. However, when breast cancer patients receive incidental radiation to the heart, there is an increased risk of cardiac disease and mortality. This is most common for patients with left-sided breast cancers and those receiving nodal irradiation as part of treatment. The overall risk of cardiac toxicity increases 4–16% with each Gray increase in mean heart radiation dose, with data suggesting that no lower limit exists which would eliminate cardiac risk entirely. Radiation techniques have improved over time, leading to lower cardiac radiation exposure than in the past. This decline is expected to reduce the incidence of radiation-induced heart dysfunction in patients. Deep inspiration breath hold (DIBH) is one such technique that was developed to reduce the risk of cardiac death and coronary events. DIBH is a non-invasive approach that capitalizes on the natural physiology of the respiratory cycle to increase the distance between the heart and the therapeutic target throughout the course of radiation therapy. DIBH has been shown to decrease the mean incidental radiation doses to the heart and left anterior descending coronary artery by approximately 20–70%. In this review, we summarize different techniques for DIBH and discuss recent data on this technique.
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Affiliation(s)
- Hayley B Stowe
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Neal D Andruska
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Francisco Reynoso
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Maria Thomas
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Alvin J. Siteman Center, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Correspondence: Carmen Bergom, Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA, Email
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12
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Lu Y, Yang D, Zhang X, Teng Y, Yuan W, Zhang Y, He R, Tang F, Pang J, Han B, Chen R, Li Y. Comparison of Deep Inspiration Breath Hold Versus Free Breathing in Radiotherapy for Left Sided Breast Cancer. Front Oncol 2022; 12:845037. [PMID: 35530354 PMCID: PMC9069140 DOI: 10.3389/fonc.2022.845037] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/29/2022] [Indexed: 01/10/2023] Open
Abstract
ObjectivesModern breast cancer techniques, such as the deep inspiration breath-hold (DIBH) technique has been applied for left-sided breast cancer. Whether the DIBH regimen is the optimal solution for left-sided breast cancer remains unclear. This meta-analysis aims to elucidate the differences of DIBH and free-breathing (FB) for patients receiving radiotherapy for left-sided breast cancer and provide a practical reference for clinical practice.MethodsRelevant research available on PubMed, Embase, Cochrane Library, and the Web of Science published before November 30, 2021 was independently and systematically examined by two investigators. Data were extracted from eligible studies for assessing their qualities and calculating the standardized mean difference (SMD) and 95% confidence intervals (CIs) using Review Manager software 5.4 (RevMan 5.4).ResultsForty-one studies with a total of 3599 left-sided breast cancer patients were included in the meta-analysis. Compared with FB, DIBH reduced heart dose (Dmean, Dmax, V30, V10, V5), left anterior descending branch (LAD) dose (Dmean, Dmax), ipsilateral lung dose (Dmean, V20, V10, V5), and heart volume significantly. Lung volume increased greatly, and a statistically significant difference. For contralateral breast mean dose, DIBH has no obvious advantage over FB. The funnel plot suggested this study has no significant publication bias.ConclusionsAlthough DIBH has no obvious advantage over FB in contralateral breast mean dose, it can significantly reduce heart dose, LAD dose, ipsilateral lung dose, and heart volume. Conversely, it can remarkably increase the ipsilateral lung volume. This study suggests that soon DIBH could be more widely utilized in clinical practice because of its excellent dosimetric performance.
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Affiliation(s)
- Yongkai Lu
- Department of Radiation Oncology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Di Yang
- Department of Radiation Oncology, Shaanxi Provincial Tumor Hospital, Affiliated Hospital of Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Xiaowei Zhang
- Department of Obstetrics and Gynecology, Xi’an Central Hospital, The Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yonggang Teng
- Department of Thoracic Surgery, Second Affiliated Hospital of Air Force Medical University, Xi’an, China
| | - Wei Yuan
- Department of Radiation Oncology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yuemei Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Ruixin He
- Department of Radiation Oncology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Fengwen Tang
- Department of Radiation Oncology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Jie Pang
- Department of Obstetrics and Gynecology, Xi’an Central Hospital, The Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Bo Han
- Department of Radiation Oncology, Weinan Central Hospital, Weinan, China
| | - Ruijuan Chen
- Department of Obstetrics and Gynecology, Xi’an Central Hospital, The Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- *Correspondence: Ruijuan Chen, ; Yi Li,
| | - Yi Li
- Department of Radiation Oncology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- *Correspondence: Ruijuan Chen, ; Yi Li,
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Tamilarasu S, Saminathan M. Dosimetric comparison of normal breathing and deep inspiration breath hold technique for synchronous bilateral breast cancer using 6MV flattened beam and flattening filter free beam. Rep Pract Oncol Radiother 2022; 27:63-75. [PMID: 35402027 PMCID: PMC8989442 DOI: 10.5603/rpor.a2021.0124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/02/2021] [Indexed: 11/25/2022] Open
Abstract
Background The present study was to investigate the usefulness of deep inspiration breath hold (DIBH) in bilateral breast patients using 6MV flattened beam (FB) and flattening filter free beam (FFFB). Materials and methods Twenty bilateral breast cancer patients were simulated, using left breast patients treated with DIBH technique. CT scans were performed in the normal breathing (NB) and DIBH method. Three-dimensional conformal radiotherapy (3DCRT) and volumetric arc therapy (VMAT) plans were generated. Results In our study the best organ at risk (OAR) sparing is achieved in the 3DCRT DIBH plan with adequate PTV coverage (V95 ≥ 47.5 Gy) as compared to 6MV FB and FFFB VMAT DIBH plans. The DIBH scan plan reduces the heart mean dose significantly at the rate of 49% in 3DCRT (p = 0.00) and 22% in VMAT (p = 0.010). Similarly, the DIBH scan plan produces lesser common lung mean dose of 18% in 3DCRT (p = 0.011) and 8% in VMAT (0.007) as compared to the NB scan. The conformity index is much better in VMAT FB (1.04 ± 0.04 vs. 1.04 ± 0.05), p =1.00 and VMAT FFFB (1.04 ± 0.05 vs. 1 ± 0.24, p = 0.345) plans as compared to 3DCRT (1.63 ± 0.2 vs. 1.47 ± 0.28, p = 0.002). The homogeneity index of all the plans is less than 0.15. The global dmax is more in VMAT FFFB DIBH plan (113.7%). The maximum MU noted in the NB scan plan (478 vs. 477MU, 1366 vs. 1299 MU and 1853 vs. 1788 MU for 3DCRT, VMAT FB and VMAT FFFB technique as compared to DIBH scan. Conclusion We recommend that the use of DIBH techniques for bilateral breast cancer patients significantly reduces the radiation doses to OARs in both 3DCRT and VMAT plans.
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Affiliation(s)
- Suresh Tamilarasu
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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Al-Hallaq HA, Cerviño L, Gutierrez AN, Havnen-Smith A, Higgins SA, Kügele M, Padilla L, Pawlicki T, Remmes N, Smith K, Tang X, Tomé WA. AAPM task group report 302: Surface guided radiotherapy. Med Phys 2022; 49:e82-e112. [PMID: 35179229 PMCID: PMC9314008 DOI: 10.1002/mp.15532] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/26/2021] [Accepted: 02/05/2022] [Indexed: 11/06/2022] Open
Abstract
The clinical use of surface imaging has increased dramatically with demonstrated utility for initial patient positioning, real-time motion monitoring, and beam gating in a variety of anatomical sites. The Therapy Physics Subcommittee and the Imaging for Treatment Verification Working Group of the American Association of Physicists in Medicine commissioned Task Group 302 to review the current clinical uses of surface imaging and emerging clinical applications. The specific charge of this task group was to provide technical guidelines for clinical indications of use for general positioning, breast deep-inspiration breath-hold (DIBH) treatment, and frameless stereotactic radiosurgery (SRS). Additionally, the task group was charged with providing commissioning and on-going quality assurance (QA) requirements for surface guided radiation therapy (SGRT) as part of a comprehensive QA program including risk assessment. Workflow considerations for other anatomic sites and for computed tomography (CT) simulation, including motion management are also discussed. Finally, developing clinical applications such as stereotactic body radiotherapy (SBRT) or proton radiotherapy are presented. The recommendations made in this report, which are summarized at the end of the report, are applicable to all video-based SGRT systems available at the time of writing. Review current use of non-ionizing surface imaging functionality and commercially available systems. Summarize commissioning and on-going quality assurance (QA) requirements of surface image-guided systems, including implementation of risk or hazard assessment of surface guided radiotherapy as a part of a total quality management program (e.g., TG-100). Provide clinically relevant technical guidelines that include recommendations for the use of SGRT for general patient positioning, breast DIBH, and frameless brain SRS, including potential pitfalls to avoid when implementing this technology. Discuss emerging clinical applications of SGRT and associated QA implications based on evaluation of technology and risk assessment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hania A Al-Hallaq
- Department of Radiation & Cellular Oncology, University of Chicago, Chicago, IL, 60637, USA
| | - Laura Cerviño
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, 33173, USA
| | | | - Susan A Higgins
- Department of Therapeutic Radiology, Yale University, New Haven, CT, 06520, USA
| | - Malin Kügele
- Department of Hematology, Oncology and Radiation Physics, Skåne University, Lund, 221 00, Sweden.,Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, 221 00, Sweden
| | - Laura Padilla
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Todd Pawlicki
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Nicholas Remmes
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Koren Smith
- IROC Rhode Island, University of Massachusetts Chan Medical School, Lincoln, RI, 02865, USA
| | | | - Wolfgang A Tomé
- Department of Radiation Oncology and Department of Neurology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, 10461, USA
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Salvestrini V, Iorio GC, Borghetti P, De Felice F, Greco C, Nardone V, Fiorentino A, Gregucci F, Desideri I. The impact of modern radiotherapy on long-term cardiac sequelae in breast cancer survivor: a focus on deep inspiration breath-hold (DIBH) technique. J Cancer Res Clin Oncol 2021; 148:409-417. [PMID: 34853887 DOI: 10.1007/s00432-021-03875-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/25/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION One of the most feared side effects of radiotherapy (RT) in the setting of breast cancer (BC) patients is cardiac toxicity. This side effect can jeopardize the quality of life (QoL) of long-term survivors. The impact of modern techniques of RT such as deep inspiration breath hold (DIBH) have dramatically changed this setting. We report and discuss the results of the literature overview of this paper. MATERIALS AND METHODS Literature references were obtained with a PubMed query, hand searching, and clinicaltrials.gov. RESULTS We reported and discussed the toxicity of RT and the improvements due to the modern techniques in the setting of BC patients. CONCLUSIONS BC patients often have a long life expectancy, thus the RT should aim at limiting toxicities and at the same time maintaining the same high cure rates. Further studies are needed to evaluate the risk-benefit ratio to identify patients at higher risk and to tailor the treatment choices.
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Affiliation(s)
- V Salvestrini
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
| | - G C Iorio
- Radiation Oncology, University of Turin, Turin, Italy
| | - P Borghetti
- Radiation Oncology, University and SpedaliCivili, Brescia, Italy
| | - F De Felice
- Radiation Oncology, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - C Greco
- Radiation Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - V Nardone
- RadiationOncology, Ospedale del Mare, Viale della Metamorfosi, Naples, Italy
| | - A Fiorentino
- Radiation Oncology, General Regional Hospital "F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - F Gregucci
- Radiation Oncology, General Regional Hospital "F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - I Desideri
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
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Hou PY, Hsieh CH, Wu LJ, Hsu CX, Kuo DY, Lu YF, Tien HJ, Hsiao HW, Shueng PW, Hsu SM. Modern Rotational Radiation Techniques with Volumetric Modulated Arc Therapy or Helical Tomotherapy for Optimal Sparing of the Lung and Heart in Left-Breast Cancer Radiotherapy Plus Regional Nodal Irradiation: A Comparative Dosimetric Analysis. Cancers (Basel) 2021; 13:cancers13205043. [PMID: 34680189 PMCID: PMC8534109 DOI: 10.3390/cancers13205043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary For advanced left-breast cancer patients, adjuvant radiotherapy (RT) with regional nodal irradiation (RNI) has been indicated to reduce cancer recurrence and mortality. Modern arc RT techniques, volumetric-modulated arc therapy (VMAT), or helical tomotherapy (HT), can minimize normal organ exposure without compromising disease control. The aim of this study is to identify which arc technique is optimal for patients receiving left-breast RT with RNI, and to explore distinct RNI volumes with or without IMN. A total of 108 eligible patients were enrolled (70 VMAT, 38 HT). VMAT reduced the mean dose and low-dose exposure to the heart, ipsilateral lung, whole lung, contralateral breast, and esophagus compared with HT. The advantage of VMAT for normal organ sparing was distinct when performing RNI with IMN irradiation. To limit normal organ exposure and reduce potential toxicities, VMAT is the optimal technique for patients with left-breast cancer who are undergoing RT with RNI. Abstract Background: For advanced breast cancer with lymph node involvement, adjuvant radiotherapy (RT) with regional nodal irradiation (RNI) has been indicated to reduce cancer recurrence and mortality. However, an extensive RT volume is associated with normal organ exposure, which increases the toxicity and affects patient outcomes. Modern arc RT techniques can improve normal organ sparing compared with conventional techniques. The aim of this study was to explore the optimal technique for left-breast RT with RNI. Methods: We retrospectively reviewed patients receiving RT with RNI for left-breast cancer. We used modern arc RT techniques with either volumetric-modulated arc therapy (VMAT) or helical tomotherapy (HT) with a novel block technique, and compared differences in dosimetry parameters between the two groups. Subgroup analysis of RNI with or without internal mammary node (IMN) volume was also performed. Results: A total of 108 eligible patients were enrolled between 2017 and 2020, of whom 70 received VMAT and 38 received HT. The median RT dose was 55 Gy. No significant differences were found regarding the surgery, RT dose, number of fractions, target volume, and RNI volume between the VMAT and HT groups. VMAT reduced the heart mean dose more than HT (3.82 vs. 5.13 Gy, p < 0.001), as well as the cardiac parameters of V5–V20, whole-lung mean dose, lung parameters of V5–V20, and contralateral-breast and esophagus mean dose. In the subgroup analysis of RNI with IMNs, the advantage of VMAT persisted in protecting the heart, lung, contralateral breast, and esophagus. HT was beneficial for lowering the thyroid mean dose. For RNI without IMN, VMAT improved the low-dose exposure of the heart and lung, but HT was similar to VMAT in terms of heart, whole-lung, and contralateral-breast mean dose. Conclusions: For patients with left-breast cancer receiving adjuvant RT with RNI, VMAT reduced the exposure dose to the heart, lung, contralateral breast, and esophagus compared with HT. VMAT was superior to HT in terms of normal organ sparing in the patients who underwent RNI with IMN irradiation. Considering the reduction in normal organ exposure and potential toxicity, VMAT is the optimal technique for patients receiving RNI when deep inspiration breath-hold is not available.
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Affiliation(s)
- Pei-Yu Hou
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei 220, Taiwan; (P.-Y.H.); (C.-H.H.); (L.-J.W.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.); (H.-J.T.); (H.-W.H.)
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 30010, Taiwan
| | - Chen-Hsi Hsieh
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei 220, Taiwan; (P.-Y.H.); (C.-H.H.); (L.-J.W.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.); (H.-J.T.); (H.-W.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 30010, Taiwan
- Institute of Traditional Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 30010, Taiwan
| | - Le-Jung Wu
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei 220, Taiwan; (P.-Y.H.); (C.-H.H.); (L.-J.W.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.); (H.-J.T.); (H.-W.H.)
| | - Chen-Xiong Hsu
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei 220, Taiwan; (P.-Y.H.); (C.-H.H.); (L.-J.W.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.); (H.-J.T.); (H.-W.H.)
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 30010, Taiwan
| | - Deng-Yu Kuo
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei 220, Taiwan; (P.-Y.H.); (C.-H.H.); (L.-J.W.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.); (H.-J.T.); (H.-W.H.)
| | - Yueh-Feng Lu
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei 220, Taiwan; (P.-Y.H.); (C.-H.H.); (L.-J.W.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.); (H.-J.T.); (H.-W.H.)
| | - Hui-Ju Tien
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei 220, Taiwan; (P.-Y.H.); (C.-H.H.); (L.-J.W.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.); (H.-J.T.); (H.-W.H.)
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 30010, Taiwan
| | - Hsiu-Wen Hsiao
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei 220, Taiwan; (P.-Y.H.); (C.-H.H.); (L.-J.W.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.); (H.-J.T.); (H.-W.H.)
| | - Pei-Wei Shueng
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei 220, Taiwan; (P.-Y.H.); (C.-H.H.); (L.-J.W.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.); (H.-J.T.); (H.-W.H.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 30010, Taiwan
- Correspondence: (P.-W.S.); (S.-M.H.); Tel.: +886-2-8966-7000 (ext. 1031) (P.-W.S.); +886-2-2826-5858 (S.-M.H.); Fax: +886-2-2820-1095 (S.-M.H.)
| | - Shih-Ming Hsu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 30010, Taiwan
- Correspondence: (P.-W.S.); (S.-M.H.); Tel.: +886-2-8966-7000 (ext. 1031) (P.-W.S.); +886-2-2826-5858 (S.-M.H.); Fax: +886-2-2820-1095 (S.-M.H.)
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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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Is it advantageous to use deep inspiration breath hold (DIBH) over free breathing for FAST-Forward dose fractionation scheme in treating carcinoma of left-sided breast? A dosimetric study. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396921000406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Aim:
To study the effect of deep inspiration breath hold (DIBH) on Fast-Forward trial for left-sided breast radiotherapy dosimetrically using tangential field-in-field (FiF), flattening filtered volumetric-modulated arc therapy (FF-VMAT) and flattening filter free volumetric-modulated arc therapy (FFF-VMAT) in comparison with free breathing (FB).
Methods:
Computed tomography images were acquired on 15 patients with carcinoma of left breast in FB and DIBH. Planning target volume (PTV) and organs at risk were contoured on both image sets. Dose of 26 Gy in five daily fractions was prescribed to PTV. FiF, FF-VMAT and FFF-VMAT plans were created in treatment planning system on both FB and DIBH. PTV V95%, V107%, D0·1 cc, CI and HI, heart V1·5 Gy, V7 Gy, lung left V8 Gy, monitor units (MU) and beam ON time were used for evaluation. Different technique analysis in same breathing condition and FB versus DIBH for same planning technique were performed.
Results:
Mean of all 15 patients was reported as mean ± 1 standard deviation. PTV V95% was 97·55 ± 0·10 (FiF), 95·75 ± 0·66 (FF-VMAT) and 96·15 ± 0·46 (FFF-VMAT) in FB while 97·34 ± 0·50 (FiF), 96·03 ± 0·71 (FF-VMAT) and 95·86 ± 0·63 (FFF-VMAT) in DIBH. Heart V7 Gy was 8·53 ± 4·26 (FiF), 8·86 ± 2·20 (FF-VMAT) and 9·27 ± 2·46 (FFF-VMAT) in FB while 6·30 ± 2·98 (FiF), 5·23 ± 2·20 (FF-VMAT) and 4·68 ± 2·01 (FFF-VMAT) in DIBH. p-value of heart V7 Gy between FB and DIBH was 0·278 (FiF), 0·009 (FF-VMAT) and 0·003 (FFF-VMAT). Beam ON time for FFF-VMAT was reduced by 65% (FF-VMAT) and 11% (FiF).
Conclusion:
Conformal dose to PTV was achieved better with VMAT plans. FFF-VMAT was delivered in less time compared to FF-VMAT and FiF for 26 Gy in five fractions. Heart dose can be significantly minimised with DIBH for VMAT plans.
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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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Comparison of thoracic and abdominal deep inspiration breath holds in whole-breast irradiation for patients with left-sided breast cancer. Breast Cancer 2021; 28:1154-1162. [PMID: 33907983 DOI: 10.1007/s12282-021-01259-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The deep inspiration breath hold (DIBH) technique is effective for heart dose reduction in patients with left-sided breast cancer. In deep breathing, some women breathe in thoracic respiration; and others, in abdominal respiration. This study evaluated differences in dose reduction in organs at risk (OAR) and reproducibilities of the target and OAR between thoracic DIBH (T-DIBH) and abdominal DIBH (A-DIBH). METHODS Fourteen patients with left-sided breast cancer who had planned to receive whole-breast irradiation were included. Computed tomography (CT) was performed in free breathing (FB), T-DIBH, and A-DIBH, and the dosimetric indexes of the target and OAR for three treatment plans were compared. In T-DIBH and A-DIBH, two series CTs were taken in each breathing method and the displacements of the target and heart were calculated. RESULTS The averaged mean heart doses (MHDs) were 1.5 Gy and 1.6 Gy in T-DIBH and A-DIBH, respectively, significantly lower than 2.7 Gy in FB (p < 0.001 for both breathing methods). Between T-DIBH and A-DIBH, no significant difference in MHD was found (p = 0.95); however, the percentage increase in lung volume positively moderately correlated with the reduction in MHD (R = 0.68). The three-dimensional target displacements were 2.3 mm in T-DIBH and 2.0 mm in A-DIBH (p = 0.64). The three-dimensional heart displacements were 1.7 mm in T-DIBH and 1.8 mm in A-DIBH (p = 0.85). CONCLUSION The present study demonstrates that the MHD and reproducibility did not differ between T-DIBH and A-DIBH. However, the superior breathing method for increasing lung volume should be determined for each patient.
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21
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Keikhai Farzaneh MJ, Momennezhad M, Naseri S. Gated Radiotherapy Development and its Expansion. J Biomed Phys Eng 2021; 11:239-256. [PMID: 33937130 PMCID: PMC8064130 DOI: 10.31661/jbpe.v0i0.948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/14/2018] [Indexed: 12/25/2022]
Abstract
One of the most important challenges in treatment of patients with cancerous tumors of chest and abdominal areas is organ movement. The delivery of treatment radiation doses to tumor tissue is a challenging matter while protecting healthy and radio sensitive tissues. Since the movement of organs due to respiration causes a discrepancy in the middle of planned and delivered dose distributions. The moderation in the fatalistic effect of intra-fractional target travel on the radiation therapy correctness is necessary for cutting-edge methods of motion remote monitoring and cancerous growth irradiancy. Tracking respiratory milling and implementation of breath-hold techniques by respiratory gating systems have been used for compensation of respiratory motion negative effects. Therefore, these systems help us to deliver precise treatments and also protect healthy and critical organs. It seems aspiration should be kept under observation all over treatment period employing tracking seed markers (e.g. fiducials), skin surface scanners (e.g. camera and laser monitoring systems) and aspiration detectors (e.g. spirometers). However, these systems are not readily available for most radiotherapy centers around the word. It is believed that providing and expanding the required equipment, gated radiotherapy will be a routine technique for treatment of chest and abdominal tumors in all clinical radiotherapy centers in the world by considering benefits of respiratory gating techniques in increasing efficiency of patient treatment in the near future. This review explains the different technologies and systems as well as some strategies available for motion management in radiotherapy centers.
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Affiliation(s)
- Mohammad Javad Keikhai Farzaneh
- PhD, Department of Medical Physics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- PhD, Department of Medical Physics, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Mehdi Momennezhad
- PhD, Department of Medical Physics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- PhD, Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shahrokh Naseri
- PhD, Department of Medical Physics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- PhD, Medical Physics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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22
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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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Assessment of deep inspiration breath hold technique setup reproducibility using mega voltage imaging for left breast cancer radiation therapy-integrated network study. Med Dosim 2020; 45:28-33. [PMID: 31153678 DOI: 10.1016/j.meddos.2019.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/20/2019] [Accepted: 04/29/2019] [Indexed: 11/23/2022]
Abstract
We evaluated daily setup reproducibility of deep inspiration breath hold (DIBH) using mega voltage (MV) imaging for left breast cancer radiation therapy. Analysis of 109 left breast cancer patients across UPMC Hillman Cancer Center network treated using DIBH technique with daily MV imaging was done. Patient characteristics, MV imaging procedure used and inter-fraction directional shifts were collected. For the statistical analyses, we separated all patients into 2 groups in each of the following 3 categories; (1) obese (BMI ≥ 30) vs nonobese, (2) mastectomy vs lumpectomy, (3) internal mammary node (IMN) treatment vs no IMN treatment. The group mean inter-fraction directional shifts were as following: (1) 0.7 mm (superior), 0.8 mm (inferior); (2) 0.65 mm (left), 0.64 mm (right); (3) 0.89 mm (anterior), 0.83 mm (posterior). Also, any directional shift ≥ 2 mm, ≥ 3 mm, ≥ 4 mm, ≥ 5 mm, ≥ 10 mm was found to be 52.9%, 37.6%, 30.9%, 21.9%, 3.7% of total fractions, respectively. In the stratified analysis, obese patients had larger directional shifts (p < 0.05) and highly associated with number of fractions for ≥ 5 mm in any directional shift compared to nonobese patients (29% vs 17%; p = 0.04). DIBH setup for left breast cancer treatment at our large cancer center network was reproducible with any mean directional shifts less than 1.0 mm using MV imaging. Daily imaging would be more beneficial for obese patients compared to nonobese patients.
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Browne P, Beaton N, Sharma H, Watson S, Mai GT, Harvey J, Bernard A, Brown E, Hargrave C, Lehman M. Identifying breast cancer patients who gain the most dosimetric benefit from deep inspiration breath hold radiotherapy. J Med Radiat Sci 2020; 67:294-301. [PMID: 32627421 PMCID: PMC7754004 DOI: 10.1002/jmrs.415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 05/23/2020] [Accepted: 06/05/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Deep inspiration breath hold (DIBH) has been proven to reduce cardiac dose for women receiving left breast and chest wall radiation therapy. However, it utilises extra departmental resources and patient exertion. The aim of this exploratory study was to investigate if any factors existed that could identify breast cancer patients who may benefit most from DIBH, to facilitate appropriate utilisation of departmental resources. METHODS Left-sided breast cancer patients aged 18-70 years, and right-sided breast cancer patients with internal mammary nodes included, were recruited. DIBH and free breathing (FB) plans were created for all patients. Patient demographic and clinical history were recorded. Variables including lung threshold value, lung volume, patient separation, maximum heart in field, volume of planning target volume (PTV), heart dose, ipsilateral lung dose were compared between plans. RESULTS Plans for 31 patients were analysed. No correlations were found between lung threshold value or patient separation and cardiac dose. Moderate to strong correlations were found with BMI, PTV volume and lung volume change however no definitive thresholds were determined. A significant difference was found in the maximum heart in field between DIBH and FB (P < 0.001) with those patients with greater than 0.7 cm heart in the field on the FB scan demonstrating greater reductions in mean heart dose. CONCLUSION Maximum heart in the field of greater than 0.7 cm in FB could be a potential factor to identify patients who may benefit most from DIBH. This factor warrants investigation in a larger patient cohort to test its validity.
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Affiliation(s)
- Patricia Browne
- Radiation Oncology DepartmentCancer ServicesPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Nakia‐Rae Beaton
- Radiation Oncology DepartmentCancer ServicesPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Harish Sharma
- Radiation Oncology DepartmentCancer ServicesPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Sharon Watson
- Radiation Oncology DepartmentCancer ServicesPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - G Tao Mai
- Radiation Oncology DepartmentCancer ServicesPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
| | - Jennifer Harvey
- Radiation Oncology DepartmentCancer ServicesPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
| | - Anne Bernard
- QFAB BioinformaticsInstitute for Molecular BioscienceUniversity of QueenslandBrisbaneQueenslandAustralia
| | - Elizabeth Brown
- Radiation Oncology DepartmentCancer ServicesPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- School of Clinical SciencesQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Catriona Hargrave
- Radiation Oncology DepartmentCancer ServicesPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- School of Clinical SciencesQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Margot Lehman
- Radiation Oncology DepartmentCancer ServicesPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
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Reducing Cardiac Radiation Dose From Breast Cancer Radiation Therapy With Breath Hold Training and Cognitive Behavioral Therapy. Top Magn Reson Imaging 2020; 29:135-148. [PMID: 32568976 DOI: 10.1097/rmr.0000000000000241] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The delivery of radiation therapy shares many of the challenges encountered in imaging procedures. As in imaging, such as MRI, organ motion must be reduced to a minimum, often for lengthy time periods, to effectively target the tumor during imaging-guided therapy while reducing radiation dose to nearby normal tissues. For patients, radiation therapy is frequently a stress- and anxiety-provoking medical procedure, evoking fear from negative perceptions about irradiation, confinement from immobilization devices, claustrophobia, unease with equipment, physical discomfort, and overall cancer fear. Such stress can be a profound challenge for cancer patients' emotional coping and tolerance to treatment, and particularly interferes with advanced radiation therapy procedures where active, complex and repetitive high-level cooperation is often required from the patient.In breast cancer, the most common cancer in women worldwide, radiation therapy is an indispensable component of treatment to improve tumor control and outcome in both breast-conserving therapy for early-stage disease and in advanced-stage patients. High technological complexity and high patient cooperation is required to mitigate the known cardiac toxicity and mortality from breast cancer radiation by reducing the unintended radiation dose to the heart from left breast or left chest wall irradiation. To address this, radiation treatment in daily deep inspiration breath hold (DIBH), to create greater distance between the treatment target and the heart, is increasingly practiced. While holding the promise to decrease cardiac toxicity, DIBH procedures often augment patients' baseline stress and anxiety reaction toward radiation treatment. Patients are often overwhelmed by the physical and mental demands of daily DIBH, including the nonintuitive timed and sustained coordination of abdominal thoracic muscles for prolonged breath holding.While technologies, such as DIBH, have advanced to millimeter-precision in treatment delivery and motion tracking, the "human factor" of patients' ability to cooperate and perform has been addressed much less. Both are needed to optimally deliver advanced radiation therapy with minimized normal tissue effects, while alleviating physical and cognitive distress during this challenging phase of breast cancer therapy.This article discusses physical training and psychotherapeutic integrative health approaches, applied to radiation oncology, to leverage and augment the gains enabled by advanced technology-based high-precision radiation treatment in breast cancer. Such combinations of advanced technologies with training and cognitive integrative health interventions hold the promise to provide simple feasible and low-cost means to improve patient experience, emotional outcomes and quality of life, while optimizing patient performance for advanced imaging-guided treatment procedures - paving the way to improve cardiac outcomes in breast cancer survivors.
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Yamauchi R, Mizuno N, Itazawa T, Saitoh H, Kawamori J. Dosimetric evaluation of deep inspiration breath hold for left-sided breast cancer: analysis of patient-specific parameters related to heart dose reduction. JOURNAL OF RADIATION RESEARCH 2020; 61:447-456. [PMID: 32100831 PMCID: PMC7299269 DOI: 10.1093/jrr/rraa006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/18/2019] [Accepted: 02/06/2020] [Indexed: 06/10/2023]
Abstract
Deep inspiration breath hold (DIBH) is a common method used worldwide for reducing the radiation dose to the heart. However, few studies have reported on the relationship between dose reduction and patient-specific parameters. The aim of this study was to compare the reductions of heart dose and volume using DIBH with the dose/volume of free breathing (FB) for patients with left-sided breast cancer and to analyse patient-specific dose reduction parameters. A total of 85 Asian patients who underwent whole-breast radiotherapy after breast-conserving surgery were recruited. Treatment plans for FB and DIBH were retrospectively generated by using an automated breast planning tool with a two-field tangential intensity-modulated radiation therapy technique. The prescribed dose was 50 Gy in 25 fractions. The dosimetric parameters (e.g., mean dose and maximum dose) in heart and lung were extracted from the dose-volume histogram. The relationships between dose-volume data and patient-specific parameters, such as age, body mass index (BMI), and inspiratory volume, were analyzed. The mean heart doses for the FB and DIBH plans were 1.56 Gy and 0.75 Gy, respectively, a relative reduction of 47%. There were significant differences in all heart dosimetric parameters (p < 0.001). For patients with a high heart dose in the FB plan, a relative reduction of the mean heart dose correlated with inspiratory volume (r = 0.646). There was correlation between the relative reduction of mean heart dose and BMI (r = -0.248). We recommend considering the possible feasibility of DIBH in low BMI patients because the degree of benefit from DIBH varied with BMI.
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Affiliation(s)
- Ryohei Yamauchi
- Department of Radiation Oncology, St Luke’s International Hospital, Tokyo, Japan
- Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan
| | - Norifumi Mizuno
- Department of Radiation Oncology, St Luke’s International Hospital, Tokyo, Japan
| | - Tomoko Itazawa
- Department of Radiation Oncology, St Luke’s International Hospital, Tokyo, Japan
| | - Hidetoshi Saitoh
- Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan
| | - Jiro Kawamori
- Department of Radiation Oncology, St Luke’s International Hospital, Tokyo, Japan
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CHANG CS, CHEN CH, LIU KC, HO CS, CHEN MF. Selection of patients with left breast cancer for IMRT with deep inspiration breath-hold technique. JOURNAL OF RADIATION RESEARCH 2020; 61:431-439. [PMID: 32123912 PMCID: PMC7299258 DOI: 10.1093/jrr/rraa003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/09/2019] [Accepted: 01/28/2020] [Indexed: 06/10/2023]
Abstract
The deep inspiration breath-hold (DIBH) technique has been utilized to reduce the cardiac dose in left-sided breast cancer (BC) patients undergoing radiotherapy. Further investigation of the parameters for selecting which patients will benefit most from DIBH is essential. We performed dosimetric comparisons for 21 patients with left-sided BC who had both computed tomography (CT)-based free-breathing (FB) and DIBH plans. The doses to the heart and left anterior descending artery (LAD) and any reduction due to the DIBH technique were analysed. Based on CTFB plans, dosimetric analysis revealed that the irradiation doses to the heart and LAD were significantly correlated with the target volume, the ipsilateral lung volume (ILV) and the total lung volume (TLV). When patients had an ILV ≥ 950 cm3 or a TLV ≥ 2200 cm3, the irradiation doses to the heart and LAD were significantly decreased. Furthermore, the reduction in the mean heart dose (MHD) was correlated to the difference in lung volume between FB and DIBH. The difference in ILV between DIBH and FB of 1.8 indicated that the patients obtained more benefit from the DIBH technique. The data suggest that lung volume (ILV and TLV) measured on a CT-simulation scan and the difference between FB and DIBH could be utilized to help select patients for DIBH.
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Affiliation(s)
- Chih-Shen CHANG
- Department of Radiation Oncology, Chang Gung Memorial Hospital at Chia-Yi, Putz City, Taiwan
| | - Chia-Hsin CHEN
- Department of Radiation Oncology, Chang Gung Memorial Hospital at Chia-Yi, Putz City, Taiwan
| | - Kuo-Chi LIU
- Department of Radiation Oncology, Chang Gung Memorial Hospital at Chia-Yi, Putz City, Taiwan
| | - Chia-Sheng HO
- Department of Radiation Oncology, Chang Gung Memorial Hospital at Chia-Yi, Putz City, Taiwan
| | - Miao-Fen CHEN
- Department of Radiation Oncology, Chang Gung Memorial Hospital at Chia-Yi, Putz City, Taiwan
- College of Medicine, Chang Gung University College of Medicine, Taiwan
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Practical Heart Sparing Breast Cancer Radiation Therapy Using Continuous Positive Airway Pressure (CPAP) in Resource-Limited Radiation Oncology Clinics. Am J Clin Oncol 2020; 42:797-801. [PMID: 31503062 DOI: 10.1097/coc.0000000000000597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to report experiences of practical heart sparing breast radiation therapy (RT) using continuous positive airway pressure (CPAP) in resource-limited radiation oncology clinics. PATIENTS AND METHODS Twelve patients underwent computed tomography-simulations with both free-breathing (FB) and CPAP under the individual maximum tolerable air pressure. For each patient, left-sided breast RT plans (9 with breast only, 3 with breast and regional nodal stations) with FB and CPAP were created using 3-dimensional conformal RT (supine tangential or wide tangential RT fields) according to RTOG 1304. For daily RT, patients started CPAP in the patients waiting area for 15 minutes before entering the treatment room and continued CPAP during RT. Treatment setup times between breast RT with and without CPAP were compared. RESULTS All patients tolerated CPAP well with 8 to 15 cm H2O of air pressure. Compared with FB, CPAP inflated the thorax and increased total lung volume by 35±16% (CPAP: 3136±751 vs. FB: 2354±657 cm, P<0.01); caudally displaced the heart by 1.8 cm (P<0.01); and decreased heart volume within tangential RT fields on computed tomography-simulation scans by 96±4% (1.4±2.5 vs. 21±17 cm, P=0.02) in all patients. Planning target volume coverage was acceptable in all RT plans. CPAP lowered mean dose (Dmean) to heart by 47±22% (2.5±1.5 vs. 5.4±3.3 Gy, P<0.01); heart volume receiving ≥25 Gy (V25) by 82±18% (2.2±2.6 vs. 9.1±7.1%, P<0.01); Dmean to left anterior descending coronary artery by 68±8% (4.7±1.9 vs. 14.8±3.3 Gy, P<0.01). CPAP decreased radiation dose to ipsilateral lung compared with FB: 9.1±5.8 versus 11.2±8 Gy (20% reduction, P=0.03) of Dmean; 15.7±12.5 vs. 20.5±17.5% (25% reduction, P=0.03) of V20. RT with CPAP did not increase treatment setup time compared with FB (week 1: 362±63 vs. 352±77 s; week 2 to 5: 217±13 vs. 201±14 s, all P>0.25). CONCLUSION Novel use of CPAP allowed efficient and practical heart sparing breast RT without increasing infrastructural requirements in resource-limited radiation oncology clinics.
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Lai J, Hu S, Luo Y, Zheng R, Zhu Q, Chen P, Chi B, Zhang Y, Zhong F, Long X. Meta-analysis of deep inspiration breath hold (DIBH) versus free breathing (FB) in postoperative radiotherapy for left-side breast cancer. Breast Cancer 2019; 27:299-307. [DOI: 10.1007/s12282-019-01023-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/31/2019] [Indexed: 12/25/2022]
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Kim A, Kalet AM, Cao N, Hippe DS, Fang LC, Young L, Meyer J, Lang EV, Mayr NA. Effects of Preparatory Coaching and Home Practice for Deep Inspiration Breath Hold on Cardiac Dose for Left Breast Radiation Therapy. Clin Oncol (R Coll Radiol) 2019; 30:571-577. [PMID: 29773446 DOI: 10.1016/j.clon.2018.04.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/23/2018] [Accepted: 04/05/2018] [Indexed: 11/19/2022]
Abstract
AIMS Deep inspiration breath hold (DIBH) reduces cardiac radiation exposure by creating cardiac-chest wall separation in breast cancer radiotherapy. DIBH requires sustaining chest wall expansion for up to 40 s and involves complex co-ordination of thoraco-abdominal muscles, which may not be intuitive to patients. We investigated the effect of in-advance preparatory DIBH coaching and home practice on cardiac doses. MATERIALS AND METHODS Successive patients from 1 February 2015 to 31 December 2016 with left-sided breast cancer who underwent tangential field radiotherapy utilising the DIBH technique were included. The study cohort consisted of patients treated by a physician who routinely provided DIBH coaching and home practice instructions at least 5 days before simulation. The control group included non-coached patients under another physician's care. Minimum, maximum and mean cardiac doses and V5, V10 and V30 from DIBH and free breathing simulation computed tomography scans were obtained from the planning system. DIBH and free breathing cardiac doses and volume exposures were compared between the coached and non-coached groups using the two-sample t-test, Fisher's exact test and the Mann-Whitney U-test. RESULTS Twenty-seven coached and 42 non-coached patients were identified. The DIBH maximum cardiac dose was lower in coached patients at 13.1 Gy compared with 19.4 Gy without coaching (P = 0.004). The percentage cardiac volume exposure in DIBH was lower in coached patients; the DIBH V10 was 0.5% without coaching and 0.1% with coaching (P = 0.005). There was also a trend towards lower DIBH V5 in the coached group compared with the non-coached group (1.2% versus 1.9%, P = 0.071). No significant differences in patient cardiopulmonary comorbidity factors that might influence cardiac doses were found between the groups. CONCLUSIONS Our results suggest that cardiac dose sparing can potentially be further improved with a 5 day regimen of preparatory DIBH coaching and in-advance home practice before simulation. These hypothesis-generating findings should be confirmed in a larger study.
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Affiliation(s)
- A Kim
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - A M Kalet
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - N Cao
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - D S Hippe
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - L C Fang
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - L Young
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - J Meyer
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - E V Lang
- Hypnalgesics, LLC, Brookline, MA, USA
| | - N A Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA.
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Schwahofer A, Jäkel O. [Planning target volume : Management of uncertainties, immobilization, image guided and adaptive radiation therapy]. Radiologe 2019; 58:736-745. [PMID: 29946893 DOI: 10.1007/s00117-018-0419-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
CLINICAL/METHODICAL ISSUE As a standard, today's radiation therapy is based on CT images which are used for therapy planning. These images are obtained once before therapy starts and serve as a basis to obtain the position and shape of the target volume. As the patient has to be positioned anew for each fraction, deviations of the tumor position relative to the radiation field but also internal motion of the tumor may occur. These deviations lead to uncertainties, which are taken into account by adding a safety margin around the clinical target volume (CTV) to create the planning target volume (PTV). STANDARD RADIOLOGICAL METHODS As a standard today, CT-based treatment planning is used, where images are obtained once prior to therapy. The information on tumor position and shape, which is obtained from these images, is used throughout the whole cycle of radiation therapy without any change. This cycle may last several weeks. METHODICAL INNOVATIONS By repeated imaging of the patient in the treatment position prior to each fraction, the position of the tumor can be assessed and corrected for each fraction. PERFORMANCE A reduction of positioning uncertainty may be used to reduce the safety margin. This leads to a decreased volume of irradiated normal tissue. ACHIEVEMENTS A reduced volume of irradiated normal tissue leads to reduced side effects and provides the opportunity of increased tumor control by dose escalation. PRACTICAL RECOMMENDATIONS Before the PTV is reduced, a detailed analysis of the uncertainties for the specific imaging method and radiation technique must be performed.
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Affiliation(s)
- A Schwahofer
- Abteilung Medizinische Physik in der Strahlentherapie, Deutsches Krebsforschungszentrum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland.
| | - O Jäkel
- Abteilung Medizinische Physik in der Strahlentherapie, Deutsches Krebsforschungszentrum Heidelberg, Im Neuenheimer Feld 280, 69120, Heidelberg, Deutschland
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Oechsner M, Düsberg M, Borm KJ, Combs SE, Wilkens JJ, Duma MN. Deep inspiration breath-hold for left-sided breast irradiation: Analysis of dose-mass histograms and the impact of lung expansion. Radiat Oncol 2019; 14:109. [PMID: 31215458 PMCID: PMC6582581 DOI: 10.1186/s13014-019-1293-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 05/08/2019] [Indexed: 11/22/2022] Open
Abstract
Background The aim of this study was to compare dose-volume histogram (DVH) with dose-mass histogram (DMH) parameters for treatment of left-sided breast cancer in deep inspiration breath-hold (DIBH) and free breathing (FB). Additionally, lung expansion and anatomical factors were analyzed and correlated to dose differences. Methods For 31 patients 3D conformal radiation therapy plans were retrospectively calculated on FB and DIBH CTs in the treatment planning system. The calculated doses, structures and CT data were transferred into MATLAB and DVHs and DMHs were calculated. Mean doses (Dmean), volumes and masses receiving certain doses (Vx, Mx) were determined for the left lung and the heart. Additionally, expansion of the left lung was evaluated using deformable image registration. Differences in DVH and DMH dose parameters between FB and DIBH were statistically analyzed and correlated to lung expansion and anatomical factors. Results DIBH reduced Dmean (DVH) and relative V20 (V20 [%]) of the left lung in all patients, on average by − 19 ± 9% (mean ± standard deviation) and − 24 ± 10%. Dmean (DMH) and M20 [%] were also significantly reduced (− 12 ± 11%, − 16 ± 13%), however 4 patients had higher DMH values in DIBH than in FB. Linear regression showed good correlations between DVH and DMH parameters, e.g. a dosimetric benefit smaller than 8.4% for Dmean (DVH) in DIBH indicated more irradiated lung mass in DIBH than in FB. The mean expansion of the left lung between FB and DIBH was 1.5 ± 2.4 mm (left), 16.0 ± 4.0 mm (anterior) and 12.2 ± 4.6 mm (caudal). No significant correlations were found between expansions and differences in Dmean for the left lung. The heart dose in DIBH was reduced in all patients by 53% (Dmean) and this dosimetric benefit correlated to lung expansion in anterior. Conclusions Treatment of left-sided breast cancer in DIBH reduced dose to the heart and in most cases the lung dose, relative irradiated lung volume and lung mass. A mass related dosimetric benefit in DIBH can be achieved as long as the volume related benefit is about ≥8–9%. The lung expansion (breathing pattern) showed no impact on lung dose, but on heart dose. A stronger chest breathing (anterior expansion) for DIBH seems to be more beneficial than abdominal breathing.
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Affiliation(s)
- Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.
| | - Mathias Düsberg
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| | - Kai Joachim Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Oberschleißheim, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Jan Jakob Wilkens
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.,Department of Radiotherapy and Radiation Oncology, Universitätsklinikum Jena, Jena, Germany
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Dell'Oro M, Giles E, Sharkey A, Borg M, Connell C, Bezak E. A Retrospective Dosimetric Study of Radiotherapy Patients with Left-Sided Breast Cancer; Patient Selection Criteria for Deep Inspiration Breath Hold Technique. Cancers (Basel) 2019; 11:cancers11020259. [PMID: 30813346 PMCID: PMC6406815 DOI: 10.3390/cancers11020259] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Several studies have investigated cardiac dose reduction when utilizing the deep inspiration breath hold (DIBH) technique in patients undergoing radiotherapy for left-sided breast cancer. This paper aims to recommend potential selection criteria based on a retrospective single institute study of free breathing (FB) and DIBH computed tomography (CT) simulation planning scans. Methods: Dosimetric comparisons were performed retrospectively for 20 patients correlating the dose reduction and patient anatomical factors (anatomical variation of chest shape, chest wall separation, total lung volume (TLV) and others). Results: Paired t-tests demonstrated significant cardiac dose reduction for most patients but not all. Minimal cardiac dose reduction was observed for three patients using their DIBH plan, with one patient receiving a higher dose. Linear regression analysis identified a positive correlation between the patient’s TLV (on the FB CT simulation scan) and the magnitude of dosimetric benefit received (0.4045 R2). Conclusion: The TLV measured on a FB plan could potentially be utilised to predict cardiac exposure and assist with patient selection for DIBH. This is important in resource allocation, as DIBH may be unnecessarily recommended for some patients with little dosimetric benefit.
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Affiliation(s)
- Mikaela Dell'Oro
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia.
| | - Eileen Giles
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia.
| | | | | | | | - Eva Bezak
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia.
- Department of Physics, University of Adelaide, Adelaide, SA 5005, Australia.
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Mkanna A, Mohamad O, Ramia P, Thebian R, Makki M, Tamim H, Jalbout W, Youssef B, Eid T, Geara F, Shahine B, Zeidan YH. Predictors of Cardiac Sparing in Deep Inspiration Breath-Hold for Patients With Left Sided Breast Cancer. Front Oncol 2018; 8:564. [PMID: 30538954 PMCID: PMC6277631 DOI: 10.3389/fonc.2018.00564] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 11/12/2018] [Indexed: 11/13/2022] Open
Abstract
Purpose: The purpose of this study was to evaluate patient-related non-dosimetric predictors of cardiac sparing with the use of deep inspiration breath-hold (DIBH) in patients with left-sided breast cancer undergoing irradiation (RT). Materials and Methods: We retrospectively reviewed charts and treatment plans of one-hundred and three patients with left-sided breast cancer. All patients had both free-breathing (FB) and DIBH (with body surface tracking) plans available. (MHD) and V4 (heart volume receiving at least 4 Gy) were extracted from dose volume histograms. Fisher's exact and Chi-square tests were used to identify predictors of reductions in MHD and V4 after DIBH. Results: One-hundred and three patients were identified and most underwent mastectomy. MHD and V4 decreased significantly in DIBH plans (0.74 ± 0.25 Gy vs. 1.72 ± 0.98 Gy, p < 0.0001 for MHD; 4 ± 4.98 cc vs. 20.79 ± 18.2 cc, p < 0.0001 for V4). Body mass index (BMI), smoking and timing of CT simulation (spring/winter vs. summer/fall) were significant predictors of reduction in MHD whereas BMI, field size, chemotherapy, axillary dissection, and timing of CT simulation predicted reduction in V4. On multivariate analysis, BMI, and timing of CT simulation remained significant predictors of the heart-sparing effect of DIBH. Conclusions: In the setting of limited resources, identifying patients who will benefit the most from DIBH is extremely important. Prior studies have identified multiple dosimetric predictors of cardiac sparing and hereby we identified new non-dosimetric factors such as BMI and timing of treatments.
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Affiliation(s)
- Abbas Mkanna
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Osama Mohamad
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Paul Ramia
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Ranim Thebian
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Maha Makki
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Wassim Jalbout
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Bassem Youssef
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Toufic Eid
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Fady Geara
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Bilal Shahine
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Youssef H Zeidan
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
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Chan TY, Tang JI, Tan PW, Roberts N. Dosimetric evaluation and systematic review of radiation therapy techniques for early stage node-negative breast cancer treatment. Cancer Manag Res 2018; 10:4853-4870. [PMID: 30425577 PMCID: PMC6205528 DOI: 10.2147/cmar.s172818] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Radiation therapy (RT) is essential in treating women with early stage breast cancer. Early stage node-negative breast cancer (ESNNBC) offers a good prognosis; hence, late effects of breast RT becomes increasingly important. Recent literature suggests a potential for an increase in cardiac and pulmonary events after RT. However, these studies have not taken into account the impact of newer and current RT techniques that are now available. Hence, this review aimed to evaluate the clinical evidence for each technique and determine the optimal radiation technique for ESNNBC treatment. Currently, six RT techniques are consistently used and studied: 1) prone positioning, 2) proton beam RT, 3) intensity-modulated RT, 4) breath-hold, 5) partial breast irradiation, and 6) intraoperative RT. These techniques show dosimetric promise. However, limited data on late cardiac and pulmonary events exist due to challenges in long-term follow-up. Moving forward, future studies are needed to validate the efficacy and clinical outcomes of these current techniques.
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Affiliation(s)
- Tabitha Y Chan
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore,
| | - Johann I Tang
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore,
| | - Poh Wee Tan
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore,
| | - Neill Roberts
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
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Bergom C, Currey A, Desai N, Tai A, Strauss JB. Deep Inspiration Breath Hold: Techniques and Advantages for Cardiac Sparing During Breast Cancer Irradiation. Front Oncol 2018; 8:87. [PMID: 29670854 PMCID: PMC5893752 DOI: 10.3389/fonc.2018.00087] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 03/13/2018] [Indexed: 12/17/2022] Open
Abstract
Historically, heart dose from left-sided breast radiotherapy has been associated with a risk of cardiac injury. Data suggests that there is not a threshold for the deleterious effects from radiation on the heart. Over the past several years, advances in radiation delivery techniques have reduced cardiac morbidity due to treatment. Deep inspiration breath hold (DIBH) is a technique that takes advantage of a more favorable position of the heart during inspiration to minimize heart doses over a course of radiation therapy. In the accompanying review article, we outline several methods used to deliver treatment with DIBH, quantify the benefits of DIBH treatment, discuss considerations for patient selection, and identify challenges associated with DIBH techniques.
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Affiliation(s)
- Carmen Bergom
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Adam Currey
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Nina Desai
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jonathan B Strauss
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Aznar MC, Duane FK, Darby SC, Wang Z, Taylor CW. Exposure of the lungs in breast cancer radiotherapy: A systematic review of lung doses published 2010-2015. Radiother Oncol 2018; 126:148-154. [PMID: 29246585 PMCID: PMC5807032 DOI: 10.1016/j.radonc.2017.11.022] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/15/2017] [Accepted: 11/25/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE We report a systematic review of lung radiation doses from breast cancer radiotherapy. METHODS AND MATERIALS Studies describing breast cancer radiotherapy regimens published during 2010-2015 and reporting lung dose were included. Doses were compared between different countries, anatomical regions irradiated, techniques and use of breathing adaptation. RESULTS 471 regimens from 32 countries were identified. The average mean ipsilateral lung dose (MLDipsi) was 9.0 Gy. MLDipsi for supine radiotherapy with no breathing adaption was 8.4 Gy for whole breast/chest wall (WB/CW) radiotherapy, 11.2 Gy when the axilla/supraclavicular fossa was irradiated, and 14.0 Gy with the addition of internal mammary chain irradiation; breathing adaptation reduced MLDipsi by 1 Gy, 2 Gy and 3 Gy respectively (p < 0.005). For WB/CW radiotherapy, MLDipsi was lowest for tangents in prone (1.2 Gy) or lateral decubitus (0.8 Gy) positions. The highest MLDipsi was for IMRT in supine position (9.4 Gy). The average mean contralateral lung dose (MLDcont) for WB/CW radiotherapy was higher for IMRT (3.0 Gy) than for tangents (0.8 Gy). CONCLUSIONS Lung doses from breast cancer radiotherapy varied substantially worldwide, even between studies describing similar regimens. Lymph node inclusion and IMRT use increased exposure, while breathing adaptation and prone/lateral decubitus positioning reduced it.
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Affiliation(s)
- Marianne C Aznar
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, UK; Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Denmark.
| | - Frances K Duane
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Sarah C Darby
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Zhe Wang
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Carolyn W Taylor
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, UK
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Corradini S, Ballhausen H, Weingandt H, Freislederer P, Schönecker S, Niyazi M, Simonetto C, Eidemüller M, Ganswindt U, Belka C. Left-sided breast cancer and risks of secondary lung cancer and ischemic heart disease : Effects of modern radiotherapy techniques. Strahlenther Onkol 2017; 194:196-205. [PMID: 28916844 DOI: 10.1007/s00066-017-1213-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 08/30/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Modern breast cancer radiotherapy techniques, such as respiratory-gated radiotherapy in deep-inspiration breath-hold (DIBH) or volumetric-modulated arc radiotherapy (VMAT) have been shown to reduce the high dose exposure of the heart in left-sided breast cancer. The aim of the present study was to comparatively estimate the excess relative and absolute risks of radiation-induced secondary lung cancer and ischemic heart disease for different modern radiotherapy techniques. METHODS Four different treatment plans were generated for ten computed tomography data sets of patients with left-sided breast cancer, using either three-dimensional conformal radiotherapy (3D-CRT) or VMAT, in free-breathing (FB) or DIBH. Dose-volume histograms were used for organ equivalent dose (OED) calculations using linear, linear-exponential, and plateau models for the lung. A linear model was applied to estimate the long-term risk of ischemic heart disease as motivated by epidemiologic data. Excess relative risk (ERR) and 10-year excess absolute risk (EAR) for radiation-induced secondary lung cancer and ischemic heart disease were estimated for different representative baseline risks. RESULTS The DIBH maneuver resulted in a significant reduction of the ERR and estimated 10-year excess absolute risk for major coronary events compared to FB in 3D-CRT plans (p = 0.04). In VMAT plans, the mean predicted risk reduction through DIBH was less pronounced and not statistically significant (p = 0.44). The risk of radiation-induced secondary lung cancer was mainly influenced by the radiotherapy technique, with no beneficial effect through DIBH. VMAT plans correlated with an increase in 10-year EAR for radiation-induced lung cancer as compared to 3D-CRT plans (DIBH p = 0.007; FB p = 0.005, respectively). However, the EARs were affected more strongly by nonradiation-associated risk factors, such as smoking, as compared to the choice of treatment technique. CONCLUSION The results indicate that 3D-CRT plans in DIBH pose the lowest risk for both major coronary events and secondary lung cancer.
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Affiliation(s)
- Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Hendrik Ballhausen
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Helmut Weingandt
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Philipp Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Cristoforo Simonetto
- Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany
| | - Markus Eidemüller
- Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany
| | - Ute Ganswindt
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Radiation Oncology, Medical University, Innsbruck, Austria
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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A 4D ultrasound real-time tracking system for external beam radiotherapy of upper abdominal lesions under breath-hold. Strahlenther Onkol 2016; 193:213-220. [DOI: 10.1007/s00066-016-1076-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
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Schönecker S, Walter F, Freislederer P, Marisch C, Scheithauer H, Harbeck N, Corradini S, Belka C. Treatment planning and evaluation of gated radiotherapy in left-sided breast cancer patients using the Catalyst TM/Sentinel TM system for deep inspiration breath-hold (DIBH). Radiat Oncol 2016; 11:143. [PMID: 27784326 PMCID: PMC5080745 DOI: 10.1186/s13014-016-0716-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 10/13/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There is a potential for adverse cardiovascular effects in long-term breast cancer survivors following adjuvant radiotherapy (RT). For this purpose, the deep inspiration breath-hold technique (DIBH) has been introduced into clinical practice, to maximally reduce the radiation dose to the heart. However, there are a variety of DIBH delivery techniques, patient positioning and visual patient feedback mechanisms. The aim of the present study was to evaluate the application of radiotherapy in DIBH using the CatalystTM/SentinelTM system, with a special emphasis on treatment planning and dosimetric plan comparison in free breathing (FB) and DIBH. PATIENTS AND METHODS A total of 13 patients with left-sided breast cancer following breast conserving surgery were included in this prospective clinical trial. For treatment application the CatalystTM/SentinelTM system (C-RAD AB, Uppsala, Sweden) was used and gating control was performed by an audio-visual patient feedback system. CT and surface data were acquired in FB and DIBH and dual treatment plans were created using Pencil Beam and Collapsed Cone Convolution. Dosimetric output parameters of organs at risk were compared using Wilcoxon signed-rank test. Central lung distance (CLD) was retrieved from iViewTM portal images during treatment delivery. RESULTS The system contains a laser surface scanner (SentinelTM) and an optical surface scanner (CatalystTM) interconnected to the LINAC systems via a gating interface and allows for a continuous and touchless surface scanning. Overall, 225 treatment fractions with audio-visual guidance were completed without any substantial difficulties. Following initial patient training and treatment setup, radiotherapy in DIBH with the CatalystTM/SentinelTM system was time-efficient and reliable. Following dual treatment planning for all patients, nine of 13 patients were treated in DIBH. In these patients, the reduction of the mean heart dose for DIBH compared to FB was 52 % (2.73 to 1.31 Gy; p = 0.011). The maximum doses to the heart and LAD were reduced by 59 % (47.90 to 19.74 Gy; p = 0.008) and 75 % (38.55 to 9.66 Gy; p = 0.008), respectively. In six of the nine patients the heart completely moved out of the treatment field by DIBH. The standard deviation of the CLD varied between 0.12 and 0.29 cm (mean: 0.16 cm). CONCLUSION The CatalystTM/SentinelTM system enabled a fast and reliable application and surveillance of DIBH in daily clinical routine. Furthermore, the present data show that using the DIBH technique during RT could significantly reduce high dose areas and mean doses to the heart. TRIAL REGISTRATION DRKS: DRKS00010929 registered on 5. August 2016.
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Affiliation(s)
- S Schönecker
- Department of Radiation Oncology, LMU University, Marchioninistraße 15, 81377, Munich, Germany
| | - F Walter
- Department of Radiation Oncology, LMU University, Marchioninistraße 15, 81377, Munich, Germany
| | - P Freislederer
- Department of Radiation Oncology, LMU University, Marchioninistraße 15, 81377, Munich, Germany
| | - C Marisch
- Medical Clinic and Policlinic I, LMU University, Munich, Germany
| | - H Scheithauer
- Department of Radiation Oncology, LMU University, Marchioninistraße 15, 81377, Munich, Germany
| | - N Harbeck
- Breast Center, Department of Obstetrics and Gynecology, LMU University, Munich, Germany
| | - S Corradini
- Department of Radiation Oncology, LMU University, Marchioninistraße 15, 81377, Munich, Germany.
| | - C Belka
- Department of Radiation Oncology, LMU University, Marchioninistraße 15, 81377, Munich, Germany
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Schönecker S, Heinz C, Söhn M, Haimerl W, Corradini S, Pazos M, Belka C, Scheithauer H. Reduction of cardiac and coronary artery doses in irradiation of left-sided breast cancer during inspiration breath hold : A planning study. Strahlenther Onkol 2016; 192:750-758. [PMID: 27632341 DOI: 10.1007/s00066-016-1039-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/12/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE The radiation dose received by the heart during adjuvant left-sided breast irradiation plays a crucial role in development of late toxicity. Although the absolute risk of cardiotoxicity can be reduced with modern irradiation techniques, cardiotoxic chemotherapy increases the risk of late damage. Thus, the radiation dose to the heart should be minimized. This study evaluated the influence of different amplitudes of inspiration breath hold (IBH) during simulated left-sided breast irradiation on cardiac doses compared to free breathing (FB). PATIENTS AND METHODS CT data of 11 lung cancer patients were retrospectively used as left-sided pseudo-breast cancer cases. Two CT scans were used, one during IBH and one during FB, and two treatment plans were generated. Relevant heart, lung, and left anterior descending artery (LAD) parameters were derived from dose-volume histograms. The normal tissue complication probabilities (NTCPs) for the heart were calculated based on the relative seriality model. Inspiration depth was quantified using chest volume and diameter, and correlated thereafter to a possible sparing of heart tissue. RESULTS Mean reduction of heart dose for IBH compared to FB was 40 % (1.65 vs. 0.99 Gy; p = 0.007). Maximum dose to the heart and LAD could be decreased by 33 % (p = 0.011) and 43 % (p = 0.024), respectively. The mean anteroposterior shift was 5 mm (range 0.9-9.5 mm). Significant negative correlations between the relative change in LAD mean dose and the mean thoracic diameter and volume change, as well as with the absolute change in thoracic diameter were seen. The NTCP for cardiac mortality could be decreased by about 78 % (p = 0.017). CONCLUSION For left-sided breast cancer patients, cardiac doses can be significantly decreased with tangential irradiation and IBH.
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Affiliation(s)
- S Schönecker
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilian-University, Ziemssenstr. 1, 80336, Munich, Germany
| | - C Heinz
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilian-University, Ziemssenstr. 1, 80336, Munich, Germany
| | - M Söhn
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilian-University, Ziemssenstr. 1, 80336, Munich, Germany
| | - W Haimerl
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilian-University, Ziemssenstr. 1, 80336, Munich, Germany
| | - S Corradini
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilian-University, Ziemssenstr. 1, 80336, Munich, Germany
| | - M Pazos
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilian-University, Ziemssenstr. 1, 80336, Munich, Germany
| | - C Belka
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilian-University, Ziemssenstr. 1, 80336, Munich, Germany
| | - H Scheithauer
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilian-University, Ziemssenstr. 1, 80336, Munich, Germany.
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Persson GF, Scherman Rydhög J, Josipovic M, Maraldo MV, Nygård L, Costa J, Berthelsen AK, Specht L, Aznar MC. Deep inspiration breath-hold volumetric modulated arc radiotherapy decreases dose to mediastinal structures in locally advanced lung cancer. Acta Oncol 2016; 55:1053-6. [PMID: 26935017 DOI: 10.3109/0284186x.2016.1142115] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 01/05/2016] [Accepted: 01/10/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Gitte F Persson
- a Department of Oncology , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
| | - Jonas Scherman Rydhög
- a Department of Oncology , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
- b Faculty of Science , Niels Bohr Institute, Copenhagen University , Copenhagen , Denmark
| | - Mirjana Josipovic
- a Department of Oncology , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
- b Faculty of Science , Niels Bohr Institute, Copenhagen University , Copenhagen , Denmark
| | - Maja V Maraldo
- a Department of Oncology , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
| | - Lotte Nygård
- a Department of Oncology , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
| | - Junia Costa
- a Department of Oncology , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
- c Department of Clinical Physiology, Nuclear Medicine and PET , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
| | - Anne K Berthelsen
- a Department of Oncology , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
- c Department of Clinical Physiology, Nuclear Medicine and PET , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
| | - Lena Specht
- a Department of Oncology , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
- d Faculty of Medical Sciences , Panum Institute, Copenhagen University , Copenhagen , Denmark
| | - Marianne C Aznar
- a Department of Oncology , Rigshospitalet Copenhagen University Hospital , Copenhagen , Denmark
- b Faculty of Science , Niels Bohr Institute, Copenhagen University , Copenhagen , Denmark
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Meyer P, Niederst C, Scius M, Jarnet D, Dehaynin N, Gantier M, Waissi W, Poulin N, Karamanoukian D. Is the lack of respiratory gating prejudicial for left breast TomoDirect treatments? Phys Med 2016; 32:644-50. [DOI: 10.1016/j.ejmp.2016.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/01/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022] Open
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Deep Inspiration Breath Hold-Based Radiation Therapy: A Clinical Review. Int J Radiat Oncol Biol Phys 2015; 94:478-92. [PMID: 26867877 DOI: 10.1016/j.ijrobp.2015.11.049] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 11/03/2015] [Accepted: 11/29/2015] [Indexed: 01/06/2023]
Abstract
Several recent developments in linear accelerator-based radiation therapy (RT) such as fast multileaf collimators, accelerated intensity modulation paradigms like volumeric modulated arc therapy and flattening filter-free (FFF) high-dose-rate therapy have dramatically shortened the duration of treatment fractions. Deliverable photon dose distributions have approached physical complexity limits as a consequence of precise dose calculation algorithms and online 3-dimensional image guided patient positioning (image guided RT). Simultaneously, beam quality and treatment speed have continuously been improved in particle beam therapy, especially for scanned particle beams. Applying complex treatment plans with steep dose gradients requires strategies to mitigate and compensate for motion effects in general, particularly breathing motion. Intrafractional breathing-related motion results in uncertainties in dose delivery and thus in target coverage. As a consequence, generous margins have been used, which, in turn, increases exposure to organs at risk. Particle therapy, particularly with scanned beams, poses additional problems such as interplay effects and range uncertainties. Among advanced strategies to compensate breathing motion such as beam gating and tracking, deep inspiration breath hold (DIBH) gating is particularly advantageous in several respects, not only for hypofractionated, high single-dose stereotactic body RT of lung, liver, and upper abdominal lesions but also for normofractionated treatment of thoracic tumors such as lung cancer, mediastinal lymphomas, and breast cancer. This review provides an in-depth discussion of the rationale and technical implementation of DIBH gating for hypofractionated and normofractionated RT of intrathoracic and upper abdominal tumors in photon and proton RT.
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