A VMAT planning technique for locally advanced breast cancer patients with expander or implant reconstructions requiring comprehensive postmastectomy radiation therapy

Locally advanced breast cancer patients with expander or implant reconstructions who require comprehensive postmastectomy radiotherapy (PMRT) can pose unique treatment planning challenges. Traditional 3D conformal radiation techniques often result in large dose inhomogeneity throughout the treatment volumes, inadequate target coverage, or excessive normal tissue doses. We have developed a volumetric modulated arc therapy (VMAT) planning technique without entering through the ipsilateral arm that produced adequate target volume coverage, excellent homogeneity throughout the target volume, and acceptable doses to the normal structures. Twenty left-sided and 10 right-sided patients with either ipsilateral or bilateral permanent implants or tissue expanders who received comprehensive PMRT between October 2014 and February 2016 were included in this study. Ten left-sided cases used deep inspiration breath hold (DIBH) technique, and others used free breathing (FB). Planning target volume (PTV) included chestwall, internal mammary nodes (IMNs), supraclavicular, and axillary lymph nodes. A VMAT plan using 4 or 5 partial arcs with 6 MV photon beam avoiding entering through the ipsilateral arm was generated for each patient. Prescription dose was 50 Gy in 25 fractions. PTV coverage, maximum depth of IMNs, dose homogeneity and dose to the heart, lungs, thyroid, contralateral intact breast or implant, liver, stomach, left anterior descending artery, ipsilateral brachial plexus, esophagus, spinal cord, and total MU were evaluated. PTV D95% (Gy) was 49.6 ± 0.9, 48.7 ± 0.9, and 49.5 ± 1.1; PTV D05% (Gy) was 55.7 ± 0.6, 55.1 ± 1.4, and 55.0 ± 0.7; maximum depth of IMNs (cm) was 4.3 ± 0.9, 4.6 ± 1.1, and 4.9 ± 2.3; ipsilateral lung, V20Gy (%) was 29.0 ± 2.1, 28.8 ± 2.5, and 27.5 ± 3.4; heart mean dose (Gy) was 4.2 ± 0.4, 7.5 ± 1.1, and 6.6 ± 0.8 for right-sided FB, left-sided FB, and left-sided DIBH cases, respectively. D95% of IMNs all received 100% prescription dose. The maximum dose (Gy) to the left anterior descending artery was 33.8 ± 11.7 for left-sided FB and 31.4 ± 7.3 for left-sided DIBH. VMAT technique avoiding ipsilateral arm can produce acceptable clinical plans for locally advanced breast cancer patients with expander or implant reconstructions receiving comprehensive PMRT.