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Zhang M, Zhang FX, Yang XL, Liang Q, Liu J, Zhou WB. Comparative dosimetric study of h-IMRT and VMAT plans for breast cancer after breast-conserving surgery. Transl Oncol 2024; 47:102012. [PMID: 38889521 PMCID: PMC11231535 DOI: 10.1016/j.tranon.2024.102012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 05/21/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
AIM To compare the dosimetric advantages and disadvantages between hybrid intensity-modulated radiation therapy (h-IMRT) and the volumetric modulated arc therapy (VMAT) technique in hypofractionated whole-breast irradiation (HF-WBI) for early-stage breast cancer (BC). METHODS The dose distribution of h-IMRT and VMAT plans was compared in 20 breast cancer patients. This comparison included evaluation of dosimetric parameters using dose volume histograms (DVHs) for the planning target volume (PTV) and organs-at-risk (OARs). Additionally, the study examined the normal tissue complication probability (NTCP), the second cancer complication probability (SCCP) and the tumor control probability (TCP) based on different models. RESULTS Significant differences were detected between the two plans, in terms of Machine units (MUs), the control points, 95 % volume (V95 %), dose homogeneity index (DHI) and conformity index (CI). The endpoint of grade II radiation pneumonitis and cardiac death due to ischemic heart disease were assessed. In h-IMRT plan, the NTCP values were marginally lower for radiation pneumonitis and slightly higher for cardiac death compared to VMAT plan, as determined by the Lyman-Kutcher-Burman model. The Schneider model was employed to predict the SCCP for both the bilateral lungs and contralateral breast, the results demonstrate that the h-IMRT plan outperforms the VMAT plan, with statistical significance. Additionally, the LQ-Poisson model was employed to forecast the TCP of the PTV, showing that the h-IMRT plan outperformed the VMAT plan (P > 0.05). CONCLUSION The h-IMRT technique, offering superior dose coverage and better therapeutic efficacy with fewer side effects as calculated by models, is more suitable for HF-WBI compared to the VMAT technique.
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Affiliation(s)
- Min Zhang
- Xiangya Hospital, Central South University, Hunan 41000, PR China
| | - Fang-Xu Zhang
- Fourth People's Hospital of Jinan, Jinan 250031, PR China
| | - Xiao-Lei Yang
- Fourth People's Hospital of Jinan, Jinan 250031, PR China
| | - Qian Liang
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Jian Liu
- Department of Otolaryngology-Head and Neck Surgery, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai 201700, PR China
| | - Wei-Bing Zhou
- Xiangya Hospital, Central South University, Hunan 41000, PR China.
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2
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Sarkar B, Pradhan A. Planning System-dependent Recommendations of Intensity-modulated Technique for Breast Radiotherapy: A Literature Review-based Adaptation and Institutional Dosimetric Experience from a Large-volume Tertiary Cancer Care Hospital. J Med Phys 2023; 48:221-229. [PMID: 37969141 PMCID: PMC10642598 DOI: 10.4103/jmp.jmp_51_23] [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: 04/20/2023] [Revised: 06/27/2023] [Accepted: 08/08/2023] [Indexed: 11/17/2023] Open
Abstract
This article aims to identify, through a literature review, the best intensity-modulated technique (IMRT)/volumetric-modulated arc therapy (VMAT) for the breast/chest wall (Br/CW) as a function of the treatment planning system (TPS) and present the institutional dosimetric data for the same. A PubMed search was conducted following intensity-modulated irradiation techniques (IMRT) presented in the study: field-in-field (FiF), tangential IMRT (t-IMRT), multi-field IMRT, tangential VMAT (t-VMAT), half-arc VMAT (HA-VMAT), and large arc VMAT (LA-VMAT). The literature with at least one arm VMAT is included in this study. A total of 370 articles were identified between 2010 and 2022, out of which 19 articles were found to be unique. These articles were classified in terms of the TPS used: Eclipse (9), Monaco (6), RayStation (2), Pinnacle (1), and one unidentified TPS. Based on the literature review, dosimetric attributes, and second cancer risk analysis (SCRA), t-IMRT was found to be the most preferable technique in Eclipse, Pinnacle, and RayStation TPS. However, for Monaco TPS, t-VMAT (approximately 30° tangential arc) offers better dose coverage with lower organ-at-risk (OAR) doses. In terms of OAR doses and SCRA, LA-VMAT (≥210°) and HA-VMAT (180°) are avoidable techniques in any TPS, and FiF should be preferred over these two techniques. In our present institution, which uses the Eclipse TPS, data for 300 patients treated with t-IMRT were collected. The data included beam angle, monitor unit [MU], target coverage (D95% and V105% [cc]), and analysis of the maximum (%), and mean dose (%) of the OAR. t-IMRT utilizes two medial and three lateral tangential beams placed at a spread of approximately 10° and 20°, respectively. The results showed a D95% of 96.3 ± 1.2% and a V105% of 4.9 ± 7.0 cc. The mean doses to the heart and ipsilateral lung were 10.1 ± 20.9% and 11.4 ± 10.2%, respectively. The mean MU was 1282.7 ± 453.4. Based on the findings, the most preferred intensity-modulated technique for Eclipse, Pinnacle, and RayStation is t-IMRT, while for Monaco, it is t-VMAT. The data from the Eclipse planning system demonstrate a satisfactory dosimetric outcome for t-IMRT. However, the use of VMAT techniques employing an arc angle between 180° and 210° or higher is strongly discouraged.
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Affiliation(s)
- Biplab Sarkar
- Department of Radiation Oncology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
- Department of Physics, GLA University, Mathura, Uttar Pradesh, India
| | - Anirudh Pradhan
- Director, Centre for Cosmology, Astrophysics and Space Science (CCASS), GLA University, Mathura, Uttar Pradesh, India
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3
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Song YQ, Hong J, Wang JY, Peng J, Han JH, Luo HL. Dosimetric comparison of different intensity-modulated radiotherapy techniques for whole-breast irradiation of right-breast cancer. Cancer Radiother 2023; 27:11-16. [PMID: 35879144 DOI: 10.1016/j.canrad.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/02/2022] [Accepted: 04/11/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE This study compared the dosimetric parameters of field-in-field forward intensity-modulated radiotherapy (FIF-IMRT) and fixed-field inversely optimized intensity-modulated radiotherapy (FFIO-IMRT) for the whole-breast irradiation of patients undergoing right-breast lumpectomy. MATERIAL AND METHODS A total of 30 patients with pT1-2N0M0 right-breast invasive ductal carcinoma were enrolled in this study. Two different treatment plans, i.e., FIF-IMRT and FFIO-IMRT, were designed for each patient. The dosimetric parameters of the two treatment plans were compared including ipsilateral lung and heart, conformity index (CI), and the homogeneity index (HI) of the planning target volume (PTV). RESULTS Fixed-field inversely optimized intensity-modulated radiotherapy was found to significantly improve CI (83.302% vs. 60.146%) and HI (11.837% vs. 19.280%), and significantly reduced V25 (18.038% vs. 19.653%) and V30 (15.790% vs. 18.492%) of the ipsilateral lung. It also significantly increased V5 (69.791% vs. 32.615%) of the ipsilateral lung and V5 (61.579% vs. 3.829%), V10 (14.130% vs. 0.381%), V20 (1.843% vs. 0.051%), and Dmean (5.211Gy vs. 1.870Gy) of the heart. CONCLUSION Regardless of improving the conformity and homogeneity of PTV and reducing the ipsilateral lung irradiation volume at high doses, FFIO-IMRT significantly raised the ipsilateral lung irradiated volume at low doses, as well as the irradiation volume and mean radiation doses to the heart. This limits its use in patients with early-stage right breast cancer.
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Affiliation(s)
- Y-Q Song
- Department of Radiation Oncology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, 223300 Huaian Jiangsu, China
| | - J Hong
- Department of Radiation Oncology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, 223300 Huaian Jiangsu, China
| | - J-Y Wang
- Department of Radiation Oncology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, 223300 Huaian Jiangsu, China
| | - J Peng
- Department of Radiation Oncology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, 223300 Huaian Jiangsu, China
| | - J-H Han
- Department of Radiation Oncology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, 223300 Huaian Jiangsu, China
| | - H-L Luo
- Department of Radiation Oncology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, 223300 Huaian Jiangsu, China.
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4
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Wang R, Shen J, Yan H, Gao X, Dong T, Li S, Wang P, Zhou J. Dosimetric comparison between intensity-modulated radiotherapy and volumetric-modulated arc therapy in patients of left-sided breast cancer treated with modified radical mastectomy: CONSORT. Medicine (Baltimore) 2022; 101:e28427. [PMID: 35029181 PMCID: PMC8757972 DOI: 10.1097/md.0000000000028427] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023] Open
Abstract
Volumetric-modulated arc therapy (VMAT) is a novel treatment strategy that protects normal tissues and enhances target volume coverage during radiotherapy.This study aimed to clarify whether VMAT is superior to intensity-modulated radiotherapy (IMRT) in treatment planning for left-sided breast cancer patients after modified radical mastectomy.Left-sided breast cancer patients treated with modified radical mastectomy were eligible for analysis. The dose distribution of both planning target volume and organs at risk were analyzed by using dose volume histograms.Twenty-four patients were eligible for analysis. Both VMAT and IMRT plans were sufficient in planning target volume coverage. In terms of conformity, VMAT was superior to IMRT (P = .034). Dmean, V5, and V10 of the heart were significantly decreased in VMAT plans when compared with IMRT plans. VMAT was as effective as IMRT plans in sparing of other normal tissues. In addition, both the mean number of monitor units and treatment time were significantly reduced when VMAT was compared with IMRT.VMAT plans was equivalent or superior to IMRT plans in dose distribution, and was associated with slightly advantage in sparing of the heart and coronary arteries. Our analyses suggested VMAT as a preferred option in left-sided breast cancer patients treated with modified radical mastectomy.
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5
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Cilla S, Romano C, Macchia G, Boccardi M, De Vivo LP, Morabito VE, Buwenge M, Strigari L, Indovina L, Valentini V, Deodato F, Morganti AG. Automated hybrid volumetric modulated arc therapy (HVMAT) for whole-breast irradiation with simultaneous integrated boost to lumpectomy area : A treatment planning study. Strahlenther Onkol 2021; 198:254-267. [PMID: 34767044 DOI: 10.1007/s00066-021-01873-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To develop an automated treatment planning approach for whole breast irradiation with simultaneous integrated boost using an automated hybrid VMAT class solution (HVMAT). MATERIALS AND METHODS Twenty-five consecutive patients with left breast cancer received 50 Gy (2 Gy/fraction) to the whole breast and an additional simultaneous 10 Gy (2.4 Gy/fraction) to the tumor cavity. Ipsilateral lung, heart, and contralateral breast were contoured as main organs-at-risk. HVMAT plans were inversely optimized by combining two open fields with a VMAT semi-arc beam. Open fields were setup to include the whole breast with a 2 cm flash region and to carry 80% of beams weight. HVMAT plans were compared with three tangential techniques: conventional wedged-field tangential plans (SWF), field-in-field forward planned tangential plans (FiF), and hybrid-IMRT plans (HMRT). Dosimetric differences among the plans were evaluated using Kruskal-Wallis one-way analysis of variance. Dose accuracy was validated using the PTW Octavius-4D phantom together with the 1500 2D-array. RESULTS No significant differences were found among the four techniques for both targets coverage. HVMAT plans showed consistently better PTVs dose contrast, conformity, and homogeneity (p < 0.001 for all metrics) and statistically significant reduction of high-dose breast irradiation. V55 and V60 decreased by 30.4, 26.1, and 20.8% (p < 0.05) and 12.3, 9.9, and 6.0% (p < 0.05) for SWF, FIF, and HMRT, respectively. Pretreatment dose verification reported a gamma pass-rate greater than the acceptance threshold of 95% for all HVMAT plans. In addition, HVMAT reduced the time for full planning optimization to about 20 min. CONCLUSIONS HVMAT plans resulted in superior target dose conformity and homogeneity compared to other tangential techniques. Due to fast planning time HVMAT can be applied for all patients, minimizing the impact on human or departmental resources.
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Affiliation(s)
- Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Largo Gemelli 1, 86100, Campobasso, Italy.
| | - Carmela Romano
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Largo Gemelli 1, 86100, Campobasso, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Mariangela Boccardi
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Livia P De Vivo
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vittoria E Morabito
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Largo Gemelli 1, 86100, Campobasso, Italy
| | - Milly Buwenge
- Radiation Oncology Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Lidia Strigari
- Medical Physics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Indovina
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Vincenzo Valentini
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alessio G Morganti
- Radiation Oncology Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,DIMES, Alma Mater Studiorum, Bologna University, Bologna, Italy
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6
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Duane FK, Kerr A, Wang Z, Darby SC, Ntentas G, Aznar MC, Taylor CW. Exposure of the oesophagus in breast cancer radiotherapy: A systematic review of oesophagus doses published 2010-2020. Radiother Oncol 2021; 164:261-267. [PMID: 34626725 DOI: 10.1016/j.radonc.2021.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/18/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Breast cancer radiotherapy can increase the risk of subsequent primary oesophageal cancer, with risk increasing according to oesophagus radiation dose. We describe oesophagus exposure from modern breast cancer regimens and discuss the risks of oesophageal cancer for women irradiated recently. MATERIALS AND METHODS A systematic review was undertaken of oesophagus doses from breast cancer radiotherapy regimens published during 2010-2020. Mean and maximum oesophagus doses were described for different target regions irradiated and different radiotherapy techniques. RESULTS In 112 published regimens from 18 countries, oesophagus doses varied with target region. For partial breast irradiation, average mean oesophagus dose was 0.2 Gy (range 0.1-0.4) in four regimens; maximum dose was not reported. For breast or chest wall radiotherapy, average oesophagus doses were mean 1.8 Gy (range 0.1-10.4) in 24 regimens and maximum 6.7 Gy (range 0.4-14.3) in seven regimens. For radiotherapy including a nodal region, average oesophagus doses were higher: mean 11.4 Gy (range <0.1-29.3) in 61 regimens and maximum 34.4 Gy (range 3.4-51.3) in 55 regimens. Average mean oesophagus doses were >10 Gy for intensity modulated nodal radiotherapy, but lower for other node techniques. CONCLUSIONS Mean oesophagus doses from partial breast and breast/chest wall regimens were usually less than 2 Gy, hence radiation-risks will be very small. However, for radiotherapy including lymph nodes, average mean oesophagus dose of 11.4 Gy may nearly double oesophageal cancer risk. Consideration of oesophageal exposure during nodal radiotherapy planning may reduce the risks of radiation-related oesophageal cancer for women irradiated today.
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Affiliation(s)
- Frances K Duane
- St. Luke's Radiation Oncology Network, St. Luke's Hospital, Dublin, Ireland; School of Medicine, Trinity College Dublin, Dublin, Ireland; Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland.
| | - Amanda Kerr
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zhe Wang
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah C Darby
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Guy's and St Thomas' NHS Foundation Trust, Department of Medical Physics, London, UK
| | - Marianne C Aznar
- Manchester Cancer Research Centre, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Carolyn W Taylor
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Macchia G, Pezzulla D, Cilla S, Boccardi M, Deodato F. New Technologies and Multidisciplinarity as Strategic Factors to Cope With Challenges in Postmastectomy Breast Cancer Radiation Therapy. Adv Radiat Oncol 2021; 6:100777. [PMID: 34604608 PMCID: PMC8473665 DOI: 10.1016/j.adro.2021.100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/25/2021] [Accepted: 08/09/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Donato Pezzulla
- Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Mariangela Boccardi
- Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
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8
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Piras A, Menna S, D'Aviero A, Marazzi F, Mazzini A, Cusumano D, Massaccesi M, Mattiucci GC, Daidone A, Valentini V, Boldrini L. New fractionations in breast cancer: a dosimetric study of 3D-CRT versus VMAT. J Med Radiat Sci 2021; 69:227-235. [PMID: 34551211 PMCID: PMC9163458 DOI: 10.1002/jmrs.530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 07/06/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Adjuvant radiation therapy (RT) following primary surgery in women affected by early breast cancer (EBC) plays a central role in reducing local recurrences and overall mortality. The FAST-FORWARD trial recently demonstrated that 1-week hypofractionated adjuvant RT is not inferior to the standard schedule in terms of local relapse, cosmetic outcomes and toxicity. The aim of this in silico study was to evaluate the dosimetric aspects of a 1-week RT course, administered through volumetric modulated arc therapy (VMAT), compared with traditional three-dimensional conformal radiation therapy (3D-CRT) with tangential fields. METHODS Patients affected by left-side EBC undergoing adjuvant RT were selected. ESTRO guidelines for the clinical target volume (CTV) delineation and FAST-FORWARD protocol for CTV to planning target volume (PTV) margin definition were followed. Total prescribed dose was 26 Gy in five fractions. The homogeneity index (HI) and the global conformity index (GCI) were taken into account for planning and dose distribution optimisation purposes. Both 3D-CRT tangential fields and VMAT plans were generated for each patient. RESULTS The analysis included 21 patients. PTV coverage comparison between 3D-CRT and VMAT plans showed significant increases for GCI (P < 0.05) in VMAT technique; no statistically significant differences were observed regarding HI. For organs at risks (OAR), statistically significant increases were observed in terms of skin V103% (P < 0.002) and ipsilateral lung V30% (P < 0.05) with 3D-CRT and of heart V5% (P < 0.05) with VMAT technique. CONCLUSIONS This in silico study showed that both 3D-CRT and VMAT are dosimetrically feasible techniques in the framework of 1-week hypofractionated treatments for left EBC.
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Affiliation(s)
- Antonio Piras
- Radioterapia Oncologica, Villa Santa Teresa, Bagheria, Palermo, Italy
| | - Sebastiano Menna
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | | | - Fabio Marazzi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | | | - Davide Cusumano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Mariangela Massaccesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Gian Carlo Mattiucci
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonino Daidone
- Radioterapia Oncologica, Villa Santa Teresa, Bagheria, Palermo, Italy
| | - Vincenzo Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
| | - Luca Boldrini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
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9
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Ambrose L, Stanton C, Lewis L, Lamoury G, Morgia M, Carroll S, Bromley R, Atyeo J. Potential gains: Comparison of a mono-isocentric three-dimensional conformal radiotherapy (3D-CRT) planning technique to hybrid intensity-modulated radiotherapy (hIMRT) to the whole breast and supraclavicular fossa (SCF) region. J Med Radiat Sci 2021; 69:75-84. [PMID: 33955205 PMCID: PMC8892437 DOI: 10.1002/jmrs.473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 04/01/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction Until late 2018, standard of practice at the Northern Sydney Cancer Centre (NSCC) for breast and nodal treatment was a conformal mono‐isocentric technique. A planning study comparing an existing mono‐isocentric three‐dimensional conformal radiotherapy (3D‐CRT) planning technique to a hybrid intensity‐modulated radiotherapy (hIMRT) approach for the whole breast and supraclavicular fossa (SCF) region was undertaken with the aim to improve plan quality by improving dose conformity/homogeneity across target volumes and reducing hotspots outside the target. Methods A cohort of 17 patients was retrospectively planned using the proposed hIMRT technique, keeping the same planning constraints as the original treated breast and SCF 3D‐CRT plan and normalising the 3D‐CRT plans to achieve minimum breast/SCF target coverage to compare organs at risk (OARs). Normal tissue index (NTI) and homogeneity index (HI) were compared for plan quality as well as for evaluating OARs. Results The hIMRT technique showed statistically significant improvements in NTI and HI, as well as improvement in maximum brachial plexus and thyroid doses. There was a negligible increase in maximum oesophagus dose which could be improved if used in optimisation. Other OAR doses in the irradiated region were comparable to the 3D‐CRT plans, however maximum doses were reduced overall. Conclusion The hIMRT planning technique maintained clinically acceptable doses to OARs and reduced normal tissue dose while maintaining equivalent dose coverage to breast and SCF planning target volumes with improved conformity and homogeneity. The reduction in maximum doses promotes a favourable toxicity profile, with potential benefit of improved long‐term cosmesis.
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Affiliation(s)
- Leigh Ambrose
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Cameron Stanton
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Lorraine Lewis
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Gillian Lamoury
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Marita Morgia
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Susan Carroll
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Regina Bromley
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - John Atyeo
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
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10
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Cilla S, Macchia G, Romano C, Morabito VE, Boccardi M, Picardi V, Valentini V, Morganti AG, Deodato F. Challenges in lung and heart avoidance for postmastectomy breast cancer radiotherapy: Is automated planning the answer? Med Dosim 2021; 46:295-303. [PMID: 33836910 DOI: 10.1016/j.meddos.2021.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 11/18/2022]
Abstract
Postmastectomy radiotherapy (PMRT) has been shown to improve the overall survival for invasive breast cancer patients. However, it represents a challenging treatment geometry and individualized planning strategies with complex field arrangements are usually adopted to decrease radiotoxicity to heart and lungs. Automated treatment planning has the potential to improve plan quality consistency and planning efficiency. Herein, we describe the application of the Pinnacle3 Autoplanning engine as a valuable technological resource able to allow the treatment of challenging patients theoretically unfit for radiotherapy for major cardiac and pulmonary comorbidities. Treatment was planned for three left-sided chest wall and regional lymph-nodes postmastectomy breast cancer patients. A deep inspiration breath-hold (DIBH) technique was used aiming to reduce the OARs irradiation. Three manually generated plans (hybrid-IMRT (HMRT), hybrid-VMAT (HVMAT) and full VMAT (MP-VMAT) and a fully automated plan created by the Autoplanning engine (AP-VMAT) were optimized in order to ensure a safe radiation therapy to the patients. The plans were evaluated based on planning target volumes (PTVs) coverage, dose homogeneity index (HI), conformity index (CN), dose to organs at risk (OARs) and normal tissue complication probabilities (NTCPs) of pericarditis, long term mortality and pneumonitis. Despite the use of deep moderated breath-hold, all human-driven plans failed to reach the stringent dose objectives for OARs. All plans provided an optimal coverage for chest wall and lymph-nodal area. AP-VMAT delivered the lowest mean dose to the heart (3.4 to 4.9 Gy) and ipsilateral lung (7.5 to 12.5 Gy) reporting the lowest NTCP for pneumonitis (<1%), confirming the only chance to comply the dose objectives. Moreover, AP-VMAT reported a decrease of the integral dose, which was lower by about 4-8% with respect to manual plans. AP-VMAT plan resulted in up to 58% increase of MUs with respect to manual plans, suggesting a more pronounced fluence modulation and plan complexity. A major difference was found for the planning time which was reduced to less than 30 minutes by using the Auto-Planning module. With improved planning quality and efficiency, Auto-planning is an effective tool to enable high-quality plans in challenging postmastectomy breast cancer radiotherapy.
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Affiliation(s)
- Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy.
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Carmela Romano
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | | | - Mariangela Boccardi
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Picardi
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Valentini
- Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy; Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy; DIMES, Alma Mater Studiorum, Bologna University, Bologna, Italy
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy; Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
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Ahmad I, Chufal KS, Bhatt CP, Miller AA, Bajpai R, Chowdhary RL, Pahuja AK, Chhabra A, Gairola M. Can the Choice of Radiotherapy Delivery Technique Influence Which Target Delineation Protocol to Use? A Plan-Quality-Based Analysis in Left Breast Cancer. ASIAN JOURNAL OF ONCOLOGY 2020. [DOI: 10.1055/s-0040-1722428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Abstract
Introduction This study investigates the optimal target delineation protocol stratified by treatment planning technique in patients undergoing whole breast radiotherapy after breast conservation surgery.
Materials and Methods Target delineation using Tangent (RTOG 0413 Whole Breast Irradiation Protocol), European SocieTy for Radiotherapy and Oncology (ESTRO), and Radiation Therapy & Oncology Group (RTOG) guidelines was performed on 10 randomly selected treatment planning computed tomography datasets of patients with left-sided breast cancer. An objective plan quality metric (PQM) scoring schema was defined and communicated to the medical physicist prior to commencement of treatment planning. Treatment planning was performed using field-in-field (FiF) intensity modulated radiotherapy technique (IMRT), inverse IMRT, and volumetric modulated arc therapy (VMAT), for each type of target. Two-way repeated measures, analysis of variance was utilized to compare the total PQM scores and dosimetric variables, stratified by treatment planning method.
Results Total PQM score of plans for FiF, IMRT, and VMAT revealed that Tangent and ESTRO delineations were equivalent regardless of planning technique (Tangent vs. ESTRO for FiF, p = 0.099; Tangent vs. ESTRO for IMRT, p = 0.029; Tangent vs. ESTRO for VMAT, p = 0.438). Both delineation protocols were significantly superior to RTOG for all treatment planning techniques.
Conclusion For all treatment planning techniques, ESTRO and Tangent delineation were equivalent and both achieved significantly higher scores than RTOG delineation.
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Affiliation(s)
- Irfan Ahmad
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Kundan Singh Chufal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Chandi Prasad Bhatt
- Department of Radiation Oncology, Sarvodaya Hospital and Research Centre, Faridabad, Haryana, India
| | - Alexis Andrew Miller
- Department of Radiation Oncology, Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - Ram Bajpai
- School of Medicine, Keele University, Staffordshire, United Kingdom
| | - Rahul Lal Chowdhary
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Anjali Kakria Pahuja
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Akanksha Chhabra
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Munish Gairola
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
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Is 5 mm breath-hold window (BHW) sufficient to treat carcinoma left breast patients post-conservative surgery: a comparative study using forward intensity-modulated radiotherapy (FIMRT) and volumetric modulated arc therapy (VMAT). JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurpose:The purpose of the study was to evaluate the impact of changes in breathing pattern inside the breath-hold window (BHW) during deep inspiration breath hold treatment for carcinoma left breast patients post-conservative surgery.Methods:Ten patients of carcinoma left breast post-conservative surgery were prospectively selected. Three sets of CT plain images were acquired, one with 5 mm deep inspiration BHW (DIBHR) and the other one with 1 mm BHW matching the lower threshold (DIBHL) and the third one with 1 mm BHW matching the upper threshold (DIBHH) as DIBHR. For all patients, forward intensity-modulated radiotherapy (FIMRT) and volumetric modulated arc therapy (VMAT) plans were generated in the 5 mm BHW CT series and the same plan being copy and pasted in other series. Target volume doses and critical structure doses were tabulated.Results:Planning target volume coverage was adequate and no significant differences were found in any CT series. Significant differences noted in average left lung V5%, V10% and V18% doses between DIBHR versus DIBHH (p values = 0·0461, 0·0283 and 0·0213, respectively) and DIBHL versus DIBHH (p values = 0·0434, 0·0484 and 0·0334, respectively) for FIMRT plans and V18% doses in DIBHR versus DIBHH (p = 0·0067) in VMAT. No differences in heart and apex of heart doses were found. Left anterior descending artery (LAD) mean doses were significant in DIBHL versus DIBHR, DIBHR versus DIBHH and DIBHL versus DIBHH (p = 0·0012, 0·0444 and 0·0048, respectively) series for FIMRT plans and DIBHR versus DIBHH and DIBHL versus DIBHH (p = 0·0341, 0·0001) for VMAT plans.Finding:The changes in the breathing pattern inside DIBH window level cause some variation in LAD doses and no other significant differences in any parameters noted, so care should be taken while treating patients with preexisting cardiac conditions.
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Objective Evaluation of Risk Factors for Radiation Dermatitis in Whole-Breast Irradiation Using the Spectrophotometric L*a*b Color-Space. Cancers (Basel) 2020; 12:cancers12092444. [PMID: 32872216 PMCID: PMC7563751 DOI: 10.3390/cancers12092444] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/23/2020] [Accepted: 08/26/2020] [Indexed: 12/31/2022] Open
Abstract
Simple Summary In this prospective study, radiation dermatitis severity of 142 Caucasian early breast cancer patients undergoing whole-breast irradiation was evaluated by physicians, the patients themselves and objective technical measurements. The primary aim and a substantial novelty of this study was to identify patient- and treatment-related risk factors for radiation dermatitis by using objective spectrophotometry: 24 patient or radiotherapy related parameters were evaluated as potential risk factors. Objective and significant risk factors for radiation dermatitis were the breast volume and the applied irradiation technique; a boost radiotherapy administration also showed a trend towards a slightly more severe radiation dermatitis. These results can help to identify those patients at increased risk of developing a severe radiation dermatitis, as susceptible patients may require special monitoring and timely treatment. Abstract Background: Radiation-induced dermatitis (RID) is frequent in breast cancer patients undergoing radiotherapy (RT). Spectrophotometry (SP) is an objective and reliable tool for assessing RID severity. Despite intensive research efforts during the past decades, no sustainable prophylactic and treatment strategies have been found. Estimation of new and reevaluation of established risk factors leading to severe RID is therefore of major importance. Methods: 142 early breast cancer patients underwent whole-breast irradiation following breast-conserving surgery. RID was evaluated by physician-assessed Common Terminology Criteria of Adverse Events (CTCAE v4.03). Spectrophotometers provided additional semi quantification of RID using the L*a*b color-space. A total of 24 patient- and treatment-related parameters as well as subjective patient-assessed symptoms were analyzed. Results: Values for a*max strongly correlated with the assessment of RID severity by physicians. Breast volume, initial darker skin, boost administration, and treatment technique were identified as risk factors for severe RID. RID severity positively correlated with the patients’ perception of pain, burning, and reduction of everyday activities. Conclusions: Physician-assessed RID gradings correlate with objective SP skin measurements. Treatment technique and high breast volumes were identified as objective and significant predictors of RID. Our data provide a solid benchmark for future studies on RID with objective SP.
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Jo IY, Kim ES, Kim WC, Min CK, Yeo S. Dosimetric comparison of incidental axillary irradiation between three‑dimensional conformal and volumetric modulated arc techniques for breast cancer. Mol Clin Oncol 2020; 12:551-556. [DOI: 10.3892/mco.2020.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 02/04/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
- In Young Jo
- Department of Radiation Oncology, Soonchunhyang University Hospital, Cheonan, Chungnam 31151, Republic of Korea
| | - Eun Seog Kim
- Department of Radiation Oncology, Soonchunhyang University Hospital, Cheonan, Chungnam 31151, Republic of Korea
| | - Woo Chul Kim
- Department of Radiation Oncology, Soonchunhyang University Hospital, Cheonan, Chungnam 31151, Republic of Korea
| | - Chul Kee Min
- Department of Radiation Oncology, Soonchunhyang University Hospital, Cheonan, Chungnam 31151, Republic of Korea
| | - Seung‑Gu Yeo
- Department of Radiation Oncology, Soonchunhyang University Hospital, Cheonan, Chungnam 31151, Republic of Korea
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Organ at risk dose calculation for left sided breast cancer treatments using intraoperative electron radiotherapy: A Monte Carlo-based feasibility study. Appl Radiat Isot 2020; 156:108977. [DOI: 10.1016/j.apradiso.2019.108977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/14/2019] [Accepted: 11/07/2019] [Indexed: 12/24/2022]
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Duma MN, Baumann R, Budach W, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Krug D, Piroth MD, Sedlmayer F, Souchon R, Sauer R. Heart-sparing radiotherapy techniques in breast cancer patients: a recommendation of the breast cancer expert panel of the German society of radiation oncology (DEGRO). Strahlenther Onkol 2019; 195:861-871. [PMID: 31321461 DOI: 10.1007/s00066-019-01495-w] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/27/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this review was to analyze the respective efficacy of various heart-sparing radiotherapy techniques. MATERIAL AND METHODS Heart-sparing can be performed in three different ways in breast cancer radiotherapy: by seeking to keep the heart out of treated volumes (i.e. by prone position or specific breathing techniques such as deep inspiration breath-hold [DIBH] and/or gating), by solely irradiating a small volume around the lumpectomy cavity (partial breast irradiation, PBI), or by using modern radiation techniques like intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT) or protons. This overview presents the available data on these three approaches. RESULTS Studies on prone position are heterogeneous and most trials only refer to patients with large breasts; therefore, no definitive conclusion can be drawn for clinical routine. Nonetheless, there seems to be a trend toward better sparing of the left anterior descending artery in supine position even for these selected patients. The data on the use of DIBH for heart-sparing in breast cancer patients is consistent and the benefit compared to free-breathing is supported by several studies. In comparison with whole breast irradiation (WBI), PBI has an advantage in reducing the heart dose. Of note, DIBH and PBI with multicatheter brachytherapy are similar with regard to the dose reduction to heart structures. WBI by IMRT/VMAT techniques without DIBH is not an effective strategy for heart-sparing in breast cancer patients with "standard" anatomy. A combination of DIBH and IMRT may be used for internal mammary radiotherapy. CONCLUSION Based on the available findings, the DEGRO breast cancer expert panel recommends the use of DIBH as the best heart-sparing technique. Nonetheless, depending on the treatment volume and localization, other techniques may be employed or combined with DIBH when appropriate.
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Affiliation(s)
- Marciana-Nona Duma
- Department of Radiotherapy and Radiation Oncology, University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07745, Jena, Germany.
| | | | - Wilfried Budach
- Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jürgen Dunst
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Petra Feyer
- Vivantes Hospital Neukoelln, Berlin, Germany
| | | | - Wulf Haase
- St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | | | - Thomas Hehr
- Marienhospital Stuttgart, Stuttgart, Germany
| | - David Krug
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Marc D Piroth
- Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Felix Sedlmayer
- Paracelsus Medical University Hospital Salzburg, Salzburg, Austria
| | | | - Rolf Sauer
- University Hospital Erlangen, Erlangen, Germany
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Arbor N, Gasteuil J, Noblet C, Moreau M, Meyer P. A GATE/Geant4 Monte Carlo toolkit for surface dose calculation in VMAT breast cancer radiotherapy. Phys Med 2019; 61:112-117. [PMID: 31036441 DOI: 10.1016/j.ejmp.2019.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/09/2019] [Accepted: 04/15/2019] [Indexed: 10/26/2022] Open
Abstract
The accuracy of superficial dose calculations for breast cancer treatments with Volumetric Modulated Arc Therapy (VMAT) is of major importance. For target volumes close to the surface, the inverse dosimetric planning can lead to very high fluences in the build-up region to properly cover the volume to be treated. Various radiotherapy modalities are currently used in parallel with additional protocols to enable a better control on the dose delivery (bolus, target volume margins). One of the difficulties currently facing medical physicists is the lack of available tools to test the impact of these different solutions on the superficial dose distribution. We present a new open source toolkit to assist medical physicists in evaluating the 3D distributions of superficial dose in VMAT breast cancer treatments. This tool is based on the GATE Monte Carlo software, a Geant4 application dedicated to medical physics. A set of macros has been developed to simulate in an easy way a full VMAT plan from the information available in the DICOM-RT files (image, plan, structure and dose). The toolkit has been tested on a 6 MV Varian NovalisTx™ accelerator. The paper presents a precise comparison of 3D surface dose distributions from experimental measurements (EBT3 films), TPS (Varian Eclipse) and Monte Carlo simulation (GATE). The comparison made it possible to highlight both the TPS biases for the surface dose calculation and the good performances of the developed toolkit. The simulation of surface dose distributions on a real patient has also been performed to illustrate the potential clinical applications.
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Affiliation(s)
- Nicolas Arbor
- Université de Strasbourg, IPHC, 23 rue du Loess, 67037 Strasbourg, France; CNRS, UMR7178, 67037 Strasbourg, France.
| | - Jean Gasteuil
- Division of Medical Physics, Department of Radiotherapy, Paul Strauss Center, Strasbourg, France
| | - Caroline Noblet
- Division of Medical Physics, Department of Radiotherapy, Paul Strauss Center, Strasbourg, France
| | - Matthieu Moreau
- Division of Medical Physics, Department of Radiotherapy, Paul Strauss Center, Strasbourg, France
| | - Philippe Meyer
- Division of Medical Physics, Department of Radiotherapy, Paul Strauss Center, Strasbourg, France
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Russo S, Esposito M, Hernandez V, Saez J, Rossi F, Paoletti L, Pini S, Bastiani P, Reggiori G, Nicolini G, Vanetti E, Tomatis S, Scorsetti M, Mancosu P. Does deep inspiration breath hold reduce plan complexity? Multicentric experience of left breast cancer radiotherapy with volumetric modulated arc therapy. Phys Med 2019; 59:79-85. [PMID: 30928069 DOI: 10.1016/j.ejmp.2019.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/14/2019] [Accepted: 02/20/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Volumetric modulated arc therapy (VMAT) for left breast treatments allows heart sparing without compromising PTV coverage. However, this technique may require highly complex plans. Deep Inspiration Breath Hold (DIBH) procedure increases the heart-to-breast distance, facilitating the dose sparing of the heart. The aim of the present work was to investigate if the cardiac-sparing benefits of the DIBH technique were achieved with lower plan modulation and complexity than Free Breathing (FB) treatments. METHODS AND MATERIALS Ten left side breast cases were considered by two centers with different treatment planning systems (TPS) and Linacs. VMAT plans were elaborated in FB and DIBH according to the same protocol. Plan complexity was evaluated by scoring several complexity indices. A new global score index accounting for both plan quality and dosimetric parameters was defined. Pre-treatment QA was performed for all VMAT plans using EPID and Epiqa software. RESULTS DIBH-VMAT plans were associated with significant PTV coverage improvement and mean heart dose reduction (p < 0.003), increasing the resulting global score index. All the evaluated complexity indices showed lower plan complexity for DIBH plans than FB ones, but only in few cases the results were statistically significant. All plans passed the gamma analysis with the selected criteria. CONCLUSIONS The DIBH technique is superior to the FB technique when the heart needs further sparing, allowing a reduction of the doses to OARs with a slightly lower degree of plan complexity and without compromising plan deliverability. These benefits were achieved regardless of the technological scenarios adopted.
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Affiliation(s)
| | - Marco Esposito
- Medical Physics Unit, AUSL Toscana Centro, Florence, Italy
| | - Victor Hernandez
- Department of Medical Physics, Hospital Universitari Sant Joan de Reus, Tarragona, Spain
| | - Jordi Saez
- Radiation Oncology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Lisa Paoletti
- Radiotherapy Unit, AUSL Toscana Centro, Florence, Italy
| | - Silvia Pini
- Medical Physics Unit, AUSL Toscana Centro, Florence, Italy
| | | | - Giacomo Reggiori
- Medical Physicist Group of Radiotherapy and Radiosurgery Dept., Humanitas Clinical and Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Giorgia Nicolini
- Medical Physics Team, Radiqa Developments, Bellinzona, Switzerland
| | - Eugenio Vanetti
- Medical Physics Team, Radiqa Developments, Bellinzona, Switzerland
| | - Stefano Tomatis
- Medical Physicist Group of Radiotherapy and Radiosurgery Dept., Humanitas Clinical and Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Dept, Humanitas Clinical and Research Hospital IRCCS, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Pietro Mancosu
- Medical Physicist Group of Radiotherapy and Radiosurgery Dept., Humanitas Clinical and Research Hospital IRCCS, Milan-Rozzano, Italy
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Xiang Q, Jie W, Zhu K, Wang Q, Cheng J. Which technique of positioning and immobilization is better for breast cancer patients in postmastectomy IMRT, single-pole or double-pole immobilization? J Appl Clin Med Phys 2018; 20:168-174. [PMID: 30512231 PMCID: PMC6333128 DOI: 10.1002/acm2.12506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 09/24/2018] [Accepted: 10/26/2018] [Indexed: 11/19/2022] Open
Abstract
Purpose Our purpose was to explore which immobilization is more suitable for clinical practice in postmastectomy intensity modulation radiotherapy, the single‐pole position or the double‐pole position? Methods Patients treated with postmastectomy intensity modulation radiotherapy were eligible. They were selected randomly for single‐pole position or double‐pole position. Dose–volume histogram (DVH) was used to evaluate plans. After their first radiotherapy, the physicians asked a question about the comfort level of their position. The dosimetric parameters, comfort levels, and reproducibility of the two immobilization techniques were collected and analyzed after all patients had finished the whole radiotherapy. Results Totally, 94 patients were enrolled. Of these, 54 patients were treated with the single‐pole position, 28 (51.9%)had left‐sided lesions. While 40 patients were treated with the double‐pole position, 20 (50%) had left‐sided lesions. Patients’ characteristics in two groups were comparable. The single‐pole and double‐pole immobilizations had similar conformity (0.60 ± 0.05 vs 0.60 ± 0.06, P = 0.887) and homogeneity index (0.14 ± 0.03 vs 0.13 ± 0.03, P = 0.407). Compared to single‐pole position, double‐pole position typically increased the mean dose, V20, and V30 of heart (P < 0.05). Moreover, patients in the single‐pole group felt more comfortable than another group (P < 0.05). There was no difference in reproducibility between the two groups (P > 0.05). Conclusions Single‐pole position seems to be more comfortable and can reduce dose coverage to heart. Both devices allow for reproducible setup and acceptable dosimetry.
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Affiliation(s)
- Qun Xiang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wuyun Jie
- Affiliated Tumor Hospital of Xinjiang Medical University, Urumuqi, China
| | - KuiKui Zhu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiong Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Cheng
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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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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Byrne M, Archibald‐Heeren B, Hu Y, Fong A, Chong L, Teh A. Comparison of semiautomated tangential VMAT with 3DCRT for breast or chest wall and regional nodes. J Appl Clin Med Phys 2018; 19:684-693. [PMID: 30125454 PMCID: PMC6123166 DOI: 10.1002/acm2.12442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/16/2018] [Accepted: 07/26/2018] [Indexed: 12/25/2022] Open
Abstract
Radiotherapy to the breast after surgery sometimes requires adjoining nodes to be included in the treatment volume. In these cases, the traditional approach has been a complex 3-Dimensional Conformal Radiotherapy (3DCRT) beam arrangement which can result in significant dose heterogeneity at the beam junctions. A Volumetric Modulated Arc Therapy (VMAT) beam arrangement has previously been proposed for breast cases, where the chest wall/breast is treated with a limited angle (partial arc) tangential VMAT technique (Virén et al. [2015] Radiat Oncol. 10:79). In our study, this approach is extended to breast and chest wall cases with adjoining nodes by adding a separate conventional VMAT arc field specifically limited to the superior nodes. This VMAT method was implemented using a semiautomated approach on 27 patients, and the resultant plan compared to a monoisocentric 3DCRT plan. Plan statistics, Dose-Volume Histogram (DVH) analysis and Radiation Oncologist (RO) preference were assessed. When compared to the 3DCRT technique, the VMAT planning method was found to result in better target volume coverage, high doses to organs at risk (OAR) were reduced but greater OAR volumes received low doses. Having said that, the volume receiving low doses with this tangential VMAT technique was less than that of other VMAT planning methods described in the literature, and the integral dose was less than the 3DCRT method. The VMAT technique also resulted in more robust junction doses that the 3DCRT method. RO review found that the VMAT technique was preferred in 81% of cases. Specifically, the VMAT plans were preferred in all categories of patients except left chest wall cases where the intermammary nodes were also treated. The VMAT technique described here is a useful addition to the treatment options available for breast/chest wall and nodal patients.
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Affiliation(s)
- Mikel Byrne
- Radiation Oncology CentresSydney Adventist HospitalWahroongaNSWAustralia
| | - Ben Archibald‐Heeren
- Radiation Oncology CentresSydney Adventist HospitalWahroongaNSWAustralia
- Radiation Oncology CentresGosfordNSWAustralia
| | - Yunfei Hu
- Centre of Medical Radiation PhysicsUniversity of WollongongWollongongNSWAustralia
- Radiation Oncology CentresGosfordNSWAustralia
| | - Andrew Fong
- Radiation Oncology CentresSydney Adventist HospitalWahroongaNSWAustralia
| | - Leena Chong
- Radiation Oncology CentresSydney Adventist HospitalWahroongaNSWAustralia
| | - Amy Teh
- Radiation Oncology CentresSydney Adventist HospitalWahroongaNSWAustralia
- Centre of Medical Radiation PhysicsUniversity of WollongongWollongongNSWAustralia
- Sydney Adventist Hospital Clinical SchoolSydney Medical SchoolUniversity of SydneySydneyNSWAustralia
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Cozzi L, Lohr F, Fogliata A, Franceschini D, De Rose F, Filippi AR, Guidi G, Vanoni V, Scorsetti M. Critical appraisal of the role of volumetric modulated arc therapy in the radiation therapy management of breast cancer. Radiat Oncol 2017; 12:200. [PMID: 29258539 PMCID: PMC5735809 DOI: 10.1186/s13014-017-0935-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
Background The aim of this review is the critical appraisal of the current use of volumetric modulated arc therapy for the radiation therapy management of breast cancer. Both clinical and treatment planning studies were investigated. Material and methods A Pubmed/MEDLINE search of the National Library of Medicine was performed to identify VMAT and breast related articles. After a first order rejection of the irrelevant findings, the remaining articles were grouped according to two main categories: clinical vs. planning studies and to some sub-categories (pointing to significant technical features). Main areas of application, dosimetric and clinical findings as well as areas of innovations were defined. Results A total of 131 articles were identified and of these, 67 passed a first order selection. Six studies reported clinical results while 61 treatment dealed with treatment planning investigations. Among the innovation lines, the use of high intensity photon beams (flattening filter free), altered fractionation schemes (simultaneous integrated boost, accelerated partial breast irradiation, single fraction), prone positioning and modification of standard VMAT (use of dynamic trajectories or hybrid VMAT methods) resulted among the main relevant fields of interest. Approximately 10% of the publications reported upon respiratory gating in conjunction with VMAT. Conclusions The role of VMAT in the radiation treatment of breast cancer seems to be consolidated in the in-silico arena while still limited evidence and only one phase II trial appeared in literature from the clinical viewpoint. More clinical reports are needed to fully proove the expected dosimetric benefits demonstrated in the planning investigations.
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Affiliation(s)
- Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy.
| | - Frank Lohr
- Radiation Oncology Department, Ospedaliero-Universitaria, Modena, Italy
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy
| | - Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy
| | - A R Filippi
- Department of Radiation Oncology, Osp. S. Luigi Gonzaga University Hospital, Torino, Italy
| | - Gabriele Guidi
- Medical Physics Department, Az. Ospedaliero-Universitaria, Modena, Italy
| | | | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
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Xi D, Ding Y, Hu R, Gu W, Mu J, Li Q. Advantages of a technique using two 50 degree arcs in simultaneous integrated boost radiotherapy for left-sidebreast cancer. Sci Rep 2017; 7:14748. [PMID: 29116237 PMCID: PMC5677093 DOI: 10.1038/s41598-017-15307-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/25/2017] [Indexed: 11/26/2022] Open
Abstract
This study evaluated radiotherapy techniques with 15 cases for simultaneous integrated boost to treat whole left breast and tumor bed following breast conserving surgery. Treatment plans were generated using three techniques: volumetric modulated arc therapy (VMAT) with a partial arc of 190° (1ARC), VMAT with two tangential mini-arcs of 50° each (2TARC) and intensity modulated radiation therapy with four fixed angle fields (4IMRT). Dosimetric parameters for the whole breast (Target), the boost tumor bed (Boost), and surrounding normal organs were compared. Chair Index (CHI) was introduced to evaluate the dose homogeneity in Target given the two levels of prescription dose. The dose coverage in Target was better in 1ARC and 2TARC than that in 4IMRT. The mean CHI in 1ARC (2.47) and 2TARC (2.62) were higher than that in 4IMRT (1.71, p < 0.05), and this indicated the dose homogeneity of Target was better in 1ARC and 2TARC than that in 4IMRT. The mean doses to right lung, and contralateral breast in 4IMRT were lower than those in 2TARC but the differences between them were small. 2TARC was better than 4IMRT with respect to the dose to ipsilateral lung and heart. Overall, 2TARC was optimal among three techniques.
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Affiliation(s)
- Dan Xi
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Yun Ding
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Rui Hu
- Department of Radiation Oncology, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 213003, China
| | - Wendong Gu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Jinming Mu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Qilin Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China.
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Duma MN, Münch S, Oechsner M, Combs SE. Heart-sparing radiotherapy in patients with breast cancer: What are the techniques used in the clinical routine?: A pattern of practice survey in the German-speaking countries. Med Dosim 2017; 42:197-202. [PMID: 28502653 DOI: 10.1016/j.meddos.2017.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 02/20/2017] [Accepted: 03/21/2017] [Indexed: 12/09/2022]
Abstract
The aim of this study was to understand the practice of care in German-speaking countries with regard to heart-sparing radiotherapy techniques. Between August 2015 and September 2015, an e-mail/fax-based survey was sent to radiation oncology departments in Germany, Austria, and the German-speaking Switzerland. The questionnaire was divided into 3 chapters: a general chapter on the department, a chapter specific for heart-sparing techniques in patients with breast cancer, and a third chapter on personal beliefs on the topic of heart sparing in patients with breast cancer. A total of 82 radiation oncology departments answered the questionnaire: 16 university clinics and 66 other departments. In general, heart-sparing techniques are being offered by 90.2% of departments for radiation oncology in the German-speaking countries. However, in the clinical routine, 87.7% of institutions use heart-sparing techniques in less than 50% of patients with breast cancer. Heart-sparing techniques are especially provided for patients with left-sided breast cancer (80%), patients after mastectomy (52.5%), and when the mammaria interna lymph drainage vessels are irradiated (41.3%). In 46.3% of departments, there are written internal guidelines for heart sparing in patients with breast cancer. Breathing-adapted radiotherapy is used as the most frequent heart-sparing technique in 64.7% of the institutions, followed by intensity-modulated radiation therapy, which is most frequently used by 22.1%. The only significant difference between university hospitals and other departments was seen for the offering of partial breast irradiation. The most commonly used heart-sparing technique is breathing-adapted radiotherapy, but there is no coherent approach for heart sparing in patients with breast cancer in the German-speaking countries. Overall, all options for cardiac protection/cardiac avoidance have their advantages and disadvantages, with deep inspiration breath-hold radiotherapyhaving the most clear data, which should be the preferred choice when using heart-sparing techniques.
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Affiliation(s)
- Marciana-Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675 München, Germany; Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764 Oberschleißheim, Germany; Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), München, Germany.
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675 München, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675 München, Germany; Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), München, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675 München, Germany; Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764 Oberschleißheim, Germany; Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), München, Germany
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Chen YG, Li AC, Li WY, Huang MY, Li XB, Chen MQ, Zhang M, Xu BH. The Feasibility Study of a Hybrid Coplanar Arc Technique Versus Hybrid Intensity-modulated Radiotherapy in Treatment of Early-stage Left-sided Breast Cancer with Simultaneous-integrated Boost. J Med Phys 2017; 42:1-8. [PMID: 28405101 PMCID: PMC5370332 DOI: 10.4103/jmp.jmp_105_16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This study demonstrated the feasibility and advantages of a hybrid, volumetric arc therapy technique that used two 90° coplanar arcs and two three-dimensional conformal tangential beams in the simultaneous-integrated boost radiotherapy of left-sided breast cancer after breast-conserving surgery. A total of nine patients with stage I, left-sided breast cancer who underwent breast-conserving surgery were selected for this retrospective study. For each patient, a hybrid arc plan was generated and then compared with two hybrid intensity-modulated radiotherapy plans. All plans were optimized using the same objectives and dose constraints. The prescription dose was 50.4 Gy to the planning target volume with simultaneous boost to 60 Gy to the expanded gross target volume in 28 fractions. The differences among these hybrid plans were analyzed by the Kolmogorov–Smirnov test or the Wilcoxon rank sum test. The hybrid arc plans achieved the clinical requirements of target dose coverage and normal tissue (NT) dose constraints. It was found that the hybrid arc plans showed advantages in the conformity index of the expanded gross target volume, the V5 of the heart, the D2 of the left ventricle, and the D2 and V50.4 of NTs. The average beam-on time and monitor units of the hybrid arc plans were significantly lower (P < 0.001).
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Affiliation(s)
- Yuan-Gui Chen
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - An-Chuan Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Wen-Yao Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Miao-Yun Huang
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Xiao-Bo Li
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Ming-Qiu Chen
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Mutian Zhang
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ben-Hua Xu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
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Left-sided breast radiotherapy after conservative surgery: comparison of techniques between volumetric modulated arc therapy, forward-planning intensity-modulated radiotherapy and conventional technique. JOURNAL OF RADIOTHERAPY IN PRACTICE 2016. [DOI: 10.1017/s1460396916000509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjectiveThis study was conducted for comparison of techniques between volumetric modulated arc therapy (VMAT), forward-planning intensity-modulated radiotherapy (FIMRT) and conventional technique for left-sided breast radiotherapy after conservative surgery.MethodsIn all, 20 postoperative left breast carcinoma patients were included in this study. In all plans the planning target volume (PTV) was the breast tissue with appropriate margin as per our institutional protocol. The contouring was done on a Monaco Sim (V5.00.02) contouring workstation. All patient were planned using partial arc VMAT in Monaco treatment planning system (TPS) (V5.00.02) and treated on Elekta Synergy linear accelerator. The 3D conformal radiotherapy (3DCRT) and FIMRT planning were done in CMS XIO (V5.00.01.1) TPS. The 3DCRT planning consisted of conventional medial and tangential wedge portals with multileaf collimator field shaping conforming to the target volume. For all the plans generated the following metrics were scored: V105%, V100%, V95%, mean dose (for PTV), V5%, V20%, D2cc and mean dose (for organs at risk).ResultsThe mean PTV volume for 20 patients was 1,074·6±405·1 cc. The highest PTV dose coverage was observed in the 3DCRT technique with 94·1±1·8% of the breast PTV receiving 95% of the prescription dose (V95%). However, it was also observed that this technique resulted in 21·3±10% of the PTV receiving more than 105% of the prescription dose (V105%), which was highest among the three techniques. In contrast, VMAT yielded lowest V95% of 93·0±1·8 and 3·3±5·5% of V105%.ConclusionThis study concluded equivalent result between FIMRT and VMAT. However, VMAT was found to be the choice of radiotherapy technique as it produces lesser dose distribution to heart compared with any other technique.
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Xu H, Hatcher G. Treatment planning study of Volumetric Modulated Arc Therapy and three dimensional field-in-field techniques for left chest-wall cancers with regional lymph nodes. Rep Pract Oncol Radiother 2016; 21:517-524. [PMID: 27698592 PMCID: PMC5036511 DOI: 10.1016/j.rpor.2016.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/31/2016] [Accepted: 07/07/2016] [Indexed: 11/22/2022] Open
Abstract
AIM This study aims to investigate whether there are dosimetric advantages to using VMAT (Volumetric Modulated Arc Therapy) for left-sided chest-wall patients over the three-dimensional conformal field-in-field (FinF) technique. BACKGROUND There is a lack of dosimetric studies dedicated for chest-wall patients. Potential dosimetric advantage could be obtained using VMAT due to complex geometry of PTVs (Planning Target Volumes) and OARs (Organs at Risk) in chest-wall and lymph nodes. MATERIALS AND METHODS VMAT and FinF plans were generated and evaluated based on DVHs (Dose Volume Histograms) for both PTVs and OARs for 22 left-sided chest-wall patients with involved regional nodes. PTV HIs (Homogeneity Indices) and CIs (Conformity Indices), and EUDs (Equivalent Uniform Doses) for PTVs and OARs were also evaluated for comparisons between VMAT and FinF. RESULTS FinF planning met PTV criteria adequately in all cases except two. In these two cases, VMAT was able to meet PTV criteria adequately. VMAT demonstrated significant reduction in left lung V20 Gy in chest-wall patients compared to FinF plans. The volumes of the right lung and right breast receiving 5 Gy were much higher in VMAT than those in FinF for all patients. CONCLUSIONS Compared to the FinF technique, there is a generally limited benefit using VMAT for left-sided chest-wall patients due to large low-dose-bath to OARs with insignificant improvement in PTV coverage. In case where FinF planning cannot meet dose constrains, VMAT provides a viable option. The use of VMAT planning over the FinF technique in chest-wall cancers should be carefully analyzed on an individual basis.
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Affiliation(s)
- Heping Xu
- Cape Breton Cancer Centre, Nova Scotia Health Authority, 1482 George St., Sydney, NS, Canada B1P 1P3
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
| | - Gillian Hatcher
- Cape Breton Cancer Centre, Nova Scotia Health Authority, 1482 George St., Sydney, NS, Canada B1P 1P3
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Three-dimensional conformal versus intensity modulated radiotherapy in breast cancer treatment: is necessary a medical reversal? Radiol Med 2016; 122:146-153. [DOI: 10.1007/s11547-016-0700-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
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Yu J, Hu T, Chen Y. Small-arc volumetric-modulated arc therapy: A new approach that is superior to fixed-field IMRT in optimizing dosimetric and treatment-relevant parameters for patients undergoing whole-breast irradiation following breast-conserving surgery. Medicine (Baltimore) 2016; 95:e4609. [PMID: 27559956 PMCID: PMC5400323 DOI: 10.1097/md.0000000000004609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Volumetric-modulated arc therapy (VMAT) is considered to deliver a better dose distribution and to shorten treatment time. There is a lack of research regarding breast irradiation after breast-conserving surgery (BCS) using VMAT with prone positioning. We developed a new small-arc VMAT methodology and compared it to conventional (fixed-field) intensity-modulated radiation therapy (IMRT) in the dosimetric and treatment relevant parameters for breast cancer patients in the prone position.Ten early-stage breast cancer patients were included in this exploratory study. All patients underwent computed tomography (CT) simulation scan in the prone position and for each patient, IMRT and VMAT plans were generated using the Monaco planning system. Two symmetrical partial arcs were applied in the VMAT plans. The angle ranges of the 2 arcs were set to approximately 60° to 100° and 220° to 260°, with small adjustments to maximize target coverage, while minimizing lung and heart exposure. The IMRT plans used 4 fixed fields. Prescribed doses were 50 Gy in 25 fractions. The target coverage, homogeneity, conformity, dose to organs at risk (OAR), treatment time, and monitor units (MU) were evaluated.Higher median conformal index (CI) and lower homogeneity index (HI) of the planning target volume (PTV) were respectively observed in VMAT and plans group (CI, 95% vs 91%; HI, 0.09 vs 0.12; P < 0.001). The volumes of ipsilateral lung receiving 30, 20, 10, and 5 Gy were lower for VMAT (P < 0.01), being 10%, 14.9%, 25.9%, and 44.9%, respectively, compared to 11.79%, 17.32%, 30.27%, and 50.58% for the IMRT plans. The mean lung dose was also reduced from 10.6 ± 1.8 to 9.6 ± 1.4 Gy (P = 0.001). The volumes of the heart receiving 30 and 40 Gy were similar for the 2 methods. In addition, the median treatment time (161 vs 412 seconds; P < 0.001) and the mean MU (713 vs 878; P < 0.001) were lower for VMAT.Small-arc VMAT plan improved CI and HI for the target, spared the dose of lung, and reduced treatment time and MU, compared to IMRT. It is a more promising irradiation technique for post-BCS radiotherapy.
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Affiliation(s)
- Jing Yu
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Tao Hu
- Department of Oncology, the Central Hospital of Wuhan
| | - Yeshan Chen
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
- Correspondence: Yeshan Chen, Cancer Center, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wujiadun Road 156, Wuhan 430022, P.R. China (e-mail: )
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Zhao H, He M, Cheng G, Han D, Wu N, Shi D, Zhao Z, Jin J. A comparative dosimetric study of left sided breast cancer after breast-conserving surgery treated with VMAT and IMRT. Radiat Oncol 2015; 10:231. [PMID: 26577189 PMCID: PMC4650319 DOI: 10.1186/s13014-015-0531-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 10/28/2015] [Indexed: 11/24/2022] Open
Abstract
Background and purposes This study compared VMAT and IMRT plans for intact breast radiotherapy for left sided breast cancer and evaluated the irradiated dose of planning target volume and OARs, especially focusing on heart and coronary artery. Materials and methods Eleven patients with left sided breast cancer whose breast was relatively smaller (the mean volumes is 296 cc) treated with breast-conserving surgery were prescribed radiotherapy of 50 Gy in 25 fractions using two or four-field step and shoot IMRT (2 or 4-F IMRT), and one or two-arc VMAT (1 or 2-arc VMAT). The 10 Gy electron boost to the tumor bed after delivery of 50 Gy was not included in the analysis. Multiple planning parameters for the PTV and the PRV-OARs were measured and analyzed. Results Treatment plans generated using VMAT had better PTV homogeneity than the IMRT plans. For the PRV-OARs, the 1-arc VMAT had significantly higher Dmean and V5 for left lung and heart, and showed worse Dmean for liver, esophagus, spinal cord, contralateral lung and breast. In contrast, the 2-arc VMAT and the 2-F or 4-F IMRT plans showed better results for the PRV-OARs than the 1-arc VMAT. However, for the heart and coronary artery, the 1-arc VMAT showed better V20 and V40 compared with the other plans. Moreover, the 2 F-IMRT had specially advantage on V5 and V20 for heart and V5 for coronary arteries, the 2-F IMRT also showed a greater MU and treatment times. Using the table of quality score to evaluate the plans, we found that 2-F IMRT had the highest scores of 13, followed by the 2-arc VMAT plan (10 points) and 1-arc VMAT plan (8 points), and finally the 4-F IMRT plan (6 points). Moreover, when a dose comparison for heart minus coronary artery was calculated, the V20 and V40 for the rest of heart in all plans were very small and closed, indicating the dose to the coronary artery contributed dramatically to the high dose volumes for the entire heart. Conclusions Compared to other plans, the 2-F IMRT plan with fewer monitor units and shorter delivery time is an appropriate technique for left sided breast cancer, which achieved good PTV coverage and sparing of organs at risk besides for the heart and coronary artery.
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Affiliation(s)
- Hongfu Zhao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Mingyuan He
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China.
| | - Dongmei Han
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Ning Wu
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Dan Shi
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Zhipeng Zhao
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Jianxue Jin
- Department of Radiation Physics, Elekta China Co. Ltd, Beijing, 100101, China
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Tyran M, Mailleux H, Tallet A, Fau P, Gonzague L, Minsat M, Moureau-Zabotto L, Resbeut M. Volumetric-modulated arc therapy for left-sided breast cancer and all regional nodes improves target volumes coverage and reduces treatment time and doses to the heart and left coronary artery, compared with a field-in-field technique. JOURNAL OF RADIATION RESEARCH 2015; 56:927-937. [PMID: 26386255 PMCID: PMC4628222 DOI: 10.1093/jrr/rrv052] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 08/04/2015] [Accepted: 08/07/2015] [Indexed: 06/05/2023]
Abstract
We compared two intensity-modulated radiotherapy techniques for left-sided breast treatment, involving lymph node irradiation including the internal mammary chain. Inverse planned arc-therapy (VMAT) was compared with a forward-planned multi-segment technique with a mono-isocenter (MONOISO). Ten files were planned per technique, delivering a 50-Gy dose to the breast and 46.95 Gy to nodes, within 25 fractions. Comparative endpoints were planning target volume (PTV) coverage, dose to surrounding structures, and treatment delivery time. PTV coverage, homogeneity and conformality were better for two arc VMAT plans; V95%(PTV-T) was 96% for VMAT vs 89.2% for MONOISO. Homogeneity index (HI)(PTV-T) was 0.1 and HI(PTV-N) was 0.1 for VMAT vs 0.6 and 0.5 for MONOISO. Treatment delivery time was reduced by a factor of two using VMAT relative to MONOISO (84 s vs 180 s). High doses to organs at risk were reduced (V30(left lung) = 14% using VMAT vs 24.4% with MONOISO; dose to 2% of the volume (D2%)(heart) = 26.1 Gy vs 32 Gy), especially to the left coronary artery (LCA) (D2%(LCA) = 34.4 Gy vs 40.3 Gy). However, VMAT delivered low doses to a larger volume, including contralateral organs (mean dose [Dmean](right lung) = 4 Gy and Dmean(right breast) = 3.2 Gy). These were better protected using MONOISO plans (Dmean(right lung) = 0.8 Gy and Dmean(right breast) = 0.4 Gy). VMAT improved PTV coverage and dose homogeneity, but clinical benefits remain unclear. Decreased dose exposure to the LCA may be clinically relevant. VMAT could be used for complex treatments that are difficult with conventional techniques. Patient age should be considered because of uncertainties concerning secondary malignancies.
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Affiliation(s)
- Marguerite Tyran
- Service de Radiothérapie, Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Hugues Mailleux
- Service de Radiothérapie, Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Agnes Tallet
- Service de Radiothérapie, Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Pierre Fau
- Service de Radiothérapie, Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Laurence Gonzague
- Service de Radiothérapie, Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Mathieu Minsat
- Service de Radiothérapie, Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Laurence Moureau-Zabotto
- Service de Radiothérapie, Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Michel Resbeut
- Service de Radiothérapie, Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13009 Marseille, France
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Liu ZM, Ge XL, Chen JY, Wang PP, Zhang C, Yang X, Zhu HC, Liu J, Qin Q, Xu LP, Lu J, Zhan LL, Cheng HY, Sun XC. Adjuvant Radiotherapy after Breast Conserving Treatment for Breast Cancer: A Dosimetric Comparison between Volumetric Modulated Arc Therapy and Intensity Modulated Radiotherapy. Asian Pac J Cancer Prev 2015; 16:3257-65. [PMID: 25921129 DOI: 10.7314/apjcp.2015.16.8.3257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radiotherapy is an important treatment of choice for breast cancer patients after breast- conserving surgery, and we compare the feasibility of using dual arc volumetric modulated arc therapy (VMAT2), single arc volumetric modulated arc therapy (VMAT1) and Multi-beam Intensity Modulated Radiotherapy (M-IMRT) on patients after breast-conserving surgery. MATERIALS AND METHODS Thirty patients with breast cancer (half right-sided and half left-sided) treated by conservative lumpectomy and requiring whole breast radiotherapy with tumor bed boost were planned with three different radiotherapy techniques: 1) VMAT1; 2) VMAT2; 3) M-IMRT. The distributions for the planning target volume (PTV) and organs at risk (OARs) were compared. Dosimetries for all the techniques were compared. RESULTS All three techniques satisfied the dose constraint well. VMAT2 showed no obvious difference in the homogeneity index (HI) and conformity index (CI) of the PTV with respect to M-IMRT and VMAT1. VMAT2 clearly improved the treatment efficiency and can also decrease the mean dose and V5Gy of the contralateral lung. The mean dose and maximum dose of the spinal cord and contralateral breast were lower for VMAT2 than the other two techniques. The very low dose distribution (V1Gy) of the contralateral breast also showed great reduction in VMAT2 compared with the other two techniques. For the ipsilateral lung of right-sided breast cancer, the mean dose was decreased significantly in VMAT2 compared with VMAT1 and M-IMRT. The V20Gy and V30Gy of the ipsilateral lung of the left- sided breast cancer for VMAT2 showed obvious reduction compared with the other two techniques. The heart statistics of VMAT2 also decreased considerably compared to VMAT1 and M-IMRT. CONCLUSIONS Compared to the other two techniques, the dual arc volumetric modulated arc therapy technique reduced radiation dose exposure to the organs at risk and maintained a reasonable target dose distribution.
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Affiliation(s)
- Zhe-Ming Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China E-mail : ;
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Chung MJ, Lee GJ, Suh YJ, Lee HC, Lee SW, Jeong S, Lee JW, Kim SH, Kang DG, Lee JH. Setup Error and Effectiveness of Weekly Image-Guided Radiation Therapy of TomoDirect for Early Breast Cancer. Cancer Res Treat 2015; 47:774-80. [PMID: 25687857 PMCID: PMC4614198 DOI: 10.4143/crt.2014.189] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 09/05/2014] [Indexed: 12/16/2022] Open
Abstract
PURPOSE This study investigated setup error and effectiveness of weekly image-guided radiotherapy (IGRT) of TomoDirect for early breast cancer. MATERIALS AND METHODS One hundred and fifty-one breasts of 147 consecutive patients who underwent breast conserving surgery followed by whole breast irradiation using TomoDirect in 2012 and 2013 were evaluated. All patients received weekly IGRT. The weekly setup errors from simulation to each treatment in reference to chest wall and surgical clips were measured. Random, systemic, and 3-dimensional setup errors were assessed. Extensive setup error was defined as 5 mm above the margin in any directions. RESULTS All mean errors were within 3 mm of all directions. The mean angle of gantry shifts was 0.6°. The mean value of absolute 3-dimensional setup error was 4.67 mm. In multivariate analysis, breast size (odds ratio, 2.82; 95% confidence interval, 1.00 to 7.90) was a significant factor for extensive error. The largest significant deviation of setup error was observed in the first week of radiotherapy (p < 0.001) and the deviations gradually decreased with time. The deviation of setup error was 5.68 mm in the first week and within 5 mm after the second week. CONCLUSION In this study, there was a significant association between breast size and significant setup error in breast cancer patients who received TomoDirect. The largest deviation occurred in the first week of treatment. Therefore, patients with large breasts should be closely observed on every fraction and fastidious attention is required in the first fraction of IGRT.
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Affiliation(s)
- Mi Joo Chung
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Guk Jin Lee
- Department of Internal Medicine, Seoul, St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Jin Suh
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo Chun Lee
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sea-Won Lee
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Songmi Jeong
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Won Lee
- Department of Radiation Oncology, Kyungpook National University, Daegu, Korea
| | - Sung Hwan Kim
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Gyu Kang
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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