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Choi S, Dreyfuss I, Taswell CS, Cyriac J, Butkus M, Takita C. Proton Beam Therapy for Breast Cancer. Crit Rev Oncog 2024; 29:67-82. [PMID: 38683154 DOI: 10.1615/critrevoncog.2023050319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Given the radiobiological and physical properties of the proton, proton beam therapy has the potential to be advantageous for many patients compared with conventional radiotherapy by limiting toxicity and improving patient outcomes in specific breast cancer scenarios.
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Affiliation(s)
- Seraphina Choi
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Isabella Dreyfuss
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | | | - Jonathan Cyriac
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Michael Butkus
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Maria P, Theodoros S, Anna Z, Michael P, Vassilis K, Kalliopi P. Synchronous bilateral chest wall irradiation with regional nodal irradiation: A literature review of techniques and a case study. Phys Med 2022; 101:50-61. [PMID: 35961182 DOI: 10.1016/j.ejmp.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/03/2022] [Accepted: 07/26/2022] [Indexed: 10/15/2022] Open
Abstract
The optimal radiotherapy technique for patients requiring both breasts or chest walls simultaneous irradiation with or without regional nodal irradiation is currently under investigation. In the last decade several publications present case reports and case series of patients treated with adjuvant radiotherapy in both breasts or chest walls for synchronous bilateral breast cancer (SBBC) with modern radiotherapy techniques. This article presents a systematic review of relevant literature as well as a case report of a SBBC patient who received bilateral chest wall radiotherapy with regional nodal irradiation at our institution with Truebeam - Edge Linear Accelerator. Solid evidence is provided that the practice of avoiding adjuvant radiotherapy in SBBC out of fear of toxicity with older radiotherapy techniques is outdated. Modern techniques can safely and effectively deliver treatment to patients requiring both sides irradiation and even in mastectomy patients in need of regional nodal irradiation.
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Affiliation(s)
- Protopapa Maria
- Mediterraneo General Hospital, Radiation Oncology and Radiosurgery Department, Ilias st. 8-12, Glyfada, Greece.
| | - Stroumbinis Theodoros
- Mediterraneo General Hospital, Radiation Oncology and Radiosurgery Department, Ilias st. 8-12, Glyfada, Greece
| | - Zygogianni Anna
- National and Kapodistrian University of Athens, Medical School, 1st Dpt of Radiology, RT Unit, Aretaieion University Hospital, Greece
| | - Psarras Michael
- Mediterraneo General Hospital, Radiation Oncology and Radiosurgery Department, Ilias st. 8-12, Glyfada, Greece
| | - Kouloulias Vassilis
- National and Kapodistrian University of Athens, Medical School, 2nd Dpt of Radiology, RT Unit, ATTIKON University Hospital, Greece
| | - Platoni Kalliopi
- National and Kapodistrian University of Athens, Medical School, 2nd Dpt of Radiology, RT Unit, ATTIKON University Hospital, Greece; National and Kapodistrian University of Athens, Medical School, 2nd Dpt of Radiology, Medical Physics Unit, ATTIKON University Hospital, Greece
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3
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Garda AE, Hunzeker AE, Michel AK, Fattahi S, Shiraishi S, Remmes NB, Schultz HL, Harmsen WS, Shumway DA, Yan ES, Park SS, Mutter RW, Corbin KS. Intensity Modulated Proton Therapy for Bilateral Breast or Chest Wall and Comprehensive Nodal Irradiation for Synchronous Bilateral Breast Cancer: Initial Clinical Experience and Dosimetric Comparison. Adv Radiat Oncol 2022; 7:100901. [PMID: 35647397 PMCID: PMC9133394 DOI: 10.1016/j.adro.2022.100901] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/09/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose Synchronous bilateral breast cancer (SBBC) poses distinct challenges for radiation therapy planning. We report our proton therapy experience in treating patients with SBBC. We also provide a dosimetric comparison of intensity modulated proton therapy (IMPT) versus photon therapy. Methods and Materials Patients with SBBC who received IMPT at our institution were retrospectively analyzed. The clinical target volume (CTV) included the breast or chest wall and comprehensive regional lymph nodes, including axilla, supraclavicular fossa, and the internal mammary chain. Intensity modulated proton therapy and volumetric modulated arc therapy (VMAT) plans were generated with the goal that 90% of the CTV would recieve at least 90% of the prescription dose (D90>=90%). Comparisons between modalities were made using the Wilcoxon signed rank test. Physician-reported acute toxic effects and photography were collected at baseline, end of treatment, and each follow-up visit. Results Between 2015 and 2018, 11 patients with SBBC were treated with IMPT. The prescription was 50 Gy in 25 fractions. The median CTV D90 was 99.9% for IMPT and 97.6% for VMAT (P = .001). The mean heart dose was 0.7 Gy versus 7.2 Gy (P = .001), the total lung mean dose was 7.8 Gy versus 17.3 Gy (P = .001), and the total lung volume recieving 20 Gy was 13.0% versus 27.4% (P = .001). The most common acute toxic effects were dermatitis (mostly grade 1-2 with 1 case of grade 3) and grade 1 to 2 fatigue. The most common toxic effects at the last-follow up (median, 32 months) were grade 1 skin hyperpigmentation, superficial fibrosis, and extremity lymphedema. No nondermatologic or nonfatigue adverse events of grade >1 were recorded. Conclusions Bilateral breast and/or chest wall and comprehensive nodal IMPT is technically feasible and associated with low rates of severe acute toxic effects. Treatment with IMPT offered improved target coverage and normal-tissue sparing compared with photon therapy. Long-term follow-up is ongoing to assess efficacy and toxic effects.
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Affiliation(s)
- Allison E. Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Ann K. Michel
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sayeh Fattahi
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - W. Scott Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Dean A. Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth S. Yan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S. Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Robert W. Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Stick LB, Jensen MF, Bentzen SM, Kamby C, Lundgaard AY, Maraldo MV, Offersen BV, Yu J, Vogelius IR. Radiation-Induced Toxicity Risks in Photon Versus Proton Therapy for Synchronous Bilateral Breast Cancer. Int J Part Ther 2021; 8:1-13. [PMID: 35530186 PMCID: PMC9009461 DOI: 10.14338/ijpt-21-00023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose This study compares photon and proton therapy plans for patients with synchronous bilateral early breast cancer and estimates risks of early and late radiation-induced toxicities. Materials and Methods Twenty-four patients with synchronous bilateral early breast cancer receiving adjuvant radiation therapy using photons, 3-dimensional conformal radiation therapy or volumetric modulated arc therapy, were included and competing pencil beam scanning proton therapy plans were created. Risks of dermatitis, pneumonitis, acute esophageal toxicity, lung and breast fibrosis, hypothyroidism, secondary lung and esophageal cancer and coronary artery events were estimated using published dose-response relationships and normal tissue complication probability (NTCP) models. Results The primary clinical target volume V95% and/or nodal clinical target volume V90% were less than 95% in 17 photon therapy plans and none of the proton plans. Median NTCP of radiation dermatitis ≥ grade 2 was 18.3% (range, 5.4-41.7) with photon therapy and 58.4% (range, 31.4-69.7) with proton therapy. Median excess absolute risk (EAR) of secondary lung cancer at age 80 for current and former smokers was 4.8% (range, 0.0-17.0) using photons and 2.7% (range, 0.0-13.6) using protons. Median EAR of coronary event at age 80, assuming all patients have preexisting cardiac risk factors, was 1.0% (range, 0.0-5.6) with photons and 0.2% (range, 0.0-1.3) with protons. Conclusion Proton therapy plans improved target coverage and reduced risk of coronary artery event and secondary lung cancer while increasing the risk of radiation dermatitis.
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Affiliation(s)
- Line Bjerregaard Stick
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Søren M. Bentzen
- Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public, Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Claus Kamby
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anni Young Lundgaard
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maja Vestmø Maraldo
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Vrou Offersen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jen Yu
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Mutter RW, Choi JI, Jimenez RB, Kirova YM, Fagundes M, Haffty BG, Amos RA, Bradley JA, Chen PY, Ding X, Carr AM, Taylor LM, Pankuch M, Vega RBM, Ho AY, Nyström PW, McGee LA, Urbanic JJ, Cahlon O, Maduro JH, MacDonald SM. Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol Biol Phys 2021; 111:337-359. [PMID: 34048815 PMCID: PMC8416711 DOI: 10.1016/j.ijrobp.2021.05.110] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022]
Abstract
Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Marcio Fagundes
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Richard A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Antoinette M Carr
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Leslie M Taylor
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Mark Pankuch
- Department of Radiation Oncology, Northwestern Medicine Proton Center, Warrenville, Illinois
| | | | - Alice Y Ho
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden and the Danish Centre for Particle Therapy, Aarhus, Denmark
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - James J Urbanic
- Department of Radiation Medicine and Applied Sciences, UC San Diego Health, Encinitas, California
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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DeCesaris CM, Mossahebi S, Jatczak J, Rao AD, Zhu M, Mishra MV, Nichols E. Outcomes of and treatment planning considerations for a hybrid technique delivering proton pencil-beam scanning radiation to women with metal-containing tissue expanders undergoing post-mastectomy radiation. Radiother Oncol 2021; 164:289-298. [PMID: 34280402 DOI: 10.1016/j.radonc.2021.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Following mastectomy, immediate breast reconstruction often involves the use of temporary tissue expanders (TEs). TEs contain metallic ports (MPs), which complicate proton pencil-beam scanning (PBS) planning. A technique was implemented for delivering PBS post-mastectomy radiation (PMRT) to patients with TEs and MPs. METHODS A protocol utilizing a hybrid single- and multi-field optimization (SFO, MFO) technique was developed. Plans were robustly optimized using a Monte Carlo algorithm. A CTV_eval structure including chest wall (CW) and regional nodal (RNI) targets and excluding the TE was evaluated. Organ at risk (OAR) dosimetry and acute toxicities were analyzed. RESULTS Twenty-nine women were treated with this technique. A 2-field SFO technique was used superior and inferior to the MP, with a 3 or 4-field MFO technique used at the level of the MP. Virtual blocks were utilized so that beams did not travel through the MP. A port-to-CW distance of 1 cm was required. Patients underwent daily image-guidance to ensure the port remained within a 0.5 cm internal planning volume (ITV). Median RT dose to CTV_eval was 50.4 Gy (45.0-50.4). Median 95% CTV_eval coverage was 99.5% (95-100). Optically stimulated luminescent dosimeter (OSLD) readings were available for 8 patients and correlated to the dose measurements in the treatment planning system (TPS); median OSLD ratio was 0.99 (range, 0.93-1.02). CONCLUSIONS Delivering PMRT with PBS for women with metal-containing TEs using a hybrid SFO/MFO technique is feasible, reproducible, and achieves excellent dose distributions. Specialized planning and image-guidance techniques are required to safely utilize this treatment in the clinic.
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Affiliation(s)
- Cristina M DeCesaris
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, United States.
| | - Sina Mossahebi
- Division of Physics, Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, United States
| | - Jenna Jatczak
- Maryland Proton Treatment Center, Baltimore, United States
| | - Avani D Rao
- Department of Radiation Oncology, Inova Schar Cancer Institute, Fairfax, United States
| | - Mingyao Zhu
- Department of Radiation Oncology, Emory University, Atlanta, United States
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, United States
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, United States
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Cunningham L, Penfold S, Giles E, Le H, Short M. Impact of Breast Size on Dosimetric Indices in Proton Versus X-ray Radiotherapy for Breast Cancer. J Pers Med 2021; 11:jpm11040282. [PMID: 33917818 PMCID: PMC8068250 DOI: 10.3390/jpm11040282] [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: 02/16/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022] Open
Abstract
Deep inspiration breath hold (DIBH) radiotherapy is a technique used to manage early stage left-sided breast cancer. This study compared dosimetric indices of patient-specific X-ray versus proton therapy DIBH plans to explore differences in target coverage, radiation doses to organs at risk, and the impact of breast size. Radiotherapy plans of sixteen breast cancer patients previously treated with DIBH radiotherapy were re-planned with hybrid inverse-planned intensity modulated X-ray radiotherapy (h-IMRT) and intensity modulated proton therapy (IMPT). The total prescribed dose was 40.05 Gy in 15 fractions for all cases. Comparisons between the clinical, h-IMRT, and IMPT evaluated doses to target volumes, organs at risk, and correlations between doses and breast size. Although no differences were observed in target volume coverage between techniques, the h-IMRT and IMPT were able to produce more even dose distributions and IMPT delivered significantly less dose to all organs at risk than both X-ray techniques. A moderate negative correlation was observed between breast size and dose to the target in X-ray techniques, but not IMPT. Both h-IMRT and IMPT produced plans with more homogeneous dose distribution than forward-planned IMRT and IMPT achieved significantly lower doses to organs at risk compared to X-ray techniques.
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Affiliation(s)
- Lisa Cunningham
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide 5000, Australia; (L.C.); (S.P.); (H.L.)
| | - Scott Penfold
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide 5000, Australia; (L.C.); (S.P.); (H.L.)
| | - Eileen Giles
- Cancer Research Institute, University of South Australia, Adelaide 5001, Australia;
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide 5000, Australia; (L.C.); (S.P.); (H.L.)
- Cancer Research Institute, University of South Australia, Adelaide 5001, Australia;
| | - Michala Short
- Cancer Research Institute, University of South Australia, Adelaide 5001, Australia;
- Correspondence: ; Tel.: +61-8-83022089
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Assessing the Need for Adjusted Organ-at-Risk Planning Goals for Patients Undergoing Adjuvant Radiation Therapy for Locally Advanced Breast Cancer with Proton Radiation. Pract Radiat Oncol 2020; 11:108-118. [PMID: 33109494 DOI: 10.1016/j.prro.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/25/2020] [Accepted: 09/04/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE Locally advanced breast cancer requires surgical management via lumpectomy or mastectomy with or without systemic therapy followed by chest wall or breast (CW) and comprehensive nodal irradiation (CNI). Radiation (RT) dose constraints for the heart and ipsilateral lung have been developed based on photon RT. Proton therapy (PBT) can deliver significantly lower doses of RT to these organs-at-risk (OARs) and may warrant adjustments to OAR planning goals. METHODS AND MATERIALS The RT plans of consecutive patients undergoing adjuvant CW-CNI RT with PBT within a single center were reviewed. A inital treatment volume, comprised of CW/intact breast + CNI (CTV_init) structure, including the CW and CNI but excluding any boost plans was analyzed. Frequency distributions were generated based on doses received by the heart, lungs, and esophagus for validated dosimetric parameters. Frequency distributions were generated and then stratified by laterality and compared using the Kruskal-Wallis H test. The 75th, 85th, and 95th percentiles for each dosimetric parameter were calculated, overall and by laterality. The 75th percentile (Q3), was used as a suggested primary goal, and the 95th percentile was used as a suggested secondary goal. RESULTS One hundred and seventy-two plans were analyzed. Forty-nine plans were right-sided, 107 were left-sided, and 16 were bilateral. The overall Q3 of the mean and V25 of the heart were 1.5 Gy and 1.7%, respectively. The mean and V25 to the heart differed significantly by laterality. Pulmonary values were similar to current recommendations. For all lateralites, the median volume of the esophagus receiving 70% prescription dose was ≤1 cm3. CONCLUSIONS We present the first dosimetric study providing complete OAR dose-volume histograms data for patients undergoing adjuvant pencil-beam scanning-PBT for locally advanced breast cancer, with detailed information on central tendencies, ranges and distributions of data. We have provided suggested planning goals and metrics for the lungs, heart, and esophagus; the latter 2 differing significantly from current Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) constraints and classical photon goals.
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