Evaluating improvements in cardiac dosimetry in breast radiotherapy and comparison of cardiac sparing techniques

  • Ahmad M. Karimi
  • Martin C. Tom
  • Bindu V. Manyam
  • Elizabeth Obi
  • Rahul D. Tendulkar
  • Sheen Cherian
  • Christopher Fleming
  • Eva Suarez
  • Mihir Naik
  • Chirag ShahEmail author
Original Research



Data from Darby et al. demonstrated that cardiac dose in patients undergoing breast radiation therapy is associated with cardiac events. Cardiac dose is primarily dependent on treatment laterality and treatment fields. More recently, techniques such deep inspiratory breath hold (DIBH) and prone positioning have been used as cardiac sparing techniques. The purpose of this study is to assess changes in cardiac dosimetry with cardiac sparing techniques.


This retrospective study included breast cancer patients treated from 2010 to 2018 at a single institution. Mean heart dose (MHD) was analyzed with respect to treatment era, laterality, cardiac sparing technique, and treatment fields, including regional nodal irradiation (RNI) and internal mammary nodal irradiation (IMNI).


Seven hundred sixty-five patients were included in this study. Average MHD was 1.87 Gy for left-sided cases and 0.71 Gy for right-sided cases (p < 0.0001). For left-sided cases, the average MHD without RNI, RNI without IMNI, and RNI with IMNI was 1.40 Gy, 2.01 Gy, and 3.48 Gy respectively. For left-sided cases without RNI, the average MHD decreased from 1.61 to 1.22 Gy using DIBH (p < 0.0001), and to 1.02 Gy with prone positioning (p < 0.0001). There was no difference in MHD between DIBH and prone techniques (p = 0.44). For left-sided cases with RNI, DIBH reduced the average MHD from 2.4 to 2.1 Gy (p = 0.04). Following the 2013 publication of Darby et al., the average MHD significantly decreased for left-sided RT cases (2.02 vs. 1.83 Gy, p = 0.03) due to increased institutional adoption of cardiac-sparing techniques.


Cardiac doses were lower following the 2013 publication of Darby et al. due to greater use of cardiac sparing techniques. Overall, the average MHD was < 1 Gy and < 2 Gy for right and left breast cancers, respectively, with lower doses achieved using DIBH and prone positioning as cardiac sparing techniques.


Breast cancer Radiation therapy Cardiac 


Compliance with ethical standards

Conflict of interest

Chirag Shah is a Scientific Consultant for ImpediMed and receives grants from Varian Medical Systems, Vision RT, as well as travel and honoraria from Varian Medical Systems and Martin C. Tom received a research grant from Blue Earth Diagnostics; Rahul D. Tendulkar received honoraria from Varian Medical Systems; Ahmad Karimi, Bindu Manyam, Elizabeth Obi, Sheen Cherian, Christopher Fleming, Eva Suarez, and Mihir Naik declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Ahmad M. Karimi
    • 1
  • Martin C. Tom
    • 1
  • Bindu V. Manyam
    • 1
  • Elizabeth Obi
    • 1
  • Rahul D. Tendulkar
    • 1
  • Sheen Cherian
    • 1
  • Christopher Fleming
    • 1
  • Eva Suarez
    • 1
  • Mihir Naik
    • 1
  • Chirag Shah
    • 1
    Email author
  1. 1.Department of Radiation OncologyTaussig Cancer Institute, Cleveland ClinicClevelandUSA

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