Advertisement

Strahlentherapie und Onkologie

, Volume 191, Issue 9, pp 734–741 | Cite as

Heart dose reduction in breast cancer treatment with simultaneous integrated boost

Comparison of treatment planning and dosimetry for a novel hybrid technique and 3D-CRT
  • Vincent JöstEmail author
  • Matthias Kretschmer
  • Marcello Sabatino
  • Florian Würschmidt
  • Jörg Dahle
  • Friedrich Ueberle
  • Jörn Lorenzen
Original Article

Abstract

Objective

The present study compares in silico treatment plans of clinically established three-dimensional conformal radiotherapy (3D-CRT) with a hybrid technique consisting of intensity-modulated radiotherapy (IMRT) and volumetric modulated arc radiotherapy (VMAT) during normally fractionated radiation of mammary carcinomas with simultaneous integrated boost on the basis of dose–volume histogram (DVH) parameters.

Patients and methods

Radiation treatment planning was performed with a hybrid and a 3D-CRT treatment plan for 20 patients. Hybrid plans were implemented with two tangential IMRT fields and a VMAT field in the angular range of the tangents. Verification of the plan was performed with a manufacturer-independent measurement system consisting of a detector array and rotation unit.

Results

The mean values of the heart dose for the entire patient collective were 3.6 ± 2.5 Gy for 3D-CRT and 2.9 ± 2.1 Gy for the hybrid technique (p < 0.01). For the left side (n = 10), the mean values for the left anterior descending artery were 21.8 ± 7.4 Gy for 3D-CRT and 17.6 ± 7.4 Gy for the hybrid technique (p < 0.01). The mean values of the ipsilateral lung were 11.9 ± 1.6 Gy for 3D-CRT and 10.5 ± 1.3 Gy for the hybrid technique (p < 0.01). Calculated dose distributions in the hybrid arm were in good accordance with measured dose (on average 95.6 ± 0.5 % for γ < 1 and 3 %/3 mm). The difference of the mean treatment time per fraction was 7 s in favor of 3D-CRT.

Conclusion

Compared with the established 3D-CRT technique, the hybrid technique allows for a decrease in dose, particularly of the mean heart and lung dose with comparable target volume acquisition and without disadvantageous low-dose load of contralateral structures. Uncomplicated implementation of the hybrid technique was demonstrated in this context. The hybrid technique combines the advantages of tangential IMRT with the superior sparing of organs at risk by VMAT.

Keywords

Breast cancer Intensity-modulated radiotherapy Volume-modulated arc therapy Heart dose Coronary arteries 

Herzdosisreduktion bei der Brustkrebsbehandlung mit simultan integriertem Boost

Vergleich von Behandlungsplanung und Dosimetrie einer neuen Hybridtechnik und der 3D-CRT

Zusammenfassung

Ziel

Die vorliegende Studie vergleicht „in silico“-Bestrahlungspläne der klinisch etablierten 3-D-konformalen Strahlentherapie (3D-CRT) mit einer Hybrid-Technik bestehend aus intensitätsmodulierter Strahlentherapie (IMRT) und volumenmodulierter Arc-Therapie (VMAT) bei normofraktionierter Bestrahlung des Mammakarzinoms mit simultan integriertem Boost auf Grundlage von Dosis-Volumen-Histogramm-(DVH)Parametern.

Patienten und Methoden

Die Strahlentherapieplanung erfolgte jeweils mit einem Hybrid- sowie einem 3D-CRT-Bestrahlungsplan für 20 Patientinnen. Hybrid-Pläne wurden mit zwei tangentialen IMRT-Feldern und einem VMAT-Feld im Winkelbereich der Tangenten umgesetzt. Die Planverifikation erfolgte mit einem herstellerunabhängigen Messsystem bestehend aus Detektorarray und Rotationseinheit.

Ergebnisse

Über das gesamte Patientenkollektiv ergaben sich Mittelwerte der Herzdosis von 3,6 ± 2,5 Gy für die 3D-CRT und 2,9 ± 2,1 Gy für die Hybrid-Technik (p < 0,01). Für linksseitige Lokalisation (n = 10) lagen die Mittelwerte für die LAD bei 21,8 ± 7,4 Gy für die 3D-CRT und bei 17,6 ± 7,4 Gy für die Hybrid-Technik (p < 0,01). Die Mittelwerte der ipsilateralen Lunge beliefen sich auf 11,9 ± 1,6 Gy für die 3D-CRT und 10,5 ± 1,3 Gy für die Hybrid-Technik (p < 0,01). Die Übereinstimmung der berechneten und gemessenen Dosisverteilungen im Hybrid-Arm (n = 10) betrug im Mittel 95,6 ± 0,5 % (für γ < 1 und 3 %/3 mm). Der Unterschied der mittleren Behandlungszeit pro Fraktion lag bei 7 s zugunsten der 3D-CRT.

Schlussfolgerung

Im Vergleich zur etablierten 3D-CRT ermöglicht die Hybrid-Technik eine Senkung insbesondere der mittleren Herz- und auch Lungenbelastung bei vergleichbarer Zielvolumenerfassung und ohne nachteilige Niedrigdosis-Belastung kontralateral gelegener Strukturen. Eine problemlose Durchführbarkeit der Hybrid-Technik konnte in diesem Kontext demonstriert werden. Die Hybrid-Technik kombiniert die Vorteile der tangentialen IMRT mit der überlegenen Risikoorganschonung durch VMAT.

Schlüsselwörter

Brustkrebs Intensitätsmodulierte Strahlentherapie Volumenmodulierte Arc-Therapie Herzdosis Koronararterien 

Notes

Acknowledgments

Author contributions: V. Jöst and M. Kretschmer contributed equally in developing the study design, collecting data, analyzing and interpreting the data, statistical analysis, and drafting the manuscript. M. Sabatino contributed to developing the study design and revising the manuscript. F. Würschmidt performed the PTV delineations and revised the manuscript. J. Dahle performed the PTV delineations and revised the manuscript. F. Ueberle revised the manuscript. J. Lorenzen performed the delineation of coronary arteries and revised the manuscript. All authors read and approved the final manuscript.

Compliance with ethical guidelines

Conflict of interest

V. Jöst, M. Kretschmer, M. Sabatino, F. Würschmidt, J. Dahle, F. Ueberle, and J. Lorenzen state that there are no conflicts of interest.

References

  1. 1.
    Popescu CC, Olivotto IA, Beckham WA et al (2010) Volumetric modulated arc therapy improves dosimetry and reduces treatment time compared to conventional intensity-modulated radiotherapy for locoregional radiotherapy of left-sided breast cancer and internal mammary nodes. Int J Radiat Oncol Biol Phys 76:287–295CrossRefPubMedGoogle Scholar
  2. 2.
    Pasler M, Georg D, Bartelt S et al (2013) Node-positive left-sided breast cancer: does VMAT improve treatment plan quality with respect to IMRT? Strahlenther Onkol 189:380–386CrossRefPubMedGoogle Scholar
  3. 3.
    Nicolini G, Clivio A, Fogliata A et al (2009) Simultaneous integrated boost radiotherapy for bilateral breast: a treatment planning and dosimetric comparison for volumetric modulated arc and fixed field intensity modulated therapy. Radiat Oncol 4:27PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Pensold S, Tümmler H, Theilig B et al (2013) Planungsstudie zur simultan integrierten Boostbestrahlung beim Mammakarzinom. 44. Jahrestagung der Deutschen Gesellschaft für Medizinische Physik page: 150–152. http://www.dgmp.de/media/document/561/2013-abstractband.pdf. Accessed 28 Jan 2014
  5. 5.
    White J, Tai A, Arthur D et al RTOG Breast Cancer Atlas for Radiation Therapy Planning: Consensus Definitions. http://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx. Accessed 30 Dec 2013
  6. 6.
    Jin GH, Chen LX, Deng XW et al (2013) A comparative dosimetric study for treating left-sided breast cancer for small breast size using five different radiotherapy techniques: conventional tangential field, filed-in-filed, tangential-IMRT, multi-beam IMRT and VMAT. Radiat Oncol 8:89PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    Badakhshi H, Kaul D, Nadobny J et al (2013) Image-guided volumetric modulated arc therapy for breast cancer: a feasibility study and plan comparison with three-dimensional conformal and intensity-modulated radiotherapy. Br J Radiol 86:20130515PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Scorsetti M, Alongi F, Fogliata A et al (2012) Phase I-II study of hypofractionated simultaneous integrated boost using volumetric modulated arc therapy for adjuvant radiation therapy in breast cancer patients: a report of feasibility and early toxicity results in the first 50 treatments. Radiat Oncol 7:145PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Hall EJ, Wuu CS (2003) Radiation-induced second cancers: the impact of 3D-CRT and IMRT. Int J Radiat Oncol Biol Phys 56:83–88CrossRefPubMedGoogle Scholar
  10. 10.
    Howell RM, Scarboro SB, Kry SF et al (2010) Accuracy of out-of-field dose calculations by a commercial treatment planning system. Phys Med Biol 55:6999–7008PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Darby SC, Ewertz M et al (2013) Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med 368:987–998CrossRefPubMedGoogle Scholar
  12. 12.
    Radiation Therapy Oncology Group (2013) RTOG 1005: A Phase III Trial of Accelerated Whole Breast Irradiation with Hypofractionation plus Concurrent Boost Versus Standard Whole Breast Irradiation plus Sequential Boost for Early-Stage Breast Cancer. http://www.rtog.org/clinicaltrials/protocoltable/studydetails.aspx?action=openFile&FileID=9366. Accessed 28 Jan 2014
  13. 13.
    Teoh M, Clark CH, Wood K et al (2011) Volumetric modulated arc therapy: a review of current literature and clinical use in practice. Br J Radiol 84:967–996PubMedCentralCrossRefPubMedGoogle Scholar
  14. 14.
    Verbakel WF, Cuijpers JP, Hoffmans D et al (2009) Volumetric intensity-modulated arc therapy vs. conventional IMRT in head-and-neck cancer: a comparative planning and dosimetric study. Int J Radiat Oncol Biol Phys 74:252–259CrossRefPubMedGoogle Scholar
  15. 15.
    Hayden AJ, Rains M, Tiver K (2012) Deep inspiration breath hold technique reduces heart dose from radiotherapy for left-sided breast cancer. J Med Imaging Radiat Oncol 56:464–472CrossRefPubMedGoogle Scholar
  16. 16.
    Reardon KA, Read PW, Morris MM et al (2013) A comparative analysis of 3D conformal deep inspiratory-breath hold and free-breathing intensity-modulated radiation therapy for left-sided breast cancer. Med Dosim 38:190–195CrossRefPubMedGoogle Scholar
  17. 17.
    Subramaniam S, Thirumalaiswamy S, Srinivas C et al (2012) Chest wall radiotherapy with volumetric modulated arcs and the potential role of flattening filter free photon beams. Strahlenther Onkol 188:484–491CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Vincent Jöst
    • 1
    Email author
  • Matthias Kretschmer
    • 1
  • Marcello Sabatino
    • 1
  • Florian Würschmidt
    • 1
  • Jörg Dahle
    • 1
  • Friedrich Ueberle
    • 2
  • Jörn Lorenzen
    • 1
  1. 1.Radiological AllianceHamburgGermany
  2. 2.Faculty Life SciencesUniversity of Applied SciencesHamburgGermany

Personalised recommendations