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Left-sided breast cancer and risks of secondary lung cancer and ischemic heart disease

Effects of modern radiotherapy techniques

Linksseitiger Brustkrebs und das Risiko von Sekundärmalignomen der Lunge und ischämischen Herzerkrankungen

Auswirkungen moderner Strahlentherapietechniken

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Abstract

Purpose

Modern breast cancer radiotherapy techniques, such as respiratory-gated radiotherapy in deep-inspiration breath-hold (DIBH) or volumetric-modulated arc radiotherapy (VMAT) have been shown to reduce the high dose exposure of the heart in left-sided breast cancer. The aim of the present study was to comparatively estimate the excess relative and absolute risks of radiation-induced secondary lung cancer and ischemic heart disease for different modern radiotherapy techniques.

Methods

Four different treatment plans were generated for ten computed tomography data sets of patients with left-sided breast cancer, using either three-dimensional conformal radiotherapy (3D-CRT) or VMAT, in free-breathing (FB) or DIBH. Dose–volume histograms were used for organ equivalent dose (OED) calculations using linear, linear–exponential, and plateau models for the lung. A linear model was applied to estimate the long-term risk of ischemic heart disease as motivated by epidemiologic data. Excess relative risk (ERR) and 10-year excess absolute risk (EAR) for radiation-induced secondary lung cancer and ischemic heart disease were estimated for different representative baseline risks.

Results

The DIBH maneuver resulted in a significant reduction of the ERR and estimated 10-year excess absolute risk for major coronary events compared to FB in 3D-CRT plans (p = 0.04). In VMAT plans, the mean predicted risk reduction through DIBH was less pronounced and not statistically significant (p = 0.44). The risk of radiation-induced secondary lung cancer was mainly influenced by the radiotherapy technique, with no beneficial effect through DIBH. VMAT plans correlated with an increase in 10-year EAR for radiation-induced lung cancer as compared to 3D-CRT plans (DIBH p = 0.007; FB p = 0.005, respectively). However, the EARs were affected more strongly by nonradiation-associated risk factors, such as smoking, as compared to the choice of treatment technique.

Conclusion

The results indicate that 3D-CRT plans in DIBH pose the lowest risk for both major coronary events and secondary lung cancer.

Zusammenfassung

Hintergrund

Moderne Strahlentherapietechniken, wie die Bestrahlung in tiefer Inspiration (DIBH) oder die volumenmodulierte Rotationstherapie (VMAT), können die hohe Dosisbelastung des Herzens bei der Bestrahlung von linksseitigem Brustkrebs deutlich verringern. Ziel dieser Planungsstudie war es zu untersuchen, inwieweit unterschiedliche Bestrahlungstechniken bei linksseitigem Brustkrebs das relative und absolute Risiko für strahleninduzierte Sekundärmalignome der Lunge und schwere koronare Herzerkrankungen beeinflussen.

Methoden

Es wurden jeweils 4 Bestrahlungspläne für Computertomographiedatensätze von 10 Patientinnen mit linksseitigem Mammakarzinom generiert: eine tangentiale 3‑dimensionale konformale Strahlentherapie (3D-CRT) und eine volumenmodulierte Strahlentherapie (VMAT), jeweils in Ruheatmung (FB) und DIBH. Die Parameter der Dosis-Volumen-Histogramme (DVH) wurden zur Berechnung der „organ equivalent dose“ (OED) herangezogen, dabei wurde ein lineares, linear-exponentielles sowie ein Plateaumodell für die Lunge angewendet. Hiermit wurden das relative Risiko („excess relative risk“ [ERR]) und das absolute 10-Jahres-Risiko („excess absolute risk“ [EAR]) von strahleninduzierten Sekundärmalignomen der Lunge und koronaren Herzerkrankungen für unterschiedliche repräsentative Baseline-Risiken berechnet.

Ergebnisse

Durch die Bestrahlung in tiefer Inspiration zeigte sich ein deutlicher Vorteil bezüglich des absoluten 10-Jahres-Risikos schwerer koronarer Ereignisse für die 3D-CRT im Vergleich zur Ruheatmung (p = 0,04). Für die VMAT war die Risikoreduktion durch DIBH insgesamt geringer und statistisch nicht signifikant (p = 0,44). Das strahleninduzierte 10-Jahres-Risiko für Sekundärmalignome der Lunge wurde vorwiegend durch die Wahl der Strahlentherapietechnik und nicht durch die Anwendung eines Atemanhaltemanövers beeinflusst. Für VMAT zeigte sich ein erhöhtes 10-Jahres-Risiko für Sekundärmalignome der Lunge im Vergleich zur 3D-CRT (DIBH p = 0,007, FB p = 0,005). Dennoch war die EAR-Berechnung am stärksten durch nichtstrahlentherapieassoziierte Risikofaktoren – wie das Rauchen – beeinflusst.

Schlussfolgerung

Die Ergebnisse zeigen, dass 3D-CRT-Pläne in tiefer Inspiration (DIBH) das niedrigste Risiko sowohl für strahleninduzierte Sekundärmalignome als auch für schwere koronare Ereignisse aufweisen.

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Change history

  • 02 November 2017

    Correction to:

    Strahlenther Onkol 2017

    https://doi.org/10.1007/s00066-017-1213-y

    Unfortunately, during copy editing, the titles of Fig. 2a and 2b were removed.

    The correct Fig. 2a and 2b are shown below. The original article has been corrected …

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Authors and Affiliations

  1. Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany

    Stefanie Corradini, Hendrik Ballhausen, Helmut Weingandt, Philipp Freislederer, Stephan Schönecker, Maximilian Niyazi, Ute Ganswindt & Claus Belka

  2. Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany

    Cristoforo Simonetto & Markus Eidemüller

  3. Department of Radiation Oncology, Medical University, Innsbruck, Austria

    Ute Ganswindt

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S. Corradini, H. Ballhausen, H. Weingandt, P. Freislederer, S. Schönecker, M. Niyazi, C. Simonetto, M. Eidemüller and U. Ganswindt declare that they have no competing interests. C. Belka has received research support and teaching honoraria from Elekta and C‑RAD.

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The original version of this article was revised: Unfortunately, during copy editing, the titles of figures 2a and 2b were removed. The correct figures 2a and 2b are shown below.

A correction to this article is available online at https://doi.org/10.1007/s00066-017-1226-6.

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Corradini, S., Ballhausen, H., Weingandt, H. et al. Left-sided breast cancer and risks of secondary lung cancer and ischemic heart disease. Strahlenther Onkol 194, 196–205 (2018). https://doi.org/10.1007/s00066-017-1213-y

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  • DOI: https://doi.org/10.1007/s00066-017-1213-y

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