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Exposure of remote organs and associated cancer risks from tangential and multi-field breast cancer radiotherapy

Dosen und Zweittumorrisiken in entfernt liegenden Organen bei tangentialer und bei Multifeld-Strahlentherapie der Brust

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Abstract

Purpose

With the ever-increasing cure rates in breast cancer, radiotherapy-induced cancers have become an important issue. This study aimed to estimate secondary cancer risks for different treatment techniques, taking into account organs throughout the body.

Material and methods

Organ doses were evaluated for a tangential three-dimensional conformal (3D-CRT) and a multi-field intensity-modulated radiotherapy (IMRT) plan using a validated, Monte Carlo-based treatment planning system. Effects of wedges and of forward versus inverse planning were systematically investigated on the basis of phantom measurements. Organ-specific cancer risks were estimated using risk coefficients derived from radiotherapy patients or from the atomic bomb survivors.

Results

In the 3D-CRT plan, mean organ doses could be kept below 1 Gy for more remote organs than the lung, heart, and contralateral breast, and decreased to a few cGy for organs in the lower torso. Multi-field IMRT led to considerably higher mean doses in organs at risk, the difference being higher than 50% for many organs. Likewise, the peripheral radiation burden was increased by external wedges. No difference was observed for forward versus inverse planning. Despite the lower doses, the total estimated secondary cancer risk in more remote organs was comparable to that in the lung or the contralateral breast. For multi-field IMRT it was 75% higher than for 3D-CRT without external wedges.

Conclusion

Remote organs are important for assessment of radiation-induced cancer risk. Remote doses can be reduced effectively by application of a tangential field configuration and a linear accelerator set-up with low head scatter radiation.

Zusammenfassung

Ziel

Wegen steigender Heilungsraten von Brustkrebs gewinnt das Risiko, durch die Strahlentherapie Zweittumore zu verursachen, an Bedeutung. Ziel dieser Studie war es, die Zweittumorrisiken für verschiedene Behandlungstechniken abzuschätzen und dabei auch die Organe zu berücksichtigen, die sich weiter entfernt vom Feld befinden.

Material und Methoden

Mit einem validierten Bestrahlungsplanungssystem mit Monte-Carlo-Algorithmus wurden Organdosen berechnet für tangentiale, dreidimensionale konformale Strahlentherapie (3‑D‑CRT) und für intensitätsmodulierte Strahlentherapie (IMRT) mit Feldern aus vielen Richtungen. Mit Phantom-Messungen wurden systematisch die Verwendung von Keilfiltern und der Einfluss von inverser Planung untersucht. Zur Berechnung von Krebsrisiken wurden sowohl Risikokoeffizienten aus Studien zu Strahlentherapiepatienten als auch zu Atombombenüberlebenden verwendet.

Ergebnisse

Im 3‑D-CRT-Plan waren die mittleren Organdosen für weiter entfernte Organe als Lunge, Herz und kontralaterale Brust unterhalb von 1 Gy und fielen mit der Entfernung im Torso bis auf einige cGy ab. Die IMRT-Technik mit vielen Feldern führte zu deutlich höheren mittleren Dosen in allen Organen außerhalb des Zielvolumens – für viele Organe um mehr als 50 %. Ebenso erhöhten externe Keilfilter die Strahlenbelastung in entfernten Organen. Kein Unterschied konnte allerdings zwischen inverser und Vorwärtsplanung festgestellt werden. Trotz der geringeren Dosen trugen weiter entfernte Organe in der Summe ähnlich hoch zum Zweittumorrisiko bei wie die Lunge oder die kontralaterale Brust. Für die IMRT-Technik war dieser Beitrag um 75 % höher als für 3‑D-CRT ohne externe Keilfilter.

Schlussfolgerung

Bei der Abschätzung von Zweittumorrisiken sind auch entfernte Organe wichtig. Deren Exposition kann durch eine tangentiale Feldkonfiguration und mit einem Beschleunigeraufbau mit geringer Streustrahlung effektiv reduziert werden.

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Acknowledgements

This work was supported by the German Federal Ministry of Education and Research (BMBF) under contract number 02NUK026 (PASSOS).

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Authors and Affiliations

  1. Institute of Radiation Protection, Helmholtz Zentrum München Deutsches Forschungszentrum für Gesundheit und Umwelt (GmbH), Ingolstädter Landstraße 1, 85764, Neuherberg, Germany

    C. Simonetto, P. Kundrát & M. Eidemüller

  2. Klinik und Poliklinik für Strahlentherapie, MVZ der Universitätsmedizin Rostock am Standort Südstadt gGmbH, Universitätsmedizin Rostock, Südring 75, 18059, Rostock, Germany

    H. Rennau, S. Sebb & G. Hildebrandt

  3. Klinik für Strahlentherapie, Universität Leipzig, Stephanstraße 9a, 04103, Leipzig, Germany

    J. Remmele & U. Wolf

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  1. C. Simonetto
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  2. H. Rennau
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Correspondence to C. Simonetto.

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Conflict of interest

C. Simonetto, H. Rennau, J. Remmele, S. Sebb, P. Kundrát, M. Eidemüller, U. Wolf and G. Hildebrandt declare that they have no competing interests.

Ethical standards

The study was approved by the ethics committee of the University Medicine Rostock (A 2014-0128).

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Simonetto, C., Rennau, H., Remmele, J. et al. Exposure of remote organs and associated cancer risks from tangential and multi-field breast cancer radiotherapy. Strahlenther Onkol 195, 32–42 (2019). https://doi.org/10.1007/s00066-018-1384-1

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