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Robustness analysis of surface-guided DIBH left breast radiotherapy: personalized dosimetric effect of real intrafractional motion within the beam gating thresholds

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Abstract

Purpose

The robustness of surface-guided (SG) deep-inspiration breath-hold (DIBH) radiotherapy (RT) for left breast cancer was evaluated by investigating any potential dosimetric effects due to the residual intrafractional motion allowed by the selected beam gating thresholds. The potential reduction of DIBH benefits in terms of organs at risk (OARs) sparing and target coverage was evaluated for conformational (3DCRT) and intensity-modulated radiation therapy (IMRT) techniques.

Methods

A total of 192 fractions of SGRT DIBH left breast 3DCRT treatment for 12 patients were analyzed. For each fraction, the average of the real-time displacement between the isocenter on the daily reference surface and on the live surface (“SGRT shift”) during beam-on was evaluated and applied to the original plan isocenter. The dose distribution for the treatment beams with the new isocenter point was then calculated and the total plan dose distribution was obtained by summing the estimated perturbed dose for each fraction. Then, for each patient, the original plan and the perturbed one were compared by means of Wilcoxon test for target coverage and OAR dose–volume histogram (DVH) metrics. A global plan quality score was calculated to assess the overall plan robustness against intrafractional motion of both 3DCRT and IMRT techniques.

Results

Target coverage and OAR DVH metrics did not show significant variations between the original and the perturbed plan for the IMRT techniques. 3DCRT plans showed significant variations for the left descending coronary artery (LAD) and the humerus only. However, none of the dose metrics exceeded the mandatory dose constraints for any of the analyzed plans. The global plan quality analysis indicated that both 3DCRT and IMRT techniques were affected by the isocenter shifts in the same way and, generally, the residual isocenter shifts more likely tend to worsen the plan in all cases.

Conclusion

The DIBH technique proved to be robust against residual intrafractional isocenter shifts allowed by the selected SGRT beam-hold thresholds. Small-volume OARs located near high dose gradients showed significant marginal deteriorations in the perturbed plans with the 3DCRT technique only. Global plan quality was mainly influenced by patient anatomy and treatment beam geometry rather than the technique adopted.

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Authors and Affiliations

  1. Department of Physics and Astronomy, University of Florence, Florence, Italy

    A. Gnerucci

  2. Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy

    M. Esposito, A. Ghirelli, S. Pini & S. Russo

  3. Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy

    L. Paoletti, R. Barca, S. Fondelli, P. Alpi, B. Grilli & S. Scoccianti

  4. Radiotherapy Unit, Azienda USL Toscana Sud Est, Grosseto, Italy

    F. Rossi

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A. Gnerucci, M. Esposito, A. Ghirelli, S. Pini, L. Paoletti, R. Barca, S. Fondelli, P. Alpi, B. Grilli, F. Rossi, S. Scoccianti, and S. Russo declare that they have no competing interests.

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This study was conducted in accordance with the Declaration of Helsinki. All patient data were obtained as part of a retrospective data registration program within the framework of 2 routine clinical practice. Written informed consent was obtained from all patients.

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66_2023_2102_MOESM1_ESM.docx

Figure 1SM (Example of the gamma analysis between shifted and original plan for a single patient) and Table 1SM (Values of DVH parameters for the original and perturbed 3D CRT and IMRT plans for each patient of the investigated sample).

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Gnerucci, A., Esposito, M., Ghirelli, A. et al. Robustness analysis of surface-guided DIBH left breast radiotherapy: personalized dosimetric effect of real intrafractional motion within the beam gating thresholds. Strahlenther Onkol 200, 71–82 (2024). https://doi.org/10.1007/s00066-023-02102-9

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