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Does mean heart dose sufficiently reflect coronary artery exposure in left-sided breast cancer radiotherapy?

Influence of respiratory gating

Spiegelt die mittlere Herzdosis im Rahmen der Radiotherapie beim linksseitigen Mammakarzinom die Dosisbelastung der Koronararterien ausreichend wider?

Einfluss der Atemtriggerung

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Abstract

Purpose

With extensive use of systemic treatment, the issue of cardiac mortality after breast cancer radiation (RT) is still important. The aim of our analysis was to clarify whether the dose to one surrogate parameter (e. g., mean heart dose, as used in most studies) reflects the dose to the other cardiovascular structures especially the left anterior descending artery depending on breathing-adapted RT.

Patients and methods

A total of 130 patients who underwent adjuvant RT (50.4 Gy plus boost 9–16 Gy) were evaluated. In all, 71 patients were treated with free-breathing and 59 patients using respiratory monitoring (gated RT). Dosimetric associations were calculated.

Results

The mean dose to the heart (Dmean heart) was reduced from 2.7 (0.8–5.2) Gy to 2.4 (1.1–4.6) Gy, the Dmean LAD (left anterior descending artery) decreased from 11.1 (1.3–28.6) Gy to 9.3 (2.2–19.9) Gy with gated RT (p = 0.04). A significant relationship was shown for Dmean heart–Dmean LAD, V25heart–Dmean LAD and Dmax heart–Dmax LAD for gated patients only (p < 0.01). For every 1 Gy increase in Dmean heart, mean LAD doses rose by 3.6 Gy, without gating V25 ≤5 % did not assure a benefit and resulted in Dmean LAD between 1.3 and 28.6 Gy.

Conclusion

A significant reduction and association of heart and coronary artery (LAD) doses using inspiratory gating was shown. However, in free-breathing plans commonly measured dose constraints do not allow precise estimation of the dose to the coronary arteries.

Zusammenfassung

Hintergrund

Das Risiko kardialer Spätfolgen nach Bestrahlung (RT) eines Mammakarzinoms spielt insbesondere auch aufgrund der zunehmenden systemischen Begleittherapien eine wichtige Rolle. Unklar ist, welche koronaren und/oder myokardialen Mechanismen hier entscheidend sind. Der Einfluss der Atemtriggerung und der daraus resultierenden geometrischen Lagevariabilität der Risikoorgane auf die Dosisverteilung am Herzen/Koronarien sollte geprüft werden, um zu klären, inwieweit die mittlere Herzdosis ein ausreichender Surrogatparameter für die Dosisbelastung der Koronarien ist.

Patienten und Methoden

Ausgewertet wurden 130 Patientinnen mit Mammakarzinom, die mit einer adjuvanten RT (50,4 Gy + Boost 9–16 Gy) bestrahlt wurden. Hiervon wurden 71 Patientinnen in freier Atmung und 59 Patientinnen inspiratorisch atemgetriggert bestrahlt. Des Weiteren wurde die kardiale/koronare Dosisbelastung mit und ohne Atemtriggerung verglichen.

Ergebnisse

Die mittlere Herdosis (Dmean Herz) wurde durch Atemtriggerung von 2,7 Gy (Spanne 0,8–5,2 Gy) auf 2,4 Gy (Spanne 1,1–4,6 Gy) reduziert. Die mittlere LAD-Dosis („left anterior descending artery“, Ramus interventricularis anterior, RIVA) nahm mit Atemtriggerung von 11,1 Gy (Spanne 1,3–28,6 Gy) auf 9,3 Gy (Spanne 2,2–19,9 Gy) ab (p = 0,04). Die Dosisparameter Dmean Herz – Dmean LAD, V25 Herz – Dmean LAD und Dmax Herz – Dmax LAD waren nur für atemgetriggerte Fälle signifikant korrelierbar (p < 0,01), mit einem durchschnittlichen Anstieg der mittleren LAD-Dosis von 3,6 Gy pro 1 Gy mittlere Herzdosis. Bei einer nicht-atemgetriggerten RT lagen die mittleren LAD-Dosen zwischen 1,3 und 28,6 Gy trotz V25 ≤5 %.

Schlussfolgerung

Unter Einsatz einer atemgetriggerten Bestrahlungstechnik lassen sich sowohl die mittlere Herz- als auch die LAD-Dosis senken und die kardialen Dosisparameter miteinander korrelieren. Für die RT ohne Atemtriggerung lässt sich die LAD-Belastung jedoch nicht sicher abschätzen.

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Authors and Affiliations

  1. Department of Radiotherapy and Radio-Oncology, Klinikum Braunschweig, Celler Straße 38, 38114, Braunschweig, Germany

    Martina Becker-Schiebe, Wolfgang Hoffmann & Fabian Wetzel

  2. Department of Gynecology and Obstetrics, Klinikum Braunschweig, Braunschweig, Germany

    Maxi Stockhammer & Heiko Franz

  3. Radiation Oncology, Hannover Medical School, Hannover, Germany

    Martina Becker-Schiebe

Authors
  1. Martina Becker-Schiebe
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  2. Maxi Stockhammer
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  4. Fabian Wetzel
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Correspondence to Martina Becker-Schiebe.

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M. Becker-Schiebe, M. Stockhammer, W. Hoffmann, F. Wetzel, and H. Franz declare that they have no competing interests.

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This article does not contain any studies with human participants or animals performed by any of the authors.

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Becker-Schiebe, M., Stockhammer, M., Hoffmann, W. et al. Does mean heart dose sufficiently reflect coronary artery exposure in left-sided breast cancer radiotherapy?. Strahlenther Onkol 192, 624–631 (2016). https://doi.org/10.1007/s00066-016-1011-y

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