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Cardiac dose-sparing effects of deep-inspiration breath-hold in left breast irradiation

Is IMRT more beneficial than VMAT?

Dosisreduktion am Herzen durch tiefe Inspiration bei Bestrahlung der linken Mamma

Ist die IMRT gegenüber der VMAT von Vorteil?

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Abstract

Background

Given the reduction in death from breast cancer, as well as improvements in overall survival, adjuvant radiotherapy is considered the standard treatment for breast cancer. However, left-sided breast irradiation was associated with an increased rate of fatal cardiovascular events due to incidental irradiation of the heart. Recently, considerable efforts have been made to minimize cardiac toxicity of left-sided breast irradiation by new treatment methods such as deep-inspiration breath-hold (DIBH) and new radiation techniques, particularly intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT). The primary aim of this study was to evaluate the effect of DIBH irradiation on cardiac dose compared with free-breathing (FB) irradiation, while the secondary objective was to compare the advantages of IMRT versus VMAT plans in both the FB and the DIBH position for left-sided breast cancer.

Methods

In all, 25 consecutive left-sided breast cancer patients underwent CT simulation in the FB and DIBH position. Five patients were excluded with no cardiac displacement following DIBH-CT simulation. The other 20 patients were irradiated in the DIBH position using respiratory gating. Four different treatment plans were generated for each patient, an IMRT and a VMAT plan in the DIBH and in the FB position, respectively. The following parameters were used for plan comparison: dose to the heart, left anterior descending coronary artery (mean dose, maximum dose, D25% and D45%), ipsilateral, contralateral lung (mean dose, D20%, D30%) and contralateral breast (mean dose). The percentage in dose reduction for organs at risk achieved by DIBH for both IMRT and VMAT plans was calculated and compared for each patient by each treatment plan.

Results

DIBH irradiation significantly reduced mean dose to the heart and left anterior descending coronary artery (LADCA) using both IMRT (heart –20%; p = 0.0002, LADCA –9%; p = 0.001) and VMAT (heart –23%; p = 0.00003, LADCA –16%; p = 0.01) techniques as compared with FB radiation. There were no significant changes in left lung dose by IMRT; however, with VMAT planning, mean dose to the left lung was reduced by –4% (p = 0.0004). In addition, DIBH significantly increased the mean dose to the contralateral breast with IMRT (+14%, p = 0.002) and significantly reduced the dose to the contralateral breast with VMAT planning (–9%, p = 0.003) compared with the FB position. Additionally, in comparison with VMAT, the IMRT technique reduced mean heart dose both in the FB and the DIBH-position by –30% (p = 0.0004) and –26% (p = 0.002), respectively. Furthermore, IMRT increased the mean dose to the left lung in both the FB and the DIBH position (+5%, p = 0.003, p = 0.006), respectively. There were no significant changes in dose to the right lung and contralateral breast either in the FB or DIBH position between IMRT and VMAT techniques.

Conclusion

Left-sided breast irradiation is best performed in the DIBH position, since a considerable dose sparing to the heart and LADCA can be achieved by using either IMRT or VMAT techniques. A significant additional decrease in heart and LADCA dose by IMRT in both FB and DIBH irradiation was seen compared with VMAT.

Zusammenfassung

Hintergrund

Auf der Basis von Metaanalysen, die eine signifikante Verbesserung der Lokalrezidivraten, aber auch des Überlebens zeigten, gilt die adjuvante Radiotherapie heute als Standardbehandlung nach brusterhaltender Therapie des Mammakarzinoms. Beim linksseitigen Mammakarzinom wurde allerdings eine erhöhte Rate fataler kardiovaskulärer Ereignisse infolge einer Exposition des Herzens mit ionisierender Strahlung ermittelt. Es besteht die Hypothese, dass diese kardiale Toxizität minimiert werden kann, und zwar durch die Bestrahlung in tiefer Inspiration (DIBH) und die Anwendung aktueller Techniken, insbesondere der intensitätsmodulierten Radiotherapie (IMRT) und der volumetrischen Rotationsbestrahlung (VMAT). Primäre Zielsetzung dieser Studie war, beim linksseitigen Mammakarzinom den Effekt der Radiotherapie in tiefer Inspiration auf die Herzbelastung im Vergleich zur freien Atmung zu zeigen. Des Weiteren sollten die Techniken der IMRT und der VMAT mit und ohne tiefe Inspiration verglichen werden.

Methoden

Insgesamt 25 konsekutiv eingeschlossene Patientinnen mit einem linksseitigen Mammakarzinom wurden nach brusterhaltender Operation einer CT-Simulation unterzogen. Datensätze in tiefer Inspiration und freier Atmung (Atemmittellage) wurden ermittelt. Fünf Patientinnen wurden wegen fehlender inspirationsabhängiger Beweglichkeit der ventralen Thoraxwand nach DIBH-CT-Stimulation ausgeschlossen. Die übrigen 20 Patientinnen erhielten eine normalfraktionierte Radiotherapie in DIBH-Technik. Für jede Patientin wurden vier verschiedene Bestrahlungspläne generiert, jeweils ein IMRT- und VMAT-Plan in DIBH-Technik und Atemmittellage. Folgende Parameter wurden für den Planvergleich herangezogen: Dosisbelastung von Herz und linker Koronararterie (LADCA; mittlere und maximale Dosis, D25% und D45%), der ipsilateralen und kontralateralen Lunge (mittlere Dosis, D20%, D30%) sowie der kontralateralen Mamma (mittlere Dosis). Die prozentualen Dosisreduktionen an den Risikoorganen infolge der DIBH-Technik wurden sowohl für IMRT- als auch für VMAT-Pläne kalkuliert und für jede individuelle Patientin zwischen den einzelnen Plänen verglichen.

Ergebnisse

Die DIBH-Bestrahlung führte zu einer signifikanten Reduktion der mittleren Dosis an Herz und LADCA, sowohl mit der IMRT- (Herz − 20 %, p = 0,0002; LADCA − 9 %, p = 0,001) als auch mit der VMAT-Technik (Herz − 23 %, p = 0,00003; LADCA − 16 %, p = 0,01) im Vergleich zur Bestrahlung in Atemmittellage. Die Dosis an der linken Lunge war durch die IMRT nicht signifikant verändert, bei VMAT-Planung war die mittlere Dosis jedoch um − 4% reduziert (p = 0,0004). Zusätzlich wurde infolge der DIBH-Bestrahlung im Vergleich zur Atemmittellage eine signifikant höhere Dosis an der kontralateralen Mamma mit der IMRT (+ 14 %, p = 0,002) gesehen, nach VMAT-Planung war die Dosis an der kontralateralen Brust signifikant verringert (− 9 %, p = 0,003). Zusätzlich reduzierte die IMRT-Technik im Vergleich zur VMAT die mittlere Herzdosis sowohl in Atemmittellage als auch nach DIBH-Positionierung um − 30 % (p = 0,0004) und − 26 % (p = 0,002). Im Vergleich zur VMAT führte die IMRT zu einer Dosiserhöhung an der linken Lunge, und zwar in Atemmittellage und DIBH-Position (+ 5 %, p = 0,003, p = 0,006). Die Dosis an der rechten Lunge und kontralateralen Mamma unterschied sich zwischen IMRT- und VMAT-Technik nicht, weder bei Atemmittellage noch bei DIBH-Positionierung.

Schlussfolgerung

Die Bestrahlung des linksseitigen Mammakarzinoms erfolgt am besten mithilfe der DIBH-Technik, zumal mit der IMRT wie auch mit der VMAT eine erhebliche Dosisreduktion an Herz und Koronararterien erreicht werden kann. Die IMRT kann im Vergleich zur VMAT-Bestrahlung eine zusätzliche Dosisreduktion an den genannten Risikoorganen sowohl in DIBH-Technik als auch in Atemmittellage erzielen.

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Acknowledgements

The present work was carried out by M.S. in fulfillment of the requirements for obtaining the degree “Dr. med.” awarded by the Friedrich Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany.

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Authors and Affiliations

  1. Department of Radiation Oncology, Coburg Cancer Center, Ketschendorferstraße 33, 96450, Coburg, Germany

    Mazen Sakka, Leonie Kunzelmann, Martin Metzger & Gerhard G. Grabenbauer

  2. Faculty of Medicine, Friedrich-Alexander University of Erlangen-Nürnberg, 91054, Erlangen, Germany

    Mazen Sakka & Gerhard G. Grabenbauer

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  1. Mazen Sakka
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  2. Leonie Kunzelmann
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Correspondence to Gerhard G. Grabenbauer.

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Sakka, M., Kunzelmann, L., Metzger, M. et al. Cardiac dose-sparing effects of deep-inspiration breath-hold in left breast irradiation. Strahlenther Onkol 193, 800–811 (2017). https://doi.org/10.1007/s00066-017-1167-0

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