Iranian Journal of Medical Physics

Iranian Journal of Medical Physics

Impacts of Increasing the Number of IMRT Beams on Heart’s Dose Distribution in Left Breast Irradiation: Dosimetric Study

Document Type : Original Paper

Authors
Mohammad Shahanawaj Ansari 1
Mohammad Ziyauddin Khan 2
Sunil Dutt Sharma 3
1 Dr.C.V.Raman University, Kota, Bilaspur (C.G.),India
2 Apollo Hospitals Bilaspur (C.G.), India
3 Bhabha Atomic Research Centre, Mumbai
10.22038/ijmp.2021.57104.1959
Abstract
Introduction: The main objective of this study was to assess the impacts of an increasing the number of IMRT beams on cardiac dose distribution in left-sided breast irradiation so that we can reduce the heart’s mean dose  up to clinically acceptable level.
Material and Methods: For this study 107 female patients, diagnosed with left-sided breast cancer were selected retrospectively. In 107 patients, there were 52 patients of chest wall irradiation including supra-clavicular fossa, while 22 patients were of breast-conserving surgery excluding supra-clavicular fossa and internal mammary lymph nodes, and 33 patients were of chest wall irradiation including internal mammary lymph nodes and supra-clavicular fossa. Exclusion criteria were previous history of left-sided breast radiation therapy, uncommon fractionated dose delivered in past, and indication of palliative radiation therapy. Intensity modulated radiotherapy plans were generated using 7, 9 and11 beams for each patient and the prescribed dose was 40.05 Gy in 15 fractions (2.67 Gy /fraction) for the targets.
Results: Heart: V5Gy(cc): This was a low-dose volume of our study in which the 11-bIMRT technique yielded better result as compared to 9- and 7-bIMRT. Maximum and minimum values of V5 were found 539.60cc in 9-bIMRT and 141.32cc in 11-bIMRT techniques respectively.V25Gy(cc): The maximum value of V25Gy was found 41.73cc in 7-bIMRT technique, while the lowest value was 0.29cc in 11-bIMRT. The IMRT technique with 11 beams showed comparatively better result on this parameter as well as 3-5cc volume of V25Gy was spared. Mean dose (Gy): Maximum value of mean dose was found 8.51Gy in 7-bIMRT while it was 6.53Gy in 11-bIMRT technique.   
Conclusion: The study indicates that increasing the number of IMRT beams reduces heart’s high-dose volume and improves the quality of treatment plans. It is judicious to use 11-bIMRT technique in left-sided breast irradiation as it produces clinically acceptable mean heart dose.
Keywords
Breast Cancer
Optimization
Heart
Radiation Dose
IMRT
Radiotherapy
Subjects
  1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021 Feb 4. doi: 10.3322/caac.21660.
  2. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. New Engl J Med 2002; 347: 1233-41.
  3. Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002; 347: 1227-32.
  4. Hille-Betz U, Vaske B, Bremer M, Soergel P, Kundu S et al. Late radiation side effects, cosmetic outcomes and pain in breast cancer patients after breastconserving surgery and three-dimensional conformal radiotherapy: risk-modifying factors. Strahlenther Onkol. 2016;192:8–
  5. Njeh CF, Saunders MW, Langton CM. Accelerated partial breast irradiation using external beam conformal radiation therapy: a review. Crit Rev Oncol Hematol 2012; 81: 1-20.
  6. Polgár C, Van Limbergen E, Pötter R, Kovács G, Polo A, Lyczek J, et al. Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence (2009). Radiother Oncol 2010; 94: 264-73.
  7. Coles CE, Brunt AM, Wheatley D, Mukesh MB, Yarnold JR. Breast radiotherapy: less is more? Clin Oncol (R Coll Radiol) 2013; 25: 127-34.
  8. Livi L, Meattini I, Marrazzo L, Simontacchi G, Pallotta S, et al. Accelerated partial breast irradiation using intensity-modulated radiotherapy versus whole breast irradiation: 5-year survival analysis of a phase-3 randomised controlled trial. Eur J Cancer 2015; 51: 451-63.
  9. Smith BD, Arthur DW, Buchholz TA, Haffty BG, Hahn CA, et al. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). J Am Coll Surg 2009; 209: 269-77.
  10. Arthur DW, Vicini FA. Accelerated partial breast irradiation as a part of breast conservation therapy. J Clin Oncol 2005; 23: 1726-35.
  11. Ansari S, Kumar Satpathy S. Half Beam Block Technique in Breast Cancer and It’s Dosimetric Analysis using different Algorithms. Iran J Med  Phys 2017; 14: 66-74.
  12. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death. Meta-analysis of individual patient data for 10 801women in 17 randomized
  13. Clarke M, Collins R, Davies C, Elphinstone P, Evans E, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival. An overview of the randomized trials. Lancet. 2005;366(9503):2087–
  14. Overgaard M, Jensen MB, Overgaard J, Hansen P, Rose C, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen. Danish breast Cancer cooperative group DBCG 82c randomized trial. Lancet. 1999;353(9165):1641–
  15. Darby S, McGale P, Taylor C, Peto R. Long-term mortality from heart disease and lung cancer after radiotherapy for early breast cancer. Prospective cohort study of about 300 000 women in US SEER cancer registries. Lancet Oncol. 2005;6(8):557–
  16. Sardaro A, Petruzzelli MF, D'Errico MP, Grimaldi L, Pili G. Radiation-induced cardiac damage in early left breast cancer patients. Risk factors, biological mechanisms, radiobiology, and dosimetric constraints. Radiother Oncol. 2012;103(2):133–
  17. Darby S, Ewertz M, McGale P, Bennet A, Blom-Goldman U, Brønnum D, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013;368(11):987–
  18. Vicini F, Sharpe M, Kestin L, Martinez A. Optimizing breast cancer treatment efficacy with intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2002;54:1336–
  19. Kestin L, Sharpe MB, Frazier R, Vicini F, et al. Intensity modulation to improve dose uniformity with tangential breast radiotherapy: initial clinical experience. Int J Radiat Oncol Biol Phys. 2000;48(5):1559–
  20. Ha B, Suh HS, Lee J, Lee KJ, Lee R, Moon BI. Long-term results of forward intensity-modulated radiation therapy for patients with early-stage breast cancer. Radiat Oncol J. 2013 Dec;31(4):191-8. DOI: 10.3857/roj.2013.31.4.191.
  21. Mukesh B, Barnett GC, Wilkinson JS, Moody AM, Wilson C, et al. Randomized controlled trial of intensity-modulated radiotherapy for early breast cancer. 5-year results confirm superior overall cosmesis. J Clin Oncol. 2013;31(36):4488–
  22. Darby S, McGale P, Correa C, Taylor C, Arriagada R, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomized trials. Lancet. 2011;378(9804):1707–
  23. Hooning MJ, Botma A, Aleman BM, Baaijens MH, Bartelink H, et al. Long-term risk of cardiovascular disease in 10-year survivors of breast cancer. J Natl Cancer Inst. 2007;99(5): 365–
  24. Henson KE, McGale P, Taylor C, Darby SC. Radiation-related mortality from heart disease and lung cancer more than 20 years after radiotherapy for breast cancer. Br J Cancer. 2013;108(1):179–
  25. Morgan EA, Kozono DE, Wang Q, Mery CM, Butrynski JE, et al. Cutaneous radiation-associated angiosarcoma of the breast: poor prognosis in a rare secondary malignancy. Ann Surg Oncol. 2012;19(12):3801–
  26. Paszat LF, Mackillop WJ, Groome PA, Schulze K, Holowaty E. Mortality from myocardial infarction following post lumpectomy radiotherapy for breast cancer: a population-based study in Ontario, Canada. Int J Radiat Oncol Biol Phys. 1999;43(4):755–
  27. Clarke M, Collins R, Darby S, Davies C, Elphinstone P, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomized trials. Lancet. 2005;366(9503):2087–
  28. Finazzi T, Nguyen VT, Zimmermann F., et al. Impact of patient and treatment characteristics on heart and lung dose in adjuvant radiotherapy for left-sided breast cancer. Radiat Oncol.2019; 14- 153. DOI:10.1186/s13014-019-1364-3.
  29. Taylor C, Correa C, Duane FK, et al. Estimating the Risks of Breast Cancer Radiotherapy: Evidence From Modern Radiation Doses to the Lungs and Heart and From Previous Randomized Trials. J Clin Oncol. 2017;35(15):1641– DOI:10.1200/JCO.2016.72.0722.
  30. Boero IJ, Paravati AJ, Triplett DP, Hwang L, Matsuno RK, Gillespie EF,et al. Modern Radiation Therapy and Cardiac Outcomes in Breast Cancer. Int J Radiat Oncol Biol Phys. 2016 Mar 15;94(4):700-8.
  31. Poortmans PM, Collette S, Kirkove C, Van Limbergen E, Budach V, Struikmans H, et al. Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer. N Engl J Med. 2015 Jul 23;373(4):317-27. DOI: 10.1056/NEJMoa1415369.
  32. Whelan TJ, Olivotto IA, Parulekar WR, Ackerman I, Chua BH, Nabid A,. Regional Nodal Irradiation in Early-Stage Breast Cancer. N Engl J Med. 2015 Jul 23;373(4):307-16. DOI: 10.1056/NEJMoa1415340.
  33. Ayata HB, Güden M, Ceylan C, Kücük N, Engin K. Comparison of dose distributions and organs at risk (OAR) doses in conventional tangential technique (CTT) and IMRT plans with different numbers of beam in left-sided breast cancer. Rep Pract Oncol Radiother. 2011 ;16(3):95-102.
  34. Nielsen M, Berg M, Pedersen A, Andersen K, Glavicic V, et al. Delineation of target volumes and organs at risk in adjuvant radiotherapy of early breast cancer. National guidelines and contouring atlas by the Danish breast Cancer cooperative group. Acta Oncol (Stockholm, Sweden). 2013; 52(4):703–
  35. Radiation therapy oncology group (2009) Breast cancer atlas for radiation therapy planning: consensus definitions. http://www.rtog.org/CoreLab/ ontouringAtlases/BreastCancerAtlas.aspx.
  36. Offersen BV, Boersma LJ, Kirkove C, et al. ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage breast cancer. Radiother Oncol. 2015;114:3– DOI:org/10.1016/j. radonc.2014.11.030.
  37. García-Vicente F, Béjar MJ, Pérez L, Torres JJ. Clinical impact of the detector size effect in 3D-CRT. Radiother Oncol. 2005 Mar;74(3):315-22. DOI: 10.1016/j.radonc.2004.10.012.
  38. Marks L, Bentzen S, Deasy J, Kong F. Radiation dose volume effects in the lung. Int J Radiat Oncol Biol Phys. 2010;76:70– DOI:org/10.1016/j. ijrobp.2009.06.091.Radiation.
  39. Kwa SLS, Lebesque JV, Theuws JC, Marks LB. Radiation pneumonitis as a function of mean lung dose: an analysis of pooled data of 540 patients. Int J Radiat Oncol Biol Phys. 1998;42:1–
  40. Livi L, Meattini I, Marrazzo L, Simontacchi G, Pallotta S, Saieva C,et al. Accelerated partial breast irradiation using intensity-modulated radiotherapy versus whole breast irradiation: 5-year survival analysis of a phase 3 randomised controlled trial. Eur J Cancer. 2015 Mar;51(4):451-463. DOI: 10.1016/j.ejca.2014.12.013.
  41. Meattini I, Saieva C, Marrazzo L, Di Brina L, Pallotta S, et al. Accelerated partial breast irradiation using intensity-modulated radiotherapy technique compared to whole breast irradiation for patients aged 70 years or older: subgroup analysis from a randomized phase 3 trial. Breast Cancer Res Treat. 2015;153:539–
  42. Pignol JP, Olivotto I, Rakovitch E, Gardner S, Sixel K et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. 2008;26:2085–
  43. Pignol JP, Truong P, Rakovitch E, Sattler MG, Whelan TJ. Ten years results of the Canadian breast intensity modulated radiation therapy (IMRT) randomized controlled trial. Radiother Oncol. 2016;121:414–
  44. Mukesh MB, Qian W, Wilkinson JS, Dorling L, Barnett GC et al. Patient reported outcome measures (PROMs) following forward planned field-in field IMRT: results from the Cambridge Breast IMRT trial. Radiother Oncol. 2014;111:270–
  45. Livi L, Meattini I, Marrazzo L, Simontacchi G, Pallotta S et al. Accelerated partial breast irradiation using intensity- modulated radiotherapy versus whole breast irradiation: 5-year survival analysis of a phase 3 randomised controlled trial. Eur J Cancer. 2015;51:451–
  46. Meattini I, Saieva C, Marrazzo L, Di Brina L, Pallotta S et al. Accelerated partial breast irradiation using intensity-modulated radiotherapy technique compared to whole breast irradiation for patients aged 70 years or older: subgroup analysis from a randomized phase 3 trial. Breast Cancer Res Treat. 2015;153:539–
  47. Sardaro A, Petruzzelli MF, D'Errico MP, Grimaldi L, Pili G et al.Radiation-induced cardiac damage in early left breast cancer patients. Risk factors, biological mechanisms, radiobiology, and dosimetric constraints. Radiother Oncol. 2012;103(2):133–
  48. Darby S, Ewertz M, McGale P, Bennet A, Blom-Goldman U et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013;368(11):987–
  49. Mege A, Zioueche A, Pourel N, Chauvet B. Radiation-related heart toxicity. Cancer Radiother. 2011;15 (6–7):495–
  50. Laxmi S , Karol E  , Ana B ,  Theresa M  , Vera B ,et al. Cardiovascular disease and breast Cancer: where these entities intersect. A Scientific Statement from the American Heart Association. Circulation. 2018;137:e30–
  51. Dumane VA, Saksornchai K, Zhou Y, Hong L, Powell S. Reduction in low-dose to normal tissue with the addition of deep inspiration breath hold (DIBH) to tangential volumetric modulated arc therapy (TVMAT) in breast cancer patients with implant reconstruction receiving regional nodal irradiation. Radiat Oncol. 2018;13(1):187.
  52. Dorr W, Herrmann T. Second primary tumors after radiotherapy for malignancies. Treatment-related parameters. Strahlenther Onkol. 2002;178(7):357–

 

 

 

 

Iranian Journal of Medical Physics
Volume 19, Issue 3
May and June 2022
Pages 145-153

  • Receive Date 17 April 2021
  • Revise Date 15 July 2021
  • Accept Date 18 August 2021