Dosimetric advantages of volumetric modulated arc therapy (VMAT) with deep inspiration breath hold (DIBH) technique in Halcyon Linac for left breast cancer treatment


      To evaluate the dosimetric advantages of incorporating the deep inspiration breath hold (DIBH) technique into left breast cancer volumetric modulated arc therapy (VMAT) treatment under Halcyon Linac and to investigate the correlation between mean heart dose (MHD) and distance from the heart to target volumes in left breast cancer VMAT treatment. Fifteen Post-lumpectomy, left-sided breast patients treated between January 2017 and October 2020 were selected. Two plans were generated for each patient using Eclipse treatment planning system (TPS) with the prescription of 50.4 Gy to planning target volume (PTV) breast and 58.8 Gy to PTV boost in 28 fractions. For each patient, DIBH and free breathing (FB) VMAT treatment plans under Halcyon Linac were generated. Dosimetric parameters, monitor unit and beam-on time of both DIBH and FB groups were compared. Three-dimensional distances from heart surface to each target volume were measured on computed tomography images using the TPS contouring tool and their correlation with MHD was evaluated by Pearson's correlation coefficient (r). Comparable target coverage was shown in both groups. Mean dose to heart, left anterior descending artery, and left ventricle in Halcyon-DIBH-VMAT group were significantly reduced by 0.49 Gy, 1.19 Gy, and 0.57 Gy, respectively, compared to Halcyon-FB-VMAT (p < 0.001). A significant lung dose reduction was also achieved in Halcyon-DIBH-VMAT group. There was also a strong negative correlation between MHD and distance from heart surface to PTV boost in both FB and DIBH group (r = −0.741, p < 0.001), but not observed for distance from heart surface to PTV breast. Incorporating DIBH into left breast cancer VMAT treatment under Halcyon Linac demonstrated significant cardiac and lung dose reduction. It was also demonstrated that MHD had a strong negative correlation with distance from heart surface to PTV boost but relatively independent of distance from heart surface to PTV breast. Recognizing the distance from the heart surface to PTV boost as the main factor in affecting MHD could potentially facilitate clinical treatment planning workflow and decision.


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        • Darby S
        • McGale P
        • 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 randomised trials.
        Lancet. 2011; 378 (Early Breast Cancer Trialists' Collaborative Group (EBCTCG)): 1707-1716
        • Fisher B
        • Anderson S
        • Bryant J
        • 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.
        N. Engl. J. Med. 2002; 347: 1233-1241
        • Pasler M
        • Lutterbach J
        • Björnsgard M
        • et al.
        VMAT techniques for lymph node-positive left sided breast cancer.
        Z. Med. Phys. 2015; 25: 104-111
        • Zhao LR
        • Zhou YB
        • Sun JG.
        Comparison of plan optimization for single and dual volumetric-modulated arc therapy versus intensity-modulated radiation therapy during post-mastectomy regional irradiation.
        Oncol. Lett. 2016; 11: 3389-3394
        • Darby SC
        • Ewertz M
        • McGale P
        • et al.
        Risk of ischemic heart disease in women after radiotherapy for breast cancer.
        N. Engl. J. Med. 2013; 368: 987-998
        • Smyth LM
        • Knight KA
        • Aarons YK
        • et al.
        The cardiac dose-sparing benefits of deep inspiration breath-hold in left breast irradiation: a systematic review.
        J. Med. Radiat. Sci. 2015; 62: 66-73
        • Bruzzaniti V
        • Abate A
        • Pinnarò P
        • et al.
        Dosimetric and clinical advantages of deep inspiration breath-hold (DIBH) during radiotherapy of breast cancer.
        J. Exp. Clin. Cancer Res. 2013; 32: 88
        • Lin A
        • Sharieff W
        • Juhasz J
        • et al.
        The benefit of deep inspiration breath hold: Evaluating cardiac radiation exposure in patients after mastectomy and after breast-conserving surgery.
        Breast Cancer. 2017; 24: 86-91
        • Nissen HD
        • Appelt AL.
        Improved heart, lung and target dose with deep inspiration breath hold in a large clinical series of breast cancer patients.
        Radiother. Oncol. 2013; 106: 28-32
        • Osman SO
        • Hol S
        • Poortmans PM
        • et al.
        Volumetric modulated arc therapy and breath-hold in image-guided locoregional left-sided breast irradiation.
        Radiother. Oncol. 2014; 112: 17-22
        • Pham TT
        • Ward R
        • Latty D
        • et al.
        Left-sided breast cancer loco-regional radiotherapy with deep inspiration breath-hold: Does volumetric-modulated arc radiotherapy reduce heart dose further compared with tangential intensity-modulated radiotherapy?.
        J. Med. Imaging Radiat. Oncol. 2016; 60: 545-553
        • Yu PC
        • Wu CJ
        • Tsai YL
        • et al.
        Dosimetric analysis of tangent-based volumetric modulated arc therapy with deep inspiration breath-hold technique for left breast cancer patients.
        Radiat. Oncol. 2018; 13: 231
        • Swamy ST
        • Radha CA
        • Kathirvel M
        • et al.
        Feasibility study of deep inspiration breath-hold based volumetric modulated arc therapy for locally advanced left sided breast cancer patients.
        Asian Pac. J. Cancer Prev. 2014; 15: 9033-9038
        • Michiels S
        • Poels K
        • Crijns W
        • et al.
        Volumetric modulated arc therapy of head-and-neck cancer on a fast-rotating O-ring linac: Plan quality and delivery time comparison with a C-arm linac.
        Radiother. Oncol. 2018; 128: 479-484
        • Netherton T
        • Li Y
        • Gao S
        • et al.
        Experience in commissioning the halcyon linac.
        Med. Phys. 2019; 46: 4304-4313
        • Cao N
        • Kalet AM
        • Young LA
        • et al.
        Predictors of cardiac and lung dose sparing in DIBH for left breast treatment.
        Phys. Med. 2019; 67: 27-33
        • Taylor CW
        • McGale P
        • Povall JM
        • et al.
        Estimating cardiac exposure from breast cancer radiotherapy in clinical practice.
        Int. J. Radiat. Oncol. Biol. Phys. 2009; 73: 1061-1068
      1. Radiation Therapy Oncology Group. RTOG 1005: A phase III trial of accelerated whole breast irradiation with hypofractionation plus concurrent boost versus standard whole breast irradiation plus sequential boost for early-stage breast cancer. 2012.[1].pdf.

        • Fogliata A
        • Seppälä J
        • Reggiori G
        • et al.
        Dosimetric trade-offs in breast treatment with VMAT technique.
        Br. J. Radiol. 2017; 9020160701
        • Piroth MD
        • Baumann R
        • Budach W
        • et al.
        Heart toxicity from breast cancer radiotherapy: Current findings, assessment, and prevention.
        Strahlenther. Onkol. 2019; 195: 1-12
        • van't Riet A
        • Mak AC
        • Moerland MA
        • et al.
        A conformation number to quantify the degree of conformality in brachytherapy and external beam irradiation: application to the prostate.
        Int. J. Radiat. Oncol. Biol. Phys. 1997; 37: 731-736
        • Kataria T
        • Sharma K
        • Subramani V
        • et al.
        Homogeneity Index: An objective tool for assessment of conformal radiation treatments.
        J. Med. Phys. 2012; 37: 207-213
        • Tonison JJ
        • Fischer SG
        • Viehrig M
        • et al.
        Radiation pneumonitis after intensity-modulated radiotherapy for esophageal cancer: Institutional data and a systematic review.
        Sci. Rep. 2019; 9: 2255
        • Ren C
        • Ji T
        • Liu T
        • et al.
        The risk and predictors for severe radiation pneumonitis in lung cancer patients treated with thoracic reirradiation.
        Radiat. Oncol. 2018; 13: 69
        • Khalil AA
        • Hoffmann L
        • Moeller DS
        • et al.
        New dose constraint reduces radiation-induced fatal pneumonitis in locally advanced non-small cell lung cancer patients treated with intensity-modulated radiotherapy.
        Acta Oncol. 2015; 54: 1343-1349
        • Browne P
        • Beaton NR
        • Sharma H
        • et al.
        Identifying breast cancer patients who gain the most dosimetric benefit from deep inspiration breath hold radiotherapy.
        J. Med. Radiat. Sci. 2020; 67: 294-301
        • Malone C
        • Fennell L
        • Folliard T
        • et al.
        Using a neural network to predict deviations in mean heart dose during the treatment of left-sided deep inspiration breath hold patients.
        Phys. Med. 2019; 65: 137-142