DOSIMETRIC ANALYSIS OF DEEP INSPIRATION BREATH HOLD TECHNIQUE ADAPTED TO TANGENTIAL-BASED VOLUMETRIC MODULATED ARC THERAPY FOR LEFT BREAST CANCER AFTER MASTECTOMY

Yıl 2025, Cilt: 15 Sayı: 4, 402 - 410, 15.12.2025

Dicle Aslan , Mustafa Tarkan Aksozen

https://doi.org/10.16919/bozoktip.1697281

Öz

Purpose: To evaluate the dosimetric properties of the deep inspiration breath hold (DIBH) technique adapted to tangential-based volumetric modulated arc therapy (TVMAT) in left breast cancer patients with mastectomy.
Method: Forty-three patients who underwent mastectomy and received chest wall and regional lymph node irradiation were included in the study. Simulation computed tomography (CT) was performed in DIBH and free-breathing (FB). Two plans were created for each patient; DIBH-TVMAT and FB-TVMAT. Both plans were realized using a mono-isocentric technique with two partial arc rotations, and the same gantry angles were used.The standard fractionation schedule for each patient was set to 50 Gy in 25 fractions. Paired-sample T-test was used to evaluate the dosimetric parameters.
Results: The comparison between FB-TVMAT and DIBH-TVMAT plans revealed mean heart doses of 8.9 Gy and 5.4 Gy, respectively (p=0.000). A 6.2% reduction was encountered in left lung volume receiving 5 Gy (V5) in the DIBH-TVMAT plan (p=0.01). A reduction of 1.3 Gy at a percentage of 28% was monitored in the mean dose of the right lung in DIBH-TVMAT (p=0.000). The mean right breast dose was 0.7 Gy lower in DIBH-TVMAT (p=0.000).
Conclusion: The results support that the adaptation of DIBH to TVMAT allows an optimal target volume dose coverage as well as leads to significant dose reductions in the left lung, right lung, heart, LADCA, and right breast for the left breast cancer patients with mastectomy.

Anahtar Kelimeler

Breast cancer , Tangential volumetric modulated arc therapy , Deep inspiration breath hold , Radiotherapy , Mastectomy

Etik Beyan

Ethical Statement All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed Consent The informed consent form was obtained from all subjects. Our study was approved by the independent ethics committee/institutional review board at Erciyes University Medical Faculty Ethical Committee. The first ethics committee approval was obtained prior to the initiation of the study, with the approval number 2020/32 and the date 15.01.2020. The second ethics committee approval was granted under the approval number 2024/175 on 13.03.2024.

Destekleyen Kurum

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Proje Numarası

2020/32

Teşekkür

None

MASTEKTOMİ SONRASI SOL MEME KANSERİNDE TANJANSİYEL TEMELLİ HACİMSEL MODÜLELİ ARK TERAPİSİNE UYARLANAN DERİN İNHALASYONDA NEFES TUTMA TEKNİĞİNİN DOZİMETRİK ANALİZİ

Öz

Amaç: Bu çalışmada, mastektomi uygulanmış sol meme kanseri hastalarında, tanjansiyel temelli hacimsel modüleli ark terapisine (TVMAT) entegre edilen derin inhalasyonda nefes tutma (DIBH) tekniğinin dozimetrik özelliklerinin değerlendirilmesi amaçlanmıştır.

Yöntem: Çalışmaya mastektomi geçirmiş ve torakal duvar ile bölgesel lenf nodlarına radyoterapi uygulanan 43 hasta dâhil edilmiştir. Simülasyon bilgisayarlı tomografileri (BT), hem DIBH hem de serbest solunum (FB) modlarında alınmıştır. Her hasta için DIBH-TVMAT ve FB-TVMAT olmak üzere iki ayrı tedavi planı oluşturulmuştur. Her iki plan da mono-izosentrik teknikle ve iki parsiyel ark rotasyonu kullanılarak, aynı gantri açılarıyla planlanmıştır. Tüm hastalar için fraksiyonasyon şeması 25 fraksiyonda toplam 50 Gy olacak şekilde standartlaştırılmıştır. Dozimetrik parametrelerin karşılaştırılmasında eşleştirilmiş örneklem t-testi kullanılmıştır.

Bulgular: FB-TVMAT ve DIBH-TVMAT planları karşılaştırıldığında, sırasıyla ortalama kalp dozları 8.9 Gy ve 5.4 Gy olarak bulunmuştur (p=0.000). DIBH-TVMAT planında sol akciğerin 5 Gy aldığı hacimde (V5) %6.2’lik bir azalma gözlenmiştir (p=0.01). Sağ akciğerin ortalama dozunda 1.3 Gy, yani %28 oranında anlamlı bir düşüş kaydedilmiştir (p=0.000). Ayrıca, sağ memeye alınan ortalama doz DIBH-TVMAT planında 0.7 Gy daha düşük bulunmuştur (p=0.000).

Sonuç: Bulgular, DIBH tekniğinin TVMAT planlamasına entegre edilmesinin hedef hacim üzerinde yeterli doz kapsamı sağladığını ve sol meme kanseri nedeniyle mastektomi uygulanmış hastalarda kalp, LADCA, sol ve sağ akciğer ile karşı meme dozlarında anlamlı azalmalar sağladığını göstermektedir.

Anahtar Kelimeler

Derin inspiryumda nefes tutma , Tanjansiyel hacimsel modüleli ark terapisi , Meme kanseri , Radyoterapi , Mastektomi

Proje Numarası

2020/32

Kaynakça

• 1. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). 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 randomised trials. Lancet 2005;366(9503):2087–106.
• 2. Klein J, Tran W, Watkins E, Vesprini D, Wright FC, Look Hong NJ, et al. Locally advanced breast cancer treated with neoadjuvant chemotherapy and adjuvant radiotherapy: a retrospective cohort analysis. BMC Cancer 2019;19(1):306.
• 3. Boyages J. Radiation therapy and early breast cancer: Current controversies. Med J Aust. 2017;207(5):216–22.
• 4. Sardaro A, Fonte M, Patrizia M, Errico D, Grimaldi L, Pili G, et al. Radiation-induced cardiac damage in early left breast cancer patients : Risk factors , biological mechanisms , radiobiology , and dosimetric constraints. Radiot Oncol. 2012;103(2):133–42.
• 5. Duma MN, Baumann R, Budach W, Dunst J, Feyer P, Fietkau R, et al .Breast Cancer Expert Panel of the German Society of Radiation Oncology (DEGRO). Heart-sparing radiotherapy techniques in breast cancer patients: a recommendation of the breast cancer expert panel of the German society of radiation oncology (DEGRO). Strahlenther Onkol. 2019;195(10):861-71.
• 6. Xie Y, Bourgeois D, Guo B, Zhang R, Oncology R, Bird M, et al. Medical Dosimetry Postmastectomy radiotherapy for left-sided breast cancer patients : Comparison of advanced techniques. Medical Dosimetry. 2021;45(1):34–40.
• 7. Darby SC, Ewertz M, McGale P, Bennet AM, 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):987–98.
• 8. Kaplinsky A, Pyatigorskaya V, Granot H, Gelernter I, Ben-Ayun M, Alezra D, et al. RPM Inspiration Gating: Improving Radiotherapy for Left Breast Cancer Patients with Anterior Heart Position. Isr Med Assoc J. 2018 ;20(9):548-52.
• 9. Latty D, Stuart KE, Wang W, Ahern V. Review of deep inspiration breath-hold techniques for the treatment of breast cancer. J Med Radiat Sci. 2015 Mar;62(1):74-81
• 10. Testolin A, Ciccarelli S, Vidano G, Avitabile R, Dusi F, Alongi F. Deep inspiration breath-hold intensity modulated radiation therapy in a large clinical series of 239 left-sided breast cancer patients: a dosimetric analysis of organs at risk doses and clinical feasibility from a single center experience. Br J Radiol 2019;92(1101):20190156.
• 11. Sakyanun P, Saksornchai K, Nantavithya C, Chakkabat C, Shotelersuk K. The effect of deep inspiration breath-hold technique on left anterior descending coronary artery and heart dose in left breast irradiation. J Cancer Educ. 2020;38(3):181–8.
• 12. Xie Y, Bourgeois D, Guo B, Zhang R. Comparison of conventional and advanced radiotherapy techniques for left-sided breast cancer after breast conserving surgery. Med Dosim. 2020;45(4):e9–16.
• 13. Donovan E, Bleakley N, Denholm E, Evans P, Gothard L, Hanson J, et al. Breast Technology Group. Randomised trial of standard 2D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy. Radiother Oncol. 2007;82(3):254-64.
• 14. Tsai CL, Wu JK, Chao HL, Tsai YC, Cheng JCH. Treatment and Dosimetric Advantages Between VMAT, IMRT, and Helical TomoTherapy in Prostate Cancer. Med Dosim. 2011;36(3):264–71.
• 15. Popescu CC, Olivotto IA, Beckham WA, Ansbacher W, Zavgorodni S, Shaffer R, et al. Volumetric Modulated Arc Therapy Improves Dosimetry and Reduces Treatment Time Compared to Conventional Intensity-Modulated Radiotherapy for Locoregional Radiotherapy of Left-Sided Breast Cancer and Internal Mammary Nodes. Int J Radiat Oncol Biol Phys. 2010;76(1):287–95.
• 16. Haciislamoglu E, Cinar Y, Gurcan F, Canyilmaz E, Gungor G, Yoney A. Secondary cancer risk after whole-breast radiation therapy: Field-in-field versus intensity modulated radiation therapy versus volumetric modulated arc therapy. Br J Radiol. 2019;92(1102):8–15.
• 17. Yu PC, Wu CJ, Nien HH, Lui LT, Shaw S, Tsai YL. Tangent-based volumetric modulated arc therapy for advanced left breast cancer. Radiat Oncol. 2018;13(1):1–10.
• 18. Lin CH, Lin LC, Que J, Ho CH. A seven-year experience of using moderate deep inspiration breath-hold for patients with early-stage breast cancer and dosimetric comparison. Med. 2019;98(19):e15510.
• 19. Lai J, Hu S, Luo Y, Zheng R, Zhu Q, Chen P, et al. Meta-analysis of deep inspiration breath hold (DIBH) versus free breathing (FB) inpostoperative radiotherapy for left-side breast cancer. Breast Cancer. 2020;27(2):299–307.
• 20. Mkanna A, Mohamad O, Ramia P, Thebian R, Makki M, Tamim H, et al. Predictors of cardiac sparing in deep inspiration breath-hold for patients with left sided breast cancer. Front Oncol. 2018;8:1–6.
• 21. Dumane VA, Saksornchai K, Zhou Y, Hong L, Powell S, Ho AY. Reduction in low-dose to normal tissue with the addition of deep inspiration breath hold (DIBH) to volumetric modulated arc therapy (VMAT) in breast cancer patients with implant reconstruction receiving regional nodal irradiation. Radiat Oncol. 2018;13(1):1–7.
• 22. Darapu A, Balakrishnan R, Sebastian P, Hussain MR, Ravindran P, John S. Is the Deep Inspiration Breath-Hold Technique Superior to the Free Breathing Technique in Cardiac and Lung Sparing while Treating both Left-Sided Post-Mastectomy Chest Wall and Supraclavicular Regions? Case Rep Oncol. 2017;10(1):37-51
• 23. Quirk S, Grendarova P, Phan T, Conroy L, Burke B, Long K, et al. A retrospective analysis to demonstrate achievable dosimetry for the left anterior descending artery in left-sided breast cancer patients treated with radiotherapy. Radiat Oncol. 2020;148:167–73.
• 24. Kivanc H, Gultekin M, Gurkaynak M, Ozyigit G, Yildiz F. Dosimetric comparison of three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for left-sided chest wall and lymphatic irradiation. J Appl Clin Med Phys 2019;20(12):36–44.
• 25. Balaji K, Yadav P, Balajisubramanian S. Physica Medica Hybrid volumetric modulated arc therapy for chest wall irradiation : For a good plan , get the right mixture. Phys Med. 2018;52:86–92.
• 26. Zhang Q, Yu XL, Hu WG, Chen JY, Wang JZ, Ye JS, et al. Dosimetric comparison for volumetric modulated arc therapy and intensitymodulated radiotherapy on the left-sided chest wall and internal mammary nodes irradiation in treating post-mastectomy breast cancer. Radiat Oncol. 2015;49(1):91–8.
• 27. Lang K, Loritz B, Schwartz A, Hunzeker A, Lenards N, Culp L, et al. Dosimetric comparison between volumetric-modulated arc therapy and a hybrid volumetric-modulated arc therapy and segmented field-in-field technique for postmastectomy chest wall and regional lymph node irradiation. Med Dosim. 2020;45(2):121-7.
• 28. Vennarini S, Fournier-Bidoz N, Aristei C, de Almeida CE, Servois V, Campana F, et al. Visualisation of the left anterior descending coronary artery on CT images used for breast radiotherapy planning. Br J Radiol 2013;86(1025):20120643.
• 29. Lorenzen EL, Taylor CW, Maraldo M, Nielsen MH, Offersen BV, Andersen MR, et al. Inter-observer variation in delineation of the heart and left anterior descending coronary artery in radiotherapy for breast cancer : A multi-centre study from Denmark and the UK. Radiot Oncol. 2013;108(2):254–8.