Volumetric-modulated arc therapy improved heart and lung sparing for a left-sided chest wall and regional nodal irradiation case (original) (raw)
Related papers
Applied Radiation Oncology, 2016
A 33-year-old, premenopausal, BRCA-negative woman with Adria-mycin-induced cardiomyopathy and left ventricular dysfunction presented to our department in 2015 for adjuvant treatment of ductal carcinoma in situ (DCIS) of the left breast. Her medical history was significant for Wilm's tumor diagnosed at age 10, treated with surgery followed by Adriamycin-based chemotherapy, which resulted in dilated cardiomyopathy. She remained on several medications for cardiomyopathy over many years, and has been followed closely by cardiologists. Her left ven-tricular ejection fraction, prior to initiating radiation, was estimated to be 37%. Three months prior to presentation, the patient sustained an episode of con-gestive heart failure exacerbation, and was found to be 13 weeks pregnant. Cardiology assessed that the patient was at high risk for decompensating with pregnancy, and was advised to undergo an elective termination, which was subsequently performed without complication. She nevertheless continued to exhibit moderate heart failure symptoms, and was started on high-dose diuretics with ultimate symptom resolution. With regard to the DCIS diagnosis, she initially presented with bloody left nipple discharge. Breast imaging studies were obtained, demonstrating suspicious microcalcifications in the retroareaolar region of the left breast. Core biopsy of the microcalcifications revealed intra-ductal papilloma. Lumpectomy was performed , with pathology consistent with a diagnosis of DCIS. Adjuvant radiation with 3D-conformal radiation therapy was recommended, following extensive discussion with her breast surgeon and cardiologist. Additionally, given the pos-itivity of ER and PR hormone receptors, she was recommended a 5-year course of Tamoxifen upon completion of left breast irradiation. IMAGING AND PATHOLOGY FINDINGS Initial left breast diagnostic mam-mogram showed grouped microcal-cifications in the retroareolar region. Diagnostic ultrasound of the left breast showed a 1-cm cyst cluster that was 4 cm from the nipple, and dilated retroare-olar ducts with minimal intraluminal debris. Subsequent bilateral breast MRI demonstrated a suspicious 8-mm mass medial to the nipple of the left breast, and suspicious nonmass enhancement in the retroareolar region of the right breast, as well as an 8-mm enhancing mass in the superior mid portion of the right breast. Ultrasound-guided core biopsies of the subareolar axis of the left breast and of retroareolar axis of the right breast revealed intraductal papillomas. The patient underwent an additional core biopsy of the left breast inferior outer quadrant, which also revealed intraductal papilloma. She then underwent bilateral lumpectomies. Whereas the right breast surgical specimen contained intraductal papilloma, her left breast lumpectomy pathology revealed an 8-mm focus DCIS, EORTC intermediate grade, with negative margins, ER+, PR+.
Cancers, 2021
Background: For advanced breast cancer with lymph node involvement, adjuvant radiotherapy (RT) with regional nodal irradiation (RNI) has been indicated to reduce cancer recurrence and mortality. However, an extensive RT volume is associated with normal organ exposure, which increases the toxicity and affects patient outcomes. Modern arc RT techniques can improve normal organ sparing compared with conventional techniques. The aim of this study was to explore the optimal technique for left-breast RT with RNI. Methods: We retrospectively reviewed patients receiving RT with RNI for left-breast cancer. We used modern arc RT techniques with either volumetric-modulated arc therapy (VMAT) or helical tomotherapy (HT) with a novel block technique, and compared differences in dosimetry parameters between the two groups. Subgroup analysis of RNI with or without internal mammary node (IMN) volume was also performed. Results: A total of 108 eligible patients were enrolled between 2017 and 2020, o...
Radiotherapy and Oncology, 2014
Purpose: To investigate the effects of using volumetric modulated arc therapy (VMAT) and/or voluntary moderate deep inspiration breath-hold (vmDIBH) in the radiation therapy (RT) of left-sided breast cancer including the regional lymph nodes. Materials and methods: For 13 patients, four treatment combinations were compared; 3D-conformal RT (i.e., forward IMRT) in free-breathing 3D-CRT(FB), 3D-CRT(vmDIBH), 2 partial arcs VMAT(FB), and VMAT(vmDIBH). Prescribed dose was 42.56 Gy in 16 fractions. For 10 additional patients, 3D-CRT and VMAT in vmDIBH only were also compared. Results: Dose conformity, PTV coverage, ipsilateral and total lung doses were significantly better for VMAT plans compared to 3D-CRT. Mean heart dose (D mean,heart ) reduction in 3D-CRT(vmDIBH) was between 0.9 and 8.6 Gy, depending on initial D mean,heart (in 3D-CRT(FB) plans). VMAT(vmDIBH) reduced the D mean,heart further when D mean,heart was still >3.2 Gy in 3D-CRT(vmDIBH). Mean contralateral breast dose was higher for VMAT plans (2.7 Gy) compared to 3DCRT plans (0.7 Gy). Conclusions: VMAT and 3D-CRT(vmDIBH) significantly reduced heart dose for patients treated with locoregional RT of left-sided breast cancer. When D mean,heart exceeded 3.2 Gy in 3D-CRT(vmDIBH) plans, VMAT(vmDIBH) resulted in a cumulative heart dose reduction. VMAT also provided better target coverage and reduced ipsilateral lung dose, at the expense of a small increase in the dose to the contralateral breast. (M. Essers).
Clinical and Translational Oncology, 2019
Purpose To evaluate acute and late skin/subcutaneous toxicities and radiation-induced lung fibrosis (RILF) in patients treated with adjuvant radiotherapy (RT) for synchronous bilateral breast cancers (SBBC), after conservative surgery. Methods/patients Twenty-five patients were treated with volumetric-modulated arc therapy (VMAT/RapidArc ®) on both breasts, and checked clinically for detecting RT toxicities during and after treatment. A high-resolution computed tomography (HRCT) was performed, for detecting RILF during follow-up. Results We registered acute Grade-1 skin toxicity in 18 patients (72%), while six patients (24%) experienced Grade-2 toxicity. No breath symptoms were reported during and after RT. Late Grade-1 subcutaneous toxicity and late Grade-2 skin toxicity were registered in four patients (16%) and one patient (4%), respectively, at a mean follow-up of 36 months. Grade-1 RILF was detected in six patients (30%). The median volume of fibrosis area was 6.5 cc (range 1.3-21.5 cc). The partial volumes receiving a specified dose (V20, V30, V40, and V50) in patients who developed lung fibrosis were significantly bigger than who did not (p < 0.01). We showed that the mean volume of the tumour boost of patients who developed fibrosis (77.7 cc) was not significantly different from the other patients (90.8 cc) (p = 0.5). Conclusion The clinical impact of this technique is favourable, and this is the first clinical study showing RILF by HRCT in a setting of SBBC. Further study with larger accrual is mandatory.
Physica medica : PM : an international journal devoted to the applications of physics to medicine and biology : official journal of the Italian Association of Biomedical Physics (AIFB), 2018
To find the optimal dose weighting for hybrid volumetric modulated arc therapy (H-VMAT), a combination of conventional 3DCRT and VMAT plans for left sided chest wall and supraclavicular radiation therapy. 20 left-sided breast cancer patients who received adjuvant radiotherapy were considered for this study. To find the optimal weighting, 5 H-VMAT plans were generated for each study case by combining different dose proportions of 3DCRT and VMAT plans including: 90% 3DCRT/10% VMAT, 80% 3DCRT/20% VMAT, 70% 3DCRT/30% VMAT, 60% 3DCRT/40% VMAT, 50% 3DCRT/50% VMAT. Further field-in-field, optimal H-VMAT and VMAT alone plans were compared. All H-VMAT plans achieved the expected target coverage. A higher conformity index was achieved for 50% 3DCRT/50% VMAT plan, while better homogeneity index was achieved for 80% 3DCRT/20% VMAT plan. Mean and low doses were less in 90% 3DCRT/10% VMAT plan. Compared with other proportions, 80% 3DCRT/20% VMAT and 70% 3DCRT/30% VMAT weighted H-VMAT plans achiev...
Applied Radiation Oncology, 2018
Objective: Postmastectomy radiation therapy (PMRT) to the chest wall and regional nodal irradiation (RNI) in women with node-positive breast cancer is known to reduce locoregional recurrence and distant metastases, as well as improve overall survival. Standard 3-dimensional (3D) conformal techniques may not be able to provide a clinically optimal plan for treatment, especially when coverage to the internal mammary nodes is required. Although advanced delivery techniques such as volumet-ric-modulated arc therapy (VMAT) can be used to better spare the heart and lungs, there is an increase in low dose exposure to normal tissue compared with 3D conformal planning. In a situation where 3D conformal planning provides an acceptable dose distribution for the majority of critical organs, it may not be justifiable to use VMAT to reduce dose to a few organs, while increasing low-dose exposure to the entire patient. In such cases, a combination of VMAT and 3D can be suitable to generate a clinically acceptable dose distribution without an unnecessary increase in low dose exposure. In this report we describe a left-and a right-sided case, which have benefited from this approach. Methods and Materials: The left-sided case was of a 59-year-old woman with stage IIIC cancer who had undergone a bilateral mastectomy requiring PMRT to the chest wall along with RNI. The right-sided case was of a 51-year-old woman with stage IIIC cancer who had undergone a lumpectomy requiring whole-breast radiation (WBI) with RNI. Computed tomography (CT) scans were acquired from the chin to the upper abdomen during free breathing at 3-mm slice spacing with the patient positioned on an angle board and head turned to the contralateral side. Contouring of the target volume was done as per Radiation Therapy Oncology Group (RTOG) guidelines. Three plans were done for each case, the first using 3D conformal planning with the partially wide tangents (PWT) technique, the second using volumetric-modulated arc therapy (VMAT) alone, and finally using a combination of 3D and VMAT. A dosimetric comparison of the plans was performed in each case. Results: For both the left-and the right-sided cases, the PTV D95, V95 as well as the IMN D95 were comparable among all the plans; however, the hotspot in terms of the PTV D05 was found to be lower for the VMAT and the combined plan. The homogeneity index (HI) and the conformity index (CI) were best with the combined plan. For both the left-and the right-sided cases, the heart was well spared with the PWT technique. The MHD was the highest with VMAT as were the volumes covered by lower doses, namely 15 Gy and 5 Gy. However, combining VMAT and PWT did not compromise the V15 Gy and V5 Gy compared with PWT. The ipsilateral lung V20 Gy was the highest (≥ 45%) with PWT technique yielding a clinically unacceptable plan in both cases. The combination of VMAT and PWT not only maintained the ipsilateral lung V20 Gy ≤ 30%, but also kept the V5 Gy comparable to or lower than the corresponding PWT plan. The trend in the result for the total lung was similar to that of the ipsilateral lung. The contralateral breast was best spared with PWT; however, the combination plan did not compromise dose to the contralateral breast compared with the former technique. Conclusions: Combination of VMAT and 3D was not only able to preserve the mean dose to the heart, but was able to also reduce the ipsilateral lung V20 Gy without increasing low dose to all of the organs compared to using VMAT alone.
Introduction: Left-sided breast cancer radiotherapy has been associated with an increase in cardiac mortality. This study investigated the potential heartsparing effect of volumetric-modulated arc radiotherapy (VMAT). We compared VMAT to tangential intensity-modulated radiotherapy (t-IMRT) in the loco-regional treatment of left-sided breast cancer, including internal mammary nodal irradiation, based on deep inspiration breath-hold (DIBH) and free-breathing (FB). Methods: Radiotherapy for 15 patients was re-planned. Four plans were compared: t-IMRT-DIBH; VMAT-DIBH; t-IMRT-FB; VMAT-FB. Prescribed dose was 50 Gy in 25 fractions. T-IMRT plans were generated using tangentially orientated fields. VMAT plans were generated using two partial arcs (average arc 190°). Results: Mean heart dose (MHD) was 5 AE 2.4 Gy, 5.7 AE 1.4 Gy, 9.7 AE 3.3 Gy and 8.1 AE 2.0 Gy for t-IMRT-DIBH, VMAT-DIBH, IMRT-FB and VMAT-FB respectively. The difference in MHD between IMRT-DIBH and VMAT-DIBH was not significant (P = 0.14). VMAT-DIBH significantly spared the volume of heart irradiated to doses of 20 Gy and above (p < 0.05), however, resulted in a significantly higher V5 Gy (P < 0.001), compared to t-IMRT-DIBH. VMAT-DIBH resulted in higher combined lung mean (11 AE 0.8 Gy vs. 8.8 AE 1.1 Gy, P < 0.001) and higher contralateral breast mean dose (5 AE 1 Gy vs. 1.6 AE 1.2 Gy, P < 0.001) compared with t-IMRT-DIBH. Conclusions: On average, there was no significant difference in MHD between VMAT-DIBH and t-IMRT-DIBH. However, VMAT-DIBH was found to benefit a select group of patients. For patients in whom the MHD was >6.3 Gy with t-IMRT-DIBH, the use of VMAT-DIBH resulted in a benefit in reducing the MHD.
Journal of Radiation Research, 2015
We compared two intensity-modulated radiotherapy techniques for left-sided breast treatment, involving lymph node irradiation including the internal mammary chain. Inverse planned arc-therapy (VMAT) was compared with a forward-planned multi-segment technique with a mono-isocenter (MONOISO). Ten files were planned per technique, delivering a 50-Gy dose to the breast and 46.95 Gy to nodes, within 25 fractions. Comparative endpoints were planning target volume (PTV) coverage, dose to surrounding structures, and treatment delivery time. PTV coverage, homogeneity and conformality were better for two arc VMAT plans; V95% PTV-T was 96% for VMAT vs 89.2% for MONOISO. Homogeneity index (HI) PTV-T was 0.1 and HI PTV-N was 0.1 for VMAT vs 0.6 and 0.5 for MONOISO. Treatment delivery time was reduced by a factor of two using VMAT relative to MONOISO (84 s vs 180 s). High doses to organs at risk were reduced (V30 left lung = 14% using VMAT vs 24.4% with MONOISO; dose to 2% of the volume (D2%) heart = 26.1 Gy vs 32 Gy), especially to the left coronary artery (LCA) (D2% LCA = 34.4 Gy vs 40.3 Gy). However, VMAT delivered low doses to a larger volume, including contralateral organs (mean dose [Dmean] right lung = 4 Gy and Dmean right breast = 3.2 Gy). These were better protected using MONOISO plans (Dmean right lung = 0.8 Gy and Dmean right breast = 0.4 Gy). VMAT improved PTV coverage and dose homogeneity, but clinical benefits remain unclear. Decreased dose exposure to the LCA may be clinically relevant. VMAT could be used for complex treatments that are difficult with conventional techniques. Patient age should be considered because of uncertainties concerning secondary malignancies.
Volumetric modulated arc therapy (VMAT) to deliver nodal irradiation in breast cancer patients
Medical oncology (Northwood, London, England), 2017
To evaluate feasibility, safety, toxicity profile and dosimetric results of volumetric modulated arc therapy (VMAT) to deliver regional nodal irradiation (RNI) after either mastectomy or breast conservation (BCS) in high-risk breast cancer patients. Between January 2015 and January 2017, a total of 45 patients were treated with VMAT to deliver RNI together with whole breast or post-mastectomy radiotherapy. The fractionation schedule comprised 50 Gy in 25 fractions given to supraclavicular and axillary apex nodes and to whole breast (after BCS) or chest wall (after mastectomy). Two opposite 50°-60° width arcs were employed for breast ad chest wall irradiation, while a single VMAT arc was used for nodal treatment. Treatment was generally well tolerated. Acute skin toxicity was G2 in 13.3% of patients. Late skin toxicity consisted of G1 induration/fibrosis in six patients (13.3%) and G2 in 1 (2.2%). Dosimetric results were consistent in terms of both target coverage and normal tissue s...