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Deep inspiration breath-hold (DIBH) radiotherapy in left-sided breast cancer

Dosimetrical comparison and clinical feasibility in 20 patients

Bestrahlung der linken Brust in tiefer Inspiration und Atemanhaltetechnik (DIBH) bei linksseitigem Brustkrebs

Dosimetrischer Vergleich und klinische Durchführbarkeit bei 20 Patientinnen

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Abstract

Background

Adjuvant radiotherapy after breast-conserving surgery (BCS) for breast cancer (BC) is a well-established indication. The risk of ischaemic heart disease after radiotherapy for BC increases linearly with the heart mean dose with no apparent threshold. Radiotherapy to the left breast in deep inspiration breath-hold (DIBH) reduces the dose to the heart. A new linac system with an integrated surface scanner (SS) for DIBH treatments was recently installed in our department. We tested it for potential benefits, safety, patients’ acceptance/compliance and associated additional workload.

Materials and methods

Twenty consecutive patients following BCS for breast carcinoma of the left side were enrolled in our institutional DIBH protocol. We compared dose to the heart and ipsilateral lung (IL) between plans in DIBH and free breathing (FB) using standard defined parameters: mean dose, maximal dose to a volume of 2 cm3 (D2 cm 3), volume receiving ≥ 5 Gy (V5), 10 Gy (V10), 15 Gy (V15) and 20 Gy (V20). Comparison of median calculated dose values was performed using a two-tailed Wilcoxon signed rank test.

Results

DIBH was associated with a statistically significant reduction (p < 0.001) in all studied parameters for the heart and the IL. In 16 of 20 patients the heart D2 cm 3 was less than 42 Gy in DIBH. In FB the heart D2 cm 3 was ≥ 42 Gy in 17 of 20 patients. The median daily treatment time was 9 min.

Conclusion

Radiotherapy of the left breast in DIBH using a SS could easily be incorporated into daily routine and is associated with significant dose reduction to the heart and IL.

Zusammenfassung

Hintergrund

Die adjuvante Strahlentherapie nach brusterhaltener Operation (BCS) bei Brustkrebs (BC) ist eine seit langem anerkannte Behandlungsform. Das postradiogene Risiko einer kardialen Ischämie steigt linear ohne erkennbaren Schwellenwert mit der mittleren Herzdosis. Die Bestrahlung der linken Brust in tiefer Inspiration unter Anhalten der Atmung (DIBH) reduziert die Herzdosis. Nach kürzlich erfolgter Installation eines neuen Linearbeschleunigers einschließlich eines laserbasierten Oberflächenscanners wurde das System bei der Bestrahlung der Brust in DIBH auf seinen möglichen Nutzen, die Sicherheit, die Patientenakzeptanz und Mitarbeit sowie die zusätzliche Arbeitsbelastung getestet.

Material und Methoden

Zwanzig Patientinnen mit linksseitigem BC wurden nach BCS entsprechend unserem klinikinternen Protokoll in TI bestrahlt. Es wurden zwischen den Plänen in DIBH und Atemmittellage die Herzdosis und die ipsilaterale Lungendosis mit Hilfe der folgenden Standardparameter verglichen: mittlere Dosis, maximale Dosis in 2 cm3 (D2 cm 3), Teilvolumina mit einer Dosis von ≥ 5 Gy (V5), 10 Gy (V10), 15 Gy (V15) und 20 Gy (V20). Zum Vergleich der medianen Dosiswerte für jeden Parameter wurde ein Wilcoxon-Vorzeichen-Rang-Test eingesetzt.

Ergebnisse

In Bezug auf das Herz und die ipsilaterale Lunge konnte bei der DIBH eine statistisch signifikante Reduktion (p < 0,001) aller untersuchten Parameter gezeigt werden. In 16 von 20 Patientinnen war die D2 cm 3 des Herzens bei der DIBH unter 42 Gy. In Atemmittellage war die D2 cm 3 des Herzens bei 17 von 20 Patientinnen ≥ 42 Gy. Die durchschnittliche Behandlungszeit betrug 9 min.

Schlussfolgerung

Die Strahlentherapie der linken Brust in DIBH mittels Oberflächenscanner ist eine leicht zu implementierende Methode, welche mit einer signifikanten Dosisreduktion des Herzens und der ipsilateralen Lunge assoziiert ist.

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Authors and Affiliations

  1. Klinik für Strahlentherapie und Radioonkologie, Evangelische Kliniken Gelsenkirchen, Munckelstraße 27, 45879, Gelsenkirchen, Deutschland

    Rodrigo Hepp M.D., Mark Ammerpohl M.D., Christina Morgenstern M.Sc., Lisa Nielinger B.Eng., Patricia Erichsen M.D. & Razvan Galalae M.D.

  2. Hochschule Hamm-Lippstadt, Lippstadt, Deutschland

    Lisa Nielinger B.Eng.

  3. Klinik für Senologie, Evangelische Kliniken Gelsenkirchen, Gelsenkirchen, Deutschland

    Abdallah Abdallah M.D.

  4. Medizinische Fakultät, Christian-Albrechts-Universität zu Kiel, Kiel, Deutschland

    Razvan Galalae M.D.

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  1. Rodrigo Hepp M.D.
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  2. Mark Ammerpohl M.D.
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  3. Christina Morgenstern M.Sc.
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  4. Lisa Nielinger B.Eng.
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  5. Patricia Erichsen M.D.
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  6. Abdallah Abdallah M.D.
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  7. Razvan Galalae M.D.
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Correspondence to Rodrigo Hepp M.D..

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Conflict of interest

R. Hepp, M. Ammerpohl, C. Morgenstern, L. Nielinger, P. Erichsen, A. Abdallah, and R. Galalae state that there are no conflicts of interest.

All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in study.

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Hepp, R., Ammerpohl, M., Morgenstern, C. et al. Deep inspiration breath-hold (DIBH) radiotherapy in left-sided breast cancer. Strahlenther Onkol 191, 710–716 (2015). https://doi.org/10.1007/s00066-015-0838-y

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