Original ReportProspective assessment of deep inspiration breath-hold using 3-dimensional surface tracking for irradiation of left-sided breast cancer
Introduction
Adjuvant radiation therapy (RT) significantly improves both local control and overall survival in a majority of breast cancer (BC) patients after breast conservation therapy or mastectomy[1], [2], [3]; however, breast and chest wall (BCW) irradiation is also associated with higher non–BC-related mortality, likely from late cardiopulmonary toxicity.[4], [5], [6] Mortality from coronary heart disease (CHD) may explain the limited benefit from RT seen in earlier studies,[7], [8], [9] such that the true survival benefit from RT may be even greater when CHD is minimized.
One recent study demonstrated a linear relationship between mean heart dose (MHD) and major coronary events. Notably, there was no lower threshold for this effect.10 These data have renewed attention to techniques for limiting unintended cardiac irradiation. Deep inspiration breath hold (DIBH) is one such technique that aims to displace the heart from the chest wall during inspiration, thereby reducing the dose and volume of irradiated heart.[11], [12]
DIBH may be achieved with either active breathing control devices (ABC-DIBH) or voluntary patient coaching (voluntary DIBH). Despite robust data to support its use,[13], [14], [15], [16] difficulties with patient comfort and cost of equipment, including daily disposable mouthpieces, have limited widespread uptake of ABC-DIBH.17 Voluntary DIBH is an alternative noninvasive option, but it may be limited by precision and reproducibility. Tools for real-time motion assessment, including surface-tracking systems (AlignRT; Vision RT, Ltd, London, United Kingdom) and patient-centered techniques like active coaching and real-time patient feedback devices, have been implemented to ensure consistent inspiration during treatment.18
The efficacy and feasibility of voluntary DIBH, however, depend on a variety of patient- and tumor-specific factors, including individual anatomy, patient compliance, tumor location, and duration of treatment. We sought to understand the feasibility, dosimetric efficacy, and practical implications (treatment time and variability) of DIBH in a prospectively enrolled registry of patients scanned with free-breathing (FB) or DIBH but ultimately treated with either technique based on physician assessment. This study represents one of the largest cohorts of patients treated with DIBH published to date and one of the few to describe practical outcomes of DIBH during treatment.
Section snippets
Patient selection
Patients with left-sided BC undergoing RT were enrolled in a prospective registry at the Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC), including patients receiving any type of breast surgery, systemic therapy, or RT fields. All patients were deemed candidates for DIBH before radiation planning based on tumor location, general health status, and perceived ability to comply with DIBH. Patients provided consent for participation in this institutional review board–approved registry
Patient characteristics
A total of 150 patients were enrolled from 2011 to 2014; 2 withdrew consent, and 2 had incomplete dosimetry because of missing scans. Thirty-eight patients were treated with FB and 110 with DIBH. FB patients were older (P = .002), more likely to have pre-existing heart disease (P = .02) and lung disease (P = .05), and less likely to have received chemotherapy (P = .01) or immediate breast reconstruction (P = .01) relative to DIBH patients (Table 1). There were no other significant differences
Discussion
This study showed that DIBH significantly reduced cardiac irradiation without significantly affecting daily treatment times and that the extent of respiratory excursion in DIBH was associated with improved MHD. DIBH is a promising tool that is being rapidly incorporated into treatment for BC on the basis of several prior studies demonstrating its dosimetric advantages. For example, Comsa et al15 demonstrated significant improvements in MHD, heart V10, and heart V30 using DIBH with ABC and
References (27)
- et al.
Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: Meta-analysis of individual patient data for 8135 women in 22 randomised trials [published correction appears in Lancet. 2014;384:1848]
Lancet
(2014) - et al.
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) - et al.
Initial clinical experience with moderate deep-inspiration breath hold using an active breathing control device in the treatment of patients with left-sided breast cancer using external beam radiation therapy
Int J Radiat Oncol Biol Phys
(2003) - et al.
Breathing adapted radiotherapy for breast cancer: Comparison of free breathing gating with the breath-hold technique
Radiother Oncol
(2005) - et al.
Deep inspiration breath hold to reduce irradiated heart volume in breast cancer patients
Int J Radiat Oncol Biol Phys
(2001) - et al.
Significant reductions in heart and lung doses using deep inspiration breath hold with active breathing control and intensity-modulated radiation therapy for patients treated with locoregional breast irradiation
Int J Radiat Oncol Biol Phys
(2003) - et al.
Introduction of moderate deep inspiration breath hold for radiation therapy of left breast: Initial experience of a regional cancer center
Pract Radiat Oncol
(2014) - et al.
Active Breathing Coordinator reduces radiation dose to the heart and preserves local control in patients with left breast cancer: Report of a prospective trial
Pract Radiat Oncol
(2015) - et al.
Current technological clinical practice in breast radiotherapy: Results of a survey in EORTC-Radiation Oncology Group affiliated institutions
Radiother Oncol
(2010) - et al.
Breathing adapted radiation therapy in comparison with prone position to reduce the doses to the heart, left anterior descending coronary artery, and contralateral breast in whole breast radiation therapy
Pract Radiat Oncol
(2014)
Clinical experience with 3-dimensional surface matching-based deep inspiration breath hold for left-sided breast cancer radiation therapy
Pract Radiat Oncol
SPECT analysis of cardiac perfusion changes after whole-breast/chest wall radiation therapy with or without active breathing coordinator: Results of a randomized phase 3 trial
Int J Radiat Oncol Biol Phys
Decline of cosmetic outcomes following accelerated partial breast irradiation using intensity modulated radiation therapy: Results of a single-institution prospective clinical trial
Int J Radiat Oncol Biol Phys
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This study was funded by a research grant from Kaye Family New Technologies.