Breathing adapted radiotherapy for breast cancer: Comparison of free breathing gating with the breath-hold technique

doi:10.1016/j.radonc.2005.07.009

Radiotherapy and Oncology

Volume 76, Issue 3, September 2005, Pages 311-318

https://doi.org/10.1016/j.radonc.2005.07.009 Get rights and content

Abstract

Background and purpose

Adjuvant radiotherapy after breast-conserving surgery for breast cancer implies a risk of late cardiac and pulmonary toxicity. This is the first study to evaluate cardiopulmonary dose sparing of breathing adapted radiotherapy (BART) using free breathing gating, and to compare this respiratory technique with voluntary breath-hold.

Patients and methods

17 patients were CT-scanned during non-coached breathing manoeuvre including free breathing (FB), end-inspiration gating (IG), end-expiration gating (EG), deep inspiration breath-hold (DIBH) and end-expiration breath-hold (EBH). The Varian Real-time Position Management system (RPM™) was used to monitor respiratory movement and to gate the scanner. For each breathing phase, a population based internal margin (IM) was estimated based on average chest wall excursion, and incorporated into an individually optimised three-field mono-isocentric wide tangential photon field treatment plan for each scan. The target included the remaining breast, internal mammary nodes and periclavicular nodes.

Results

The mean anteroposterior chest wall excursion during FB was 2.5 mm. For IG and EG, the mean excursions within gating windows were 1.1 and 0.7 mm, respectively, whereas for DIBH and EBH the excursions were 4.1 and 2.6 mm, respectively.

For patients with left-sided cancer, the median heart volume receiving more than 50% of the prescription dose was reduced from 19.2% for FB to 2.8% for IG and 1.9% for DIBH, and the median left anterior descending (LAD) coronary artery volume was reduced from 88.9% to 22.4% for IG and 3.6% for DIBH. Simultaneously, the median ipsilateral relative lung volume irradiated to >50% of the prescribed target dose for both right- and left-sided cancers was reduced from 45.6% for FB to 29.5% for IG and 27.7% for DIBH. For EBH and EG, both the irradiated heart, LAD and lung volumes increased compared to FB.

Conclusions

This is the first study to demonstrate the dosimetric benefits of free breathing gated breast cancer radiotherapy. IG compared favourably with DIBH, substantially reducing cardiac doses simultaneous with significant pulmonary tissue sparing.

Section snippets

Patients and methods

17 consecutive patients who had received radical breast-conserving surgery for stage II breast cancer (i.e. with axillary lymph node metastases) and been referred for adjuvant radiotherapy at our department between August 2002 and January 2003 were included in the study, provided informed consent was obtained according to the protocol approved by the Scientific Ethical Committees of Copenhagen and Frederiksberg (No. KF 01-004/02).

We have previously reported the experimental procedure with

Results

17 patients were consecutively enrolled in the study, nine with left-sided and eight with right-sided cancer. Patient age ranged from 51 to 70 years (median: 57 years). Patient compliance was high and the standardised breathing procedure was easily comprehensible for the patients. Training of all breathing manoeuvres took at maximum 20 min.

With the RPM-system™, patient breathing data could be registered with ease, and the very close proximity of the reflective marker to the ipsilateral breast

Discussion

Current clinical policy for adjuvant breast cancer radiotherapy must aim at reducing any high-dose cardiac and pulmonary irradiation, whilst maintaining target coverage [11]. We have investigated how this may be achieved by the use of BART. This is the first study that demonstrates the dosimetric advantages of FB gated breast cancer radiotherapy, and that it compares favourably with the breath-hold techniques. For neither heart/LAD nor lung was there a statistically significant difference

Acknowledgements

This study was financially supported by the Copenhagen Hospital Corporation Research Fund, the Danish Cancer Society, the Danish Cancer Research Foundation and Varian Medical Systems, Inc., to which we are indebted. We are also grateful to the Washington-Stanford Radiation Oncology Center, Fremont, CA, for providing Stine Korreman access to a Cadplan workstation for part of the data analysis for this study.

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Our workflow for DIBH with Helical-Tomotherapy addresses patient safety, treatment precision and challenges specific to this treatment unit. The workflow prevents junction issues by varying daily breath-hold durations and avoiding junction locations, providing a practical solution for left-sided breast cancer treatment with HT.
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The use of breath-hold techniques in radiotherapy, such as deep-inspiration breath hold, is increasing although guidelines for clinical implementation are lacking. In these recommendations, we aim to provide an overview of available technical solutions and guidance for best practice in the implementation phase. We will discuss specific challenges in different tumour sites including factors such as staff training and patient coaching, accuracy, and reproducibility. In addition, we aim to highlight the need for further research in specific patient groups. This report also reviews considerations for equipment, staff training and patient coaching, as well as image guidance for breath-hold treatments. Dedicated sections for specific indications, namely breast cancer, thoracic and abdominal tumours are also included.
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The study comprised two groups – left-sided breast cancer patients engaging DIBH and right-sided breast cancer patients using free breathing through radiotherapy. The primary end point was the feasibility of DIBH, defined as left-sided breast cancer patients' ability to breath hold for 15 s, decrease in heart dose in DIBH compared with the free breathing treatment plan and reproducibility of radiotherapy delivery using mid-lung distance (MLD) assessed on electronic portal imaging as the surrogate. The time required for treatment delivery, patient-reported outcomes and resource requirement were compared between the groups.
Between February and November 2018, 32 left-sided and 30 right-sided breast cancer patients from six radiotherapy centres were enrolled. Two left-sided breast cancer patients did not undergo DIBH (one treated in free breathing as per investigator choice, one withdrawn). The mean heart dose was reduced from 2.8 Gy (free breathing) to 1.5 Gy (DIBH). Set-up reproducibility in the first week of treatment assessed by MLD was 1.88 ± 1.04 mm (average ± 1 standard deviation) for DIBH and 1.59 ± 0.93 mm for free breathing patients. Using a reproducibility cut-off for MLD of 2 mm (1 standard deviation) as per study protocol, DIBH was feasible for 67% of DIBH patients. Radiotherapy delivery using DIBH took about 2 min longer than for free breathing. Anxiety was not significantly different in DIBH patients and decreased over the course of treatment in both groups.
Although DIBH was shown to require about 2 min longer per treatment slot, it has the potential to reduce heart dose in left-sided breast cancer patients by nearly a half, provided careful assessment of breath hold reproducibility is carried out.
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Breast irradiationBreathing adapted radiotherapy for breast cancer: Comparison of free breathing gating with the breath-hold technique

Abstract

Background and purpose

Patients and methods

Results

Conclusions

Section snippets

Patients and methods

Results

Discussion

Acknowledgements

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Radiother Oncol

Eur J Cancer

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Clin Radiol

Int J Radiat Oncol Biol Phys

Breast irradiation
Breathing adapted radiotherapy for breast cancer: Comparison of free breathing gating with the breath-hold technique