Cardiac dose reduction with deep inspiration breath hold for left-sided breast cancer radiotherapy patients with and without regional nodal irradiation

Yeung, Raymond S.; Conroy, Leigh; Long, Karen; Walrath, Daphne; Li, Haocheng; Smith, Wendy; Hudson, Alana; Phan, Tien

doi:10.1186/s13014-015-0511-8

Cited by 95 publications

(57 citation statements)

References 23 publications

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“…(7) Our technique is similar to the voluntary breath-hold (VBH) technique used in the UK HeartSpare study; (13) however, the two techniques were developed independently. Bartlett et al (13) characterized the VBH technique using electronic portal imaging (EPID) and cone-beam CT. For offline EPID measurements, random and systematic errors of σ = 2.1 mm and Σ = 1.8 mm, respectively, were reported in the μ direction of the medial tangent beam.…”

Section: Discussionmentioning

confidence: 99%

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Evaluation of target and cardiac position during visually monitored deep inspiration breath‐hold for breast radiotherapy

Conroy

Yeung

Watt

et al. 2016

J Applied Clin Med Phys

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A low-resource visually monitored deep inspiration breath-hold (VM-DIBH) technique was successfully implemented in our clinic to reduce cardiac dose in left-sided breast radiotherapy. In this study, we retrospectively characterized the chest wall and heart positioning accuracy of VM-DIBH using cine portal images from 42 patients. Central chest wall position from field edge and in-field maximum heart distance (MHD) were manually measured on cine images and compared to the planned positions based on the digitally reconstructed radiographs (DRRs). An in-house program was designed to measure left anterior descending artery (LAD) and chest wall separation on the planning DIBH CT scan with respect to breathhold level (BHL) during simulation to determine a minimum BHL for VM-DIBH eligibility. Systematic and random setup uncertainties of 3.0 mm and 2.6 mm, respectively, were found for VM-DIBH treatment from the chest wall measurements. Intrabeam breath-hold stability was found to be good, with over 96% of delivered fields within 3 mm. Average treatment MHD was significantly larger for those patients where some of the heart was planned in the field compared to patients whose heart was completely shielded in the plan (p < 0.001). No evidence for a minimum BHL was found, suggesting that all patients who can tolerate DIBH may yield a benefit from it. PACS number(s): 87.53. Jw, 87.53.Kn,

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Section: Discussionmentioning

confidence: 99%

“…1, bottom pictures). Based on results from a previous study, (7) patients with intent to treat regional nodes including IMCs had only a DIBH CT scan. These patients were treated in FB only if they were unable to perform reproducible DIBH as evaluated by the simulator radiation therapists.…”

Section: A2 Ct Simulationmentioning

confidence: 99%

Evaluation of target and cardiac position during visually monitored deep inspiration breath‐hold for breast radiotherapy

Conroy

Yeung

Watt

et al. 2016

J Applied Clin Med Phys

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“…Another approach is the application of respiratory-gated and breath-hold RT, such as deep inspiration breath-hold (DIBH) [14–19], which probably allows for a real dose reduction without any increases in low dose areas. Currently, several vendor specific systems are in use: for example the Active Breathing Control (ABC) device designed at William Beaumont Hospital, Michigan [20]; the Varian Real-time Position Management system (RPM TM ) (Varian Medical Systems, Palo Alto, CA, USA [21]), or the AlignRT system of Vision RT Ltd, London, UK, [22].…”

Section: Introductionmentioning

confidence: 99%

Treatment planning and evaluation of gated radiotherapy in left-sided breast cancer patients using the CatalystTM/SentinelTM system for deep inspiration breath-hold (DIBH)

et al. 2016

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BackgroundThere is a potential for adverse cardiovascular effects in long-term breast cancer survivors following adjuvant radiotherapy (RT). For this purpose, the deep inspiration breath-hold technique (DIBH) has been introduced into clinical practice, to maximally reduce the radiation dose to the heart. However, there are a variety of DIBH delivery techniques, patient positioning and visual patient feedback mechanisms. The aim of the present study was to evaluate the application of radiotherapy in DIBH using the CatalystTM/SentinelTM system, with a special emphasis on treatment planning and dosimetric plan comparison in free breathing (FB) and DIBH.Patients and methodsA total of 13 patients with left-sided breast cancer following breast conserving surgery were included in this prospective clinical trial. For treatment application the CatalystTM/SentinelTM system (C-RAD AB, Uppsala, Sweden) was used and gating control was performed by an audio-visual patient feedback system. CT and surface data were acquired in FB and DIBH and dual treatment plans were created using Pencil Beam and Collapsed Cone Convolution. Dosimetric output parameters of organs at risk were compared using Wilcoxon signed-rank test. Central lung distance (CLD) was retrieved from iViewTM portal images during treatment delivery.ResultsThe system contains a laser surface scanner (SentinelTM) and an optical surface scanner (CatalystTM) interconnected to the LINAC systems via a gating interface and allows for a continuous and touchless surface scanning. Overall, 225 treatment fractions with audio-visual guidance were completed without any substantial difficulties. Following initial patient training and treatment setup, radiotherapy in DIBH with the CatalystTM/SentinelTM system was time-efficient and reliable. Following dual treatment planning for all patients, nine of 13 patients were treated in DIBH. In these patients, the reduction of the mean heart dose for DIBH compared to FB was 52 % (2.73 to 1.31 Gy; p = 0.011). The maximum doses to the heart and LAD were reduced by 59 % (47.90 to 19.74 Gy; p = 0.008) and 75 % (38.55 to 9.66 Gy; p = 0.008), respectively. In six of the nine patients the heart completely moved out of the treatment field by DIBH. The standard deviation of the CLD varied between 0.12 and 0.29 cm (mean: 0.16 cm).ConclusionThe CatalystTM/SentinelTM system enabled a fast and reliable application and surveillance of DIBH in daily clinical routine. Furthermore, the present data show that using the DIBH technique during RT could significantly reduce high dose areas and mean doses to the heart.Trial registration DRKS: DRKS00010929 registered on 5. August 2016.

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“…75 % of all patients were able to reach a Dmean under 1.55 Gy. The NB plans had a Dmean heart of 2.31 Gy (Range 0.71-4.21 Gy), which means that the DIBH-technique could halve the Dmean heart according to literature [16,39,[54][55][56][57][58]. The maximum heart distance (maximal thickness of heart irradiated) was mostly less than 1 cm (Range 0.8-1.2 cm) during irradiation of our DIBH breast cancer cases, mostly less than 2 cm (Range 1.1-3.2 cm) in the NB plans.…”

Section: Dosimetric Outcomesmentioning

confidence: 81%

“…Based on available findings, the DEGRO breast cancer expert panel recommends a Dmean heart dose < 2.5 Gy [55]. Additionally, the study of Yeung et al [39] showed that all patients receiving WBRT (whole breast irradiation) with DIBH met a Dmean heart < 4 Gy and had less heart problems. Remarkably, in our series all patients with DIBH could reach a Dmean heart < 1.2 Gy and almost all patients with NB a Dmean heart < 2.3 Gy which means that our data could comply the DEGRO-recommendations.…”

Section: Discussionmentioning

confidence: 99%

5 years of experience with DIBH (Deep inspiration breath-hold) combined with SGRT (Surface-Guided Radiation Therapy) in left-sided breast cancer

Steffal

Schratter-Sehn

Brinda-Raitmayr

et al. 2020

Senologie - Zeitschrift für Mammadiagnostik und -therapie

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Background Radiation treatment to the left breast is associated with increased cardiac morbidity as well as mortality. Deep inspiration breath-hold (DIBH) technique with Surface Guided Radiation Therapy (SGRT) could have dosimetric advantages over the free breathing technique (NB, normal breathing) in cardiac (heart and LAD) and ipsilateral lung sparing in patients with left-sided breast cancer after surgery. Therefore this technique was implemented in 2013 at the institute of radiooncology at the KFJ/SMZ-South – Hospital Vienna. Methods From Oct 2013 – December 2018 548 patients were referred to radiotherapy following conservative operation of left-sided invasive breast cancer. All patients gave their informed consent and underwent training sessions for the DIBH-technique independent of age or breathing activity or respiratory disorders. Patients who turned out to be unfit for DIBH were enrolled for NB. The relative reduction in Dmean heart and left lung dose was compared between the two cohorts. Acute radiation induced side effects were classified according to the Radiation Therapy Oncology Group/The European Organisation for Research (RTOG) 37; late toxicity rates according to the Common Terminology Criteria for Adverse Events (CTCAE Version 4.03) Results The median age of the DIBH-patients was 58 years (27–90), of the NB-patients 65 (30–80) years. Follow-up was obtained until June 2019. The median follow-up was 52 months (range 7–73 m). The average coverage of Dmean left lung was 6.91 Gy (1.44 Gy – 12.4 Gy). The average coverage of Dmean heart was 1.17 Gy (0.12 Gy – 3.19 Gy) in the DIBH-cohort. The NB – plans had a Dmean of 8.92 Gy (5.23–16.9 Gy) at the ipsilateral lung and a Dmean of 2.31 Gy (0.71–4.21 Gy) at the heart. This shows that the DIBH-technique halved the Dmean of the heart. The amount of acute side effects was comparable between the two groups: RTOG 1: 70.8 % vs. 64 %, RTOG 3 6.6 % vs. 5.6 %, no reaction 3.2 % vs. 1.4 %. There were more CTCAE 1-late events in the NB-group (51.6 % vs. 12.67 %). Conclusion Deep inspiration breath-hold (DIBH) technique with Surface Guided Radiation Therapy (SGRT) is a rather simple, reproducable method with a high acceptance of the patients who can actively participate in the whole treatment process. The mean dose at the heart and the left lung can be reduced, at the heart even by as much as 50 %.

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Cardiac dose reduction with deep inspiration breath hold for left-sided breast cancer radiotherapy patients with and without regional nodal irradiation

Cited by 95 publications

References 23 publications

Evaluation of target and cardiac position during visually monitored deep inspiration breath‐hold for breast radiotherapy

Evaluation of target and cardiac position during visually monitored deep inspiration breath‐hold for breast radiotherapy

Treatment planning and evaluation of gated radiotherapy in left-sided breast cancer patients using the CatalystTM/SentinelTM system for deep inspiration breath-hold (DIBH)

5 years of experience with DIBH (Deep inspiration breath-hold) combined with SGRT (Surface-Guided Radiation Therapy) in left-sided breast cancer

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