Is there a preferred IMRT technique for left‐breast irradiation?

Jeulink, Marloes; Dahele, Max; Meijnen, Philip; Slotman, Ben J.; Verbakel, Wilko F.A.R.

doi:10.1120/jacmp.v16i3.5266

Cited by 38 publications

(35 citation statements)

References 20 publications

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“…The trends presented by the maximum, minimum, and mean data were observed in all cases on a head‐to‐head plan analysis. All VMAT plans utilized the same treatment planning technique, different from other documented VMAT breast planning methods . Despite the different planning technique, our study produces comparable results while further quantifying the dosimetric trade‐offs between VMAT and 3D field‐in‐field tangents …”

Section: Discussionmentioning

confidence: 59%

“…Respiratory gating techniques such as voluntary deep inspiration breath‐hold (DIBH), which has been shown to protect the heart by displacing it from the chest wall, are not available at many institutions . VMAT and intensity‐modulated radiotherapy (IMRT) with built‐in skin flash may decrease the heart dose but increase low‐dose exposure of nearby healthy tissues compared with three‐dimensional (3D) field‐in‐field tangents . Selected cases have been presented where our radiation oncologists have requested VMAT to spare large volumes of the heart from receiving prescription dose.…”

Section: Introductionmentioning

confidence: 99%

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Dosimetric comparison of VMAT with integrated skin flash to 3D field‐in‐field tangents for left breast irradiation

Bogue

Wan

Lavey³

et al. 2019

J Applied Clin Med Phys

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Volumetric modulated arc therapy (VMAT) has been implemented for left breast irradiation to reduce prescription dose to the heart and improve dose homogeneity across the targeted breast. Our in‐house method requires application of a bolus during the optimization process with a target outside of the body, then removing the bolus during the final calculation in order to incorporate skin flash in VMAT plans. To quantify the dosimetric trade‐offs between traditional 3D field‐in‐field tangents and VMAT with integrated skin flash for these patients, we compared nine consecutive patients who recently received radiation to their entire left breast but not their regional lymphatics. Tangent plans used non‐divergent tangents of mixed energies and VMAT plans utilized four 6 MV arcs of roughly 260°. Mean dose to the heart, contralateral lung, and contralateral breast and their volume receiving 5%, 10%, and 20% of the prescription dose were higher in all nine VMAT plans than in the static tangential beam plans. For all critical structures, the mean VMAT DVH was higher in the low‐dose region and crossed the 3D field‐in‐field DVH between 23.13% and 34.18% of the prescription dose (984.75‐1454.70 cGy). However, the volume of the contralateral breast and heart receiving the prescription dose was slightly lower in the VMAT plans, but not statistically significant. VMAT provided superior homogeneity, with a mean homogeneity index of 9.41 ± 1.64 compared to 11.05 ± 1.82 for 3D tangents. Results indicate that VMAT spares the heart, contralateral lung, and contralateral breast from prescription dose at the cost of increasing their mean and low‐dose volume and delivers a more homogenous dose distribution to the breast. For these reasons, VMAT is selectively applied at the request of the physician for left breast radiation without respiratory gating to spare the heart from prescription dose in cases of poor anatomical geometry.

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Section: Discussionmentioning

confidence: 59%

Section: Introductionmentioning

confidence: 99%

Dosimetric comparison of VMAT with integrated skin flash to 3D field‐in‐field tangents for left breast irradiation

Bogue

Wan

Lavey³

et al. 2019

J Applied Clin Med Phys

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“…From this summary, the present study is the only one where the mean doses of all OARs were lowered using the AvS. Pasler et al 27 improved with tangential setting all the structures except the I lung ; Jeulink et al 25 did not improve the contralateral structures; Virén et al 26 were deteriorating the ipsilateral structures, especially the heart. This variability in dose distribution for similar concepts for planning is proof that it is difficult to find the best trade-offs for OAR sparing.…”

Section: 10mentioning

confidence: 99%

“…95% and V 107% , 3 cm 3 ); on the contrary, none of the three studies mentioned previously 25,26,27 applied so stringent rules to the target dose homogeneity as part of the trade-off balance.…”

Section: 10mentioning

confidence: 99%

“…A Dutch group (Jeulink et al 25 ) compared two partial arcs (X jaw setting ,18 cm) and six small arcs, doubling the entrances from the tangential direction with respect to the central part of the arcs (the increased number of arcs allowed a smaller X jaw setting). They planned with a simultaneous boost to 40.05 and 50.25 Gy in 15 fractions with RapidArc, no nodal regions and no DIBH.…”

Section: 10mentioning

confidence: 99%

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Dosimetric trade-offs in breast treatment with VMAT technique

Fogliata

Seppälä

Reggiori

et al. 2017

The British Journal of Radiology

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Objective: Breast planning with volumetric modulated arc therapy (VMAT) has been explored, especially for leftsided breast treatments, with the primary intent of lowering the heart dose and improving target dose homogeneity. As a trade-off, larger healthy tissue volumes would receive low dose levels, with the potential risk of increasing late toxicities and secondary cancer induction, although no clinical data are available today to confirm the risk level. The scope of this work is to explore the dosimetric trade-offs using two different VMAT plans. Methods: Two planning strategies for dual-partial-arc VMAT, RA_avoid and RA_full, with and without avoidance sectors, were explored in a cohort of 20 patients, for whole left breast irradiation for 40.05 Gy to the mean target dose in 15 fractions. Common dose objectives included a stringent dose homogeneity, mean dose to the heart ,5 Gy, ipsilateral lung (I lung ) ,8 Gy, contralateral lung (C lung ) ,2 Gy and contralateral breast (C breast ) ,3 Gy.Results: RA_full showed a better dose conformity, lower high-dose spillage in the healthy tissue and lower skin dose. RA_avoid presented a reduction of the mean doses for all critical structures: 51% to the heart, 12% to the I lung , 81% to the C lung and 73% to the C breast . All differences were significant with p , 0.0001. Conclusion: The adaptation of VMAT options to planning objectives reduced significantly the healthy tissue dose levels at the price of some high-dose spillage. Evaluation of the trade-offs for application to the different critical structures should drive in improving the usage of the VMAT technique for breast cancer treatment. Advances in knowledge: Different planning strategies in the same VMAT technique could give significant variations in dose distributions. The choice of the trade-offs would affect the possible future late toxicity and secondary cancer induction risk. INTRODUCTIONRadiotherapy treatment is an integral part of the standard of care of patients with breast cancer after breast-conserving surgery. Different fractionation schemes have been applied, from the conventional 50 Gy in 25 fractions to hypofractionated regimes like 40.05 Gy delivered in 15 fractions, as proposed by the START (UK Standardisation of Breast Radiotherapy) Trial B.

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Fixed‐jaw technique to improve IMRT plan quality for the treatment of cervical and upper thoracic esophageal cancer

Song

Liu

et al. 2019

J Applied Clin Med Phys

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The purpose of this study was to investigate the potential advantages of the fixed‐jaw technique (FJT) over the conventional split‐field technique (SFT) for cervical and upper thoracic esophageal cancer (EC) patients treated with intensity‐modulated radiotherapy. The SFT and FJT plans were generated for 15 patients with cervical and upper thoracic EC. Dosimetric parameters and delivery efficiency were compared. An area ratio (AR) of the jaw opening to multileaf collimator (MLC) aperture weighted by the number of monitor units (MUs) was defined to evaluate the impact of the transmission through the MLC on the dose gradient outside the PTV50.4, and the correlation between the gradient index (GI) and AR was analyzed. The FJT plans achieved a better GI and AR (P < 0.001). There was a positive correlation between the GI and AR in the FJT (r = 0.883, P < 0.001) and SFT plans (r = 0.836, P < 0.001), respectively. Moreover, the mean dose (Dmean), V5Gy–V40Gy for the lungs and the Dmean, V5Gy–V50Gy for the body‐PTV50.4 in the FJT plans were lower than those in the SFT plans (P < 0.05). The FJT plans demonstrated a reduction trend in the doses to the spinal cord PRV and heart, but only the difference in the heart Dmean reached statistical significance (P < 0.05). The FJT plans reduced the number of MUs and subfields by 5.5% and 17.9% and slightly shortened the delivery time by 0.23 min (P < 0.05). The gamma‐index passing rates were above 95% for both plans. The FJT combined with target splitting can provide superior organs at risk sparing and similar target coverage without compromising delivery efficiency and should be a preferred intensity‐modulated radiotherapy planning method for cervical and upper thoracic EC patients.

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Is there a preferred IMRT technique for left‐breast irradiation?

Cited by 38 publications

References 20 publications

Dosimetric comparison of VMAT with integrated skin flash to 3D field‐in‐field tangents for left breast irradiation

Dosimetric comparison of VMAT with integrated skin flash to 3D field‐in‐field tangents for left breast irradiation

Dosimetric trade-offs in breast treatment with VMAT technique

Fixed‐jaw technique to improve IMRT plan quality for the treatment of cervical and upper thoracic esophageal cancer

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