Top

Radiation Oncology

Published in:

Open Access 01-12-2022 | Breast Cancer | Research

Dosimetric effect of respiratory motion on planned dose in whole-breast volumetric modulated arc therapy using moderate and ultra-hypofractionation

Authors: Mikko Mankinen, Tuomas Virén, Jan Seppälä, Heikki Hakkarainen, Tuomas Koivumäki

Published in: Radiation Oncology | Issue 1/2022

Abstract

Background and purpose

The interplay effect of respiratory motion on the planned dose in free-breathing right-sided whole-breast irradiation (WBI) were studied by simulating hypofractionated VMAT treatment courses.

Materials and methods

Ten patients with phase-triggered 4D-CT images were included in the study. VMAT plans targeting the right breast were created retrospectively with moderately hypofractionated (40.05 Gy in 15 fractions of 2.67 Gy) and ultra-hypofractionated (26 Gy 5 fractions of 5.2 Gy) schemes. 3D-CRT plans were generated as a reference. All plans were divided into respiratory phase-specific plans and calculated in the corresponding phase images. Fraction-specific dose was formed by deforming and summing the phase-specific doses in the planning image for each fraction. The fraction-specific dose distributions were deformed and superimposed onto the planning image, forming the course-specific respiratory motion perturbed dose distribution. Planned and respiratory motion perturbed doses were compared and changes due to respiratory motion and choice of fractionation were evaluated.

Results

The respiratory motion perturbed PTV coverage (V95%) decreased by 1.7% and the homogeneity index increased by 0.02 for VMAT techniques, compared to the planned values. Highest decrease in CTV coverage was 0.7%. The largest dose differences were located in the areas of steep dose gradients parallel to respiratory motion. The largest difference in DVH parameters between fractionation schemes was 0.4% of the prescribed dose. Clinically relevant changes to the doses of organs at risk were not observed. One patient was excluded from the analysis due to large respiratory amplitude.

Conclusion

Respiratory motion of less than 5 mm in magnitude did not result in clinically significant changes in the planned free-breathing WBI dose. The 5 mm margins were sufficient to account for the respiratory motion in terms of CTV dose homogeneity and coverage for VMAT techniques. Steep dose gradients near the PTV edges might decrease the CTV coverage. No clinical significance was found due to the choice of fractionation.

Available only for authorised users

START Trialists' Group, Bentzen SM, Agrawal RK, Aird EG, Barrett JM, Barrett-Lee PJ et al. The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet 2008;371(9618):1098–107, https://doi.org/10.1016/S0140-6736(08)60348-7

Brunt AM, Haviland JS, Wheatley DA, Sydenham MA, Alhasso A, Bloomfield DJ, et al. Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial. Lancet. 2020;395(10237):1613–26. https://doi.org/10.1016/s0140-6736(20)30932-6.CrossRef

Rodin D, Tawk B, Mohamad O, Grover S, Moraes FY, Yap ML, et al. Hypofractionated radiotherapy in the real-world setting: An international ESTRO-GIRO survey. Radiother Oncol. 2021;157:32–9. https://doi.org/10.1016/j.radonc.2021.01.003.CrossRefPubMedPubMedCentral

Machiels M, Weytjens R, Bauwens W, Vingerhoed W, Billiet C, Huget P, et al. Accelerated adaptation of ultrahypofractionated radiation therapy for breast cancer at the time of the COVID-19 Pandemic. Clin Oncol. 2021;33:166–71. https://doi.org/10.1016/j.clon.2020.11.027.CrossRef

Hunter D, Mauldon E, Anderson N. Cost-containment in hypofractionated radiation therapy: a literature review. J Med Radiat Sci. 2018;65(2):148–57. https://doi.org/10.1002/jmrs.273.CrossRefPubMedPubMedCentral

Popescu CC, Olivotto IA, Beckham WA, Ansbacher W, Zavgorodni S, Shaffer R, et al. Volumetric modulated arc therapy improves dosimetry and reduces treatment time compared to conventional intensity-modulated radiotherapy for locoregional radiotherapy of left-sided breast cancer and internal mammary nodes. Int J Radiat Oncol Biol Phys. 2010;76(1):287–95. https://doi.org/10.1016/j.ijrobp.2009.05.038.CrossRefPubMed

Bogue J, Wan J, Lavey RS, Parsai EI. Dosimetric comparison of VMAT with integrated skin flash to 3D field-in-field tangents for left breast irradiation. J Appl Clin Med Phys. 2019;20(2):24–9. https://doi.org/10.1002/acm2.12527.CrossRefPubMedPubMedCentral

Virén T, Heikkilä J, Myllyoja K, Koskela K, Lahtinen T, Seppälä J. Tangential volumetric modulated arc therapy technique for left-sided breast cancer radiotherapy. Radiat Oncol. 2015;10:79. https://doi.org/10.1186/s13014-015-0392-x.CrossRefPubMedPubMedCentral

Piras A, Menna S, D’Aviero A, Marazzi F, Mazzini A, Cusumano D, et al. New fractionations in breast cancer: a dosimetric study of 3D-CRT versus VMAT. J Med Radiat Sci. 2021;00:1–9. https://doi.org/10.1002/jmrs.530.CrossRef

10.

Court LE, Seco J, Lu XQ, Ebe K, Mayo C, Ionascu D, et al. Use of a realistic breathing lung phantom to evaluate dose delivery errors. Med Phys. 2010;37(11):5850–7. https://doi.org/10.1118/1.3496356.CrossRefPubMed

11.

Keall PJ, Mageras GS, Balter JM, Emery RS, Forster KM, Jiang SB, et al. The management of respiratory motion in radiation oncology of AAPM Task Group 76. Med Phys. 2006;33(10):3874–900. https://doi.org/10.1118/1.2349696.CrossRefPubMed

12.

Richter A, Sweeney R, Baier K, Flentje M, Guckenberger M. Effect of breathing motion in radiotherapy of breast cancer: 4D dose calculation and motion tracking via EPID. Strahlenther Onkol. 2009;185(7):425–30. https://doi.org/10.1007/s00066-009-1980-1.CrossRefPubMed

13.

Jones S, Fitzgerald R, Owen R, Ramsay J. Quantifying intra- and inter-fractional motion in breast radiotherapy. J Med Radiat Sci. 2015;62(1):40–6. https://doi.org/10.1002/jmrs.61.CrossRefPubMed

14.

Bedi C, Kron T, Willis D, Hubbard P, Milner A, Chua B. Comparison of radiotherapy treatment plans for left-sided breast cancer patients based on three- and four-dimensional computed tomography imaging. Clin Oncol. 2011;23(9):601–7. https://doi.org/10.1016/j.clon.2011.04.004.CrossRef

15.

Ding C, Li X, Huq MS, Saw CB, Heron DE, Yue NJ. The effect of respiratory cycle and radiation beam-on timing on the dose distribution of free-breathing breast treatment using dynamic IMRT. Med Phys. 2007;34(9):3500–9. https://doi.org/10.1118/1.2760308.CrossRefPubMed

16.

Chung JH, Chun M, Kim JI, Park JM, Shin KH. Three-dimensional versus four-dimensional dose calculation for breast intensity-modulated radiation therapy. Br J Radiol. 2020;93(1110):20200047. https://doi.org/10.1259/bjr.20200047.CrossRefPubMed

17.

Bortfeld T, Jokivarsi K, Goitein M, Kung J, Jiang SB. Effects of intra-fraction motion on IMRT dose delivery: statistical analysis and simulation. Phys Med Biol. 2002;47(13):2203–20. https://doi.org/10.1088/0031-9155/47/13/302.CrossRefPubMed

18.

Offersen BV, Boersma LJ, Kirkove C, Hol S, Aznar MC, Biete Sola A, et al. ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage breast cancer. Radiother Oncol. 2015;114(1):3–10. https://doi.org/10.1016/j.radonc.2014.11.030.CrossRefPubMed

19.

Nicolini G, Fogliata A, Clivio A, Vanetti E, Cozzi L. Planning strategies in volumetric modulated arc therapy for breast. Med Phys. 2011;38(7):4025–31. https://doi.org/10.1118/1.3598442.CrossRef

20.

Heikkilä J, Virsunen H, Voutilainen L, Vuolukka K, Nevantaus A, Haatanen M et al. PO-1104 Implementing an automated target delineation service in multi-institutional environment in Finland, https://www.thegreenjournal.com/article/S0167-8140(19)31524-5/fulltext; 2019 [accessed 9 July 2021]

21.

Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple hypothesis testing. J R Stat Soc B Met. 1995;57(1):289–300. https://doi.org/10.1111/j.2517-6161.1995.tb02031.x.CrossRef

22.

Seppälä J, Vuolukka K, Virén T, Heikkilä J, Honkanen JTJ, Pandey A, et al. Breast deformation during the course of radiotherapy: the need for an additional outer margin. Phys Med. 2019;65:1–5. https://doi.org/10.1016/j.ejmp.2019.07.021.CrossRefPubMed

23.

Batumalai V, Holloway L, Delaney GP. A review of setup error in supine breast radiotherapy using cone-beam computed tomography. Med Dosim. 2016;41(3):225–9. https://doi.org/10.1016/j.meddos.2016.05.001.CrossRefPubMed

24.

Persson GF, Nygaard DE, Olsen M, Juhler-Nøttrup T, Pedersen AN, Specht L, et al. Can audio coached 4D CT emulate free breathing during the treatment course? Acta Oncol. 2008;47(7):1397–405. https://doi.org/10.1080/02841860802256442.CrossRefPubMed

25.

Jensen CA, Acosta Roa AM, Lund JÅ, Frengen J. Intrafractional baseline drift during free breathing breast cancer radiation therapy. Acta Oncol. 2017;56(6):867–73. https://doi.org/10.1080/0284186x.2017.1288924.CrossRefPubMed

Title: Dosimetric effect of respiratory motion on planned dose in whole-breast volumetric modulated arc therapy using moderate and ultra-hypofractionation
Authors: Mikko Mankinen
Tuomas Virén
Jan Seppälä
Heikki Hakkarainen
Tuomas Koivumäki
Publication date: 01-12-2022
Publisher: BioMed Central
Keywords: Breast Cancer
Breast Cancer
Published in: Radiation Oncology / Issue 1/2022
Electronic ISSN: 1748-717X
DOI: https://doi.org/10.1186/s13014-022-02014-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Dosimetric effect of respiratory motion on planned dose in whole-breast volumetric modulated arc therapy using moderate and ultra-hypofractionation

Abstract

Background and purpose

Materials and methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background and purpose

Materials and methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2022

Factors associated with long-term survival in gemcitabine-concurrent proton radiotherapy for non-metastatic locally advanced pancreatic cancer: a single-center retrospective study

Feasibility of linac-based fractionated stereotactic radiotherapy and stereotactic radiosurgery for patients with up to ten brain metastases

A review of radiomics and genomics applications in cancers: the way towards precision medicine

Impact of chronic graft-versus-host disease on quality of life and cognitive function of long-term transplant survivors after allogeneic hematopoietic stem cell transplantation with total body irradiation

Effect of stomach size on organs at risk in pancreatic stereotactic body radiotherapy

Predictors of radiation-induced hypothyroidism in nasopharyngeal carcinoma survivors after intensity-modulated radiotherapy