Top

Published in:

01-04-2020 | Radiotherapy | Original Article

Hybrid planning techniques for hypofractionated whole-breast irradiation using flattening filter-free beams

Authors: Karunakaran Balaji, M.Sc., Sitaraman Balaji Subramanian, DNB, Krishnamoorthi Sathiya, DNB, Moorthi Thirunavukarasu, M.Sc., Chandrasekaran Anu Radha, Ph.D., Velayudham Ramasubramanian, Ph.D.

Published in: Strahlentherapie und Onkologie | Issue 4/2020

Abstract

Objective

The aim of this study was to assess the feasibility of flattening filter-free (FFF) photon beams in hybrid intensity-modulated radiation therapy (H-IMRT) and hybrid volumetric modulated arc therapy (H-VMAT) for left-sided whole-breast radiation therapy with a boost volume (RT) using a hypofractionated dose regimen.

Patients and methods

RT plans of 25 patients with left-sided early-stage breast cancer were created with H‑IMRT and H‑VMAT techniques under breath-hold conditions using 6‑MV FFF beams. In hybrid techniques, three-dimensional conformal radiotherapy (3DCRT) plans were kept as base-dose plans for the VMAT and IMRT plans. In addition, H‑IMRT in step-and-shoot mode was also calculated to assess its achievability with FFF beams.

Results

All hybrid plans achieved the expected target coverage. H‑VMAT showed better coverage and homogeneity index results for the boost target (p < 0.002), while H‑IMRT presented better results for the whole-breast target (p < 0.001). Mean doses to normal tissues were comparable between both plans, while H‑IMRT reduced the low-dose levels to heart and ipsilateral lung (p < 0.05). H‑VMAT revealed significantly better results with regard to monitor units (MU) and treatment time (p < 0.001).

Conclusion

The 6‑MV FFF beam technique is feasible for large-field 3DCRT-based hybrid planning in whole-breast and boost planning target volume irradiation. For breath-hold patients, the H‑VMAT plan is superior to H‑IMRT for hypofractionated dose regimens, with reduced MU and treatment delivery time.

Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Darby S, McGale P, Correa C et al (2011) Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 378:1707–1716CrossRef

Clarke M, Collins R, Darby S et al (2005) Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 366:2087–2106CrossRefPubMed

Vinh-Hung V, Verschraegen C (2004) Breast-conserving surgery with or without radiotherapy: pooled-analysis for risks of ipsilateral breast tumor recurrence and mortality. J Natl Cancer Inst 96:115–121CrossRefPubMed

Bartelink H, Horiot JC, Poortmans PM et al (2007) Impact of a higher radiation dose on local control and survival in breast-conserving therapy of early breast cancer: 10-year results of the randomized boost versus no boost EORTC 22881–10882 trial. J Clin Oncol 25:3259–3265CrossRefPubMed

Jones HA, Antonini N, Hart AM et al (2009) Impact of pathological characteristics on local relapse after breast-conserving therapy: a subgroup analysis of the EORTC boost versus no boost trial. J Clin Oncol 27:4939–4947CrossRefPubMedPubMedCentral

Dellas K, Vonthein R, Zimmer J et al (2014) Hypofractionation with simultaneous integrated boost for early breast cancer: results of the German multicenter phase II trial (ARO-2010-01). Strahlenther Onkol 190:646–653CrossRefPubMed

Haviland JS, Owen RJ, Dewar JA et al (2013) The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol 4:1086–1094CrossRef

Whelan TJ, Pignol JP, Levine MN et al (2010) Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med 362:513–520CrossRefPubMed

James ML, Lehman M, Hider PN et al (2010) Fraction size in radiation treatment for breast conservation in early breast cancer. Cochrane Database Syst Rev 7:CD003860. https://doi.org/10.1002/14651858.CD003860.pub3 CrossRefPubMed

10.

Alford SL, Prassas GN, Vogelesang CR et al (2013) Adjuvant breast radiotherapy using a simultaneous integrated boost: clinical and dosimetric perspectives. J Med Imaging Radiat Oncol 57:222–229CrossRefPubMed

11.

Van Parijs H, Reynders T, Heuninckx K et al (2014) Breast conserving treatment for breast cancer: dosimetric comparison of different non-invasive techniques for additional boost delivery. Radiat Oncol 9:36CrossRefPubMedPubMedCentral

12.

Bantema-Joppe EJ, Vredeveld EJ, de Bock GH et al (2013) Five year outcomes of hypofractionated simultaneous integrated boost irradiation in breast conserving therapy; patterns of recurrence. Radiother Oncol 108:269–272CrossRefPubMed

13.

Balaji K, Yadav P, BalajiSubramanian S et al (2018) Hybrid volumetric modulated arc therapy for chest wall irradiation: for a good plan, get the right mixture. Phys Med 52:86–92. https://doi.org/10.1016/j.ejmp.2018.06.641 CrossRefPubMed

14.

Balaji K, Subramanian B, Yadav P et al (2016) Radiation therapy for breast cancer: literature review. Med Dosim 41(3):253–257. https://doi.org/10.1016/j.meddos.2016.06.005 CrossRefPubMed

15.

Filippi AR, Ragona R, Piva C et al (2015) Optimized volumetric modulated arc therapy versus 3D-CRT for early stage mediastinal Hodgkin lymphoma without axillary involvement: a comparison of second cancers and heart disease risk. Int J Radiat Oncol Biol Phys 92(1):161–168. https://doi.org/10.1016/j.ijrobp.2015.02.030 CrossRefPubMed

16.

Mayo CS, Urie MM, Fitzgerald TJ (2005) Hybrid IMRT plans–concurrently treating conventional and IMRT beams for improved breast irradiation and reduced planning time. Int J Radiat Oncol Biol Phys 61:922–932. https://doi.org/10.1016/j.ijrobp.2004.10.033 CrossRefPubMed

17.

Jeulink M, Dahele M, Meijnen P et al (2015) Is there a preferred IMRT technique for left-breast irradiation? J Appl Clin Med Phys 16:197–205. https://doi.org/10.1120/jacmp.v16i3.5266 CrossRefPubMedCentral

18.

Chen YG, Li AC, Li WY et al (2017) The feasibility study of a hybrid coplanar arc technique versus hybrid intensity-modulated radiotherapy in treatment of early-stage left-sided breast cancer with simultaneous-integrated boost. J Med Phys 42(1):1–8. https://doi.org/10.4103/jmp.JMP_56_17 CrossRefPubMedPubMedCentral

19.

Lin J, Yeh D, Yeh H et al (2015) Dosimetric comparison of hybrid volumetric-modulated arc therapy, volumetric-modulated arc therapy and intensity-modulated radiation therapy for left-sided early breast cancer. Med Dosim 40(3):262–267. https://doi.org/10.1016/j.meddos.2015.05.003 CrossRefPubMed

20.

BalajiSubramanian S, Balaji K, Thirunavukarasu M et al (2016) Bilateral breast irradiation using hybrid Volumetric Modulated Arc Therapy (h-VMAT) technique: a planning case report. Cureus 8(12):e914. https://doi.org/10.7759/cureus.91424 CrossRef

21.

Aly MM, Glatting G, Jahnke L et al (2015) Comparison of breast simultaneous integrated boost (SIB) radiotherapy techniques. Radiat Oncol 10:139. https://doi.org/10.1186/s13014-015-0452-2 CrossRefPubMedPubMedCentral

22.

Jost V, Kretschmer M, Sabatino M et al (2015) Heart dose reduction in breast cancer treatment with simultaneous integrated boost: comparison of treatment planning and dosimetry for a novel hybrid technique and 3D-CRT. Strahlenther Onkol 191:734–741CrossRefPubMed

23.

Kragl G, Wetterstedt S, Knausl B et al (2009) Dosimetric characteristics of 6 and 10 MV unflattened photonbeams. Radiother Oncol 93(1):141–146CrossRefPubMed

24.

Sharma SD (2011) Unflattened photon beams from the standard flattening filter free accelerators for radiotherapy: advantages, limitations and challenges. J Med Phys 36(3):123–125CrossRefPubMedPubMedCentral

25.

Georg D, Knoos T, McClean B (2011) Current status and future perspective of flattening filter free photon beams. Med Phys 38(3):1280–1293CrossRefPubMed

26.

Spruijt KH, Dahele M, Cuijpers JP et al (2013) Flattening filter free vs flattened beams for breast irradiation. Int J Radiat Oncol Biol Phys 85(2):506–513. https://doi.org/10.1016/j.ijrobp.2012.03.040 CrossRefPubMed

27.

Subramaniam S, Thirumalaiswamy S, Srinivas C et al (2012) Chest wall radiotherapy with volumetric modulated arcs and the potential role of flattening filter free photon beams. Strahlenther Onkol 188:484–491. https://doi.org/10.1007/s00066-012-0075-6 CrossRefPubMed

28.

Dobler B, Maier J, Knott B et al (2016) Second Cancer Risk after simultaneous integrated boost radiation therapy of right sided breast cancer with and without flattening filter. Strahlenther Onkol 192:687–695. https://doi.org/10.1007/s00066-016-1025-5 CrossRefPubMed

29.

Bahrainy M, Kretschmer M, Jost V et al (2016) Treatment of breast cancer with simultaneous integrated boost in hybrid plan technique. Strahlenther Onkol 192:333–341. https://doi.org/10.1007/s00066-016-0960-5 CrossRefPubMed

30.

White J, Tai A, Arthur D et al (2019) RTOG breast cancer atlas for radiation therapy planning: consensus definitions. https://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx. Accessed 15 Apr 2019

31.

Nicolini G, Fogliata A, Clivio A et al (2011) Planning strategies in volumetric modulated arc therapy for breast. Med Phys 38:4025–4031CrossRef

32.

Nakamura JL, Verhey LJ, Smith V et al (2001) Dose conformity of gamma knife radiosurgery and risk factors for complications. Int J Radiat Oncol Biol Phys 51(5):1313–1319CrossRefPubMed

33.

International Commission on Radiation Units and Measurements (2010) ICRU Report 83: prescribing recording and reporting photon beam intensity modulated radiation therapy (IMRT). ICRU Rep 10(1):1–92

34.

Ohtakara K, Hayashi S, Hoshi H (2011) Dose gradient analyses in linac-based Intracranial stereotactic radiosurgery using Paddick’s gradient index: consideration of the optimal method for plan evaluation. J Radiat Res 52:592–599. https://doi.org/10.1269/jrr.11005 CrossRefPubMed

35.

Kundrat P, Remmele J, Rennau H (2019) Minimum breast distance largely explains individual variability in doses to contralateral breast from breast-cancer radiotherapy. Radiother Oncol 131:186–191. https://doi.org/10.1016/j.radonc.2018.08.022 CrossRefPubMed

36.

Koulis TA, Phan T, Olivotto IA (2015) Hypofractionated whole breast radiotherapy: current perspectives. Breast Cancer 7:363–370. https://doi.org/10.2147/BCTT.S81710 CrossRefPubMedPubMedCentral

37.

Kim KS, Shin KH, Choi N, Lee S (2016) Hypofractionated whole breast irradiation: new standard in early breast cancer after breast-conserving surgery. Radiat Oncol J 34(2):81–87. https://doi.org/10.3857/roj.2016.01697 CrossRefPubMedPubMedCentral

38.

Bentzen SM, Agrawal RK, Aird EG et al (2008) The UK standardisation of breast radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet 9:331–341. https://doi.org/10.1016/S1470-2045(08)70077-9 CrossRef

39.

Bentzen SM, Agrawal RK, Aird EG et al (2008) The UK standardisation of breast radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet 371:1098–1107. https://doi.org/10.1016/S0140-6736(08)60348-7 CrossRefPubMed

40.

Agrawal RK, Alhasso A, BarrettLee PJ et al (2011) First results of the randomised UK FAST Trial of radiotherapy hypofractionation for treatment of early breast cancer (CRUKE/04/015). Radiother Oncol 100:93–100. https://doi.org/10.1016/j.radonc.2011.06.026 CrossRefPubMed

41.

Brunt AM, Wheatley D, Yarnold J et al (2016) Acute skin toxicity associated with a 1-week schedule of whole breast radiotherapy compared with a standard 3‑week regimen delivered in the UK FAST-Forward Trial. Radiother Oncol 120:114–118. https://doi.org/10.1016/j.radonc.2016.02.027 CrossRefPubMedPubMedCentral

42.

Scorsetti M, Alongi F, Fogliata A et al (2012) Phase i–ii study of hypofractionated simultaneous integrated boost using volumetric modulated arc therapy for adjuvant radiation therapy in breast cancer patients: a report of feasibility and early toxicity results in the first 50 treatments. Radiat Oncol 7:145CrossRefPubMedPubMedCentral

43.

Zhou S, Zhu X, Zhang M et al (2016) Estimation of internal organ motion-induced variance in radiation dose in non-gated radiotherapy. Phys Med Biol 61:8157–8179. https://doi.org/10.1088/0031-9155/61/23/8157 CrossRefPubMed

44.

Ramasubramanian V, Balaji K, Balaji Subramanian S et al (2019) Hybrid volumetric modulated arc therapy for whole breast irradiation: a dosimetric comparison of different arc designs. Radiol med 124(6):546–554. https://doi.org/10.1007/s11547-019-00994-1 CrossRefPubMed

45.

Jin G, Chen L, Deng X et al (2013) A comparative dosimetric study for treating left-sided breast cancer for small breast size using five different radiotherapy techniques: conventional tangential field, filed-in-filed, Tangential-IMRT, Multi-beam IMRT and VMAT. Radiat Oncol 8:89CrossRefPubMedPubMedCentral

46.

Viren T, Heikkilä J, Myllyoja K et al (2015) Tangential volumetric modulated arc therapy technique for left-sided breast cancer radiotherapy. Radiat Oncol 10:79CrossRefPubMedPubMedCentral

47.

Haciislamoglu E, Colak F, Canyilmaz E et al (2015) Dosimetric comparison of left-sided whole-breast irradiation with 3DCRT, forward-planned IMRT, inverse-planned IMRT, helical tomotherapy, and volumetric arc therapy. Phys Med 31(4):360–367. https://doi.org/10.1016/j.ejmp.2015.02.005 CrossRefPubMed

48.

Wang Y, Vassil A, Tendulkar R et al (2014) Feasibility of using nonflat photon beams for whole-breast irradiation with breath hold. J Appl Clin Med Phys 15(1):4397. https://doi.org/10.1120/jacmp.v15i1.4397 CrossRefPubMed

49.

Hall EJ (2006) Intensity-modulated radiation therapy, protons, and the risk of second cancers. Int J Radiat Oncol Biol Phys 65(1):1–7. https://doi.org/10.1016/j.ijrobp.2006.01.027 CrossRefPubMed

50.

Darby SC, Ewertz M, McGale P et al (2013) Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med 368(11):987–998. https://doi.org/10.1056/NEJMoa1209825 CrossRefPubMed

51.

Gagliardi G, Constine LS, Moiseenko V et al (2010) Radiation dose-volume effects in the heart. Int J Radiat Oncol Biol Phys 76(3):S77–S85. https://doi.org/10.1016/j.ijrobp.2009.04.093 CrossRefPubMed

52.

Marks LB, Bentzen SM, Deasy JO et al (2010) Radiation dose-volume effects in the lung. Int J Radiat Oncol Biol Phys 76(3):70–76. https://doi.org/10.1016/j.ijrobp.2009.06.091 CrossRef

53.

Blom GU, Wennberg B, Svane G et al (2010) Reduction of radiation pneumonitis by V20-constraints in breast cancer. Radiat Oncol 5:99. https://doi.org/10.1186/1748-717X-5-99 CrossRef

54.

Mah D, Miller E, Kuo H et al (2011) Flattening filter free beams for 3D breast planning. Med Phys 38:3632CrossRef

Title: Hybrid planning techniques for hypofractionated whole-breast irradiation using flattening filter-free beams
Authors: Karunakaran Balaji, M.Sc.
Sitaraman Balaji Subramanian, DNB
Krishnamoorthi Sathiya, DNB
Moorthi Thirunavukarasu, M.Sc.
Chandrasekaran Anu Radha, Ph.D.
Velayudham Ramasubramanian, Ph.D.
Publication date: 01-04-2020
Publisher: Springer Berlin Heidelberg
Keyword: Radiotherapy
Published in: Strahlentherapie und Onkologie / Issue 4/2020
Print ISSN: 0179-7158
Electronic ISSN: 1439-099X
DOI: https://doi.org/10.1007/s00066-019-01555-1

At a glance: The STEP trials

Springer Medicine

Hybrid planning techniques for hypofractionated whole-breast irradiation using flattening filter-free beams

Abstract

Objective

Patients and methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Objective

Patients and methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 4/2020

Role of stereotactic body radiation therapy in the treatment of liver metastases: clinical results and prognostic factors

Stereotactic body radiotherapy in patients with hepatocellular carcinoma in a multimodal treatment setting

Long-term outcome after intraoperative radiotherapy as a boost in breast cancer

Long-term quality of life after preoperative radiochemotherapy in patients with localized and locally advanced breast cancer

Correction to: Timing of thoracic radiotherapy is more important than dose intensification in patients with limited-stage small cell lung cancer: a parallel comparison of two prospective studies

Provider decision regret—a useful method for analysis of palliative thoracic re-irradiation for lung cancer?