Non-coplanar volumetric modulated arc therapy for locoregional radiotherapy of left-sided breast cancer including internal mammary nodes

Yuan Xu; Pan Ma; Zhihui Hu; Yuan Tian; Kuo Men; Shulian Wang; Yingjie Xu; Jianrong Dai

doi:10.2478/raon-2021-0045

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Non-coplanar volumetric modulated arc therapy for locoregional radiotherapy of left-sided breast cancer including internal mammary nodes

Radiology and Oncology

Volume 55 (2021): Issue 4 (December 2021)

By: Yuan Xu, Pan Ma, Zhihui Hu, Yuan Tian, Kuo Men, Shulian Wang, Yingjie Xu and Jianrong Dai

Open Access

|Nov 2021

Abstract

Background

Non-coplanar volumetric modulated arc therapy (ncVMAT) is proposed to reduce toxicity in heart and lungs for locoregional radiotherapy of left-sided breast cancer, including internal mammary nodes (IMN).

Patients and methods

This retrospective study included 10 patients with left-sided breast cancer who underwent locoregional radiotherapy after breast-conserving surgery. For each patient, the ncVMAT plan was designed with four partial arcs comprising two coplanar arcs and two non-coplanar arcs, with a couch rotating to 90°. The prescribed dose was normalized to cover 95% of planning target volume (PTV), with 50 Gy delivered in 25 fractions. For each ncVMAT plan, dosimetric parameters were compared with the coplanar volumetric modulated arc therapy (coV-MAT) plan.

Results

T here were improvements in conformity index, homogeneity index and V₅₅ of total target volume (PTVall) comparing ncVMAT to coVMAT (p < 0.001). Among the organs at risk, the average V₃₀, V₂₀, V₁₀, V₅, and mean dose (D_mean) of the heart decreased significantly (p < 0.001). Furthermore, ncVMAT significantly reduced the mean V₂₀, V₁₀, V₅, and D_mean of left lung and the mean V₁₀ and V₅ and D_mean of contralateral lung (p < 0.001). An improved sparing of the left anterior descending coronary artery and right breast were also observed with ncVMAT (p < 0.001).

Conclusions

Compared to coVMAT, ncVMAT provides improved conformity and homogeneity of whole P TV, better dose sparing of the heart, bilateral lungs, left anterior descending coronary artery (LAD), and right breast for locoregional radiotherapy of left-sided breast cancer with IMN, potentially reducing the risk of normal tissue damage.

References

Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Darby S, McGale P, Correa C, Taylor C, Arriagada R, Clarke M, et al. 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 2011; 378: 1707-16. doi: 10.1016/S0140-6736(11)61629-2
Open DOI Search in Google Scholar Back to article
Corradini S, Niyazi M, Niemoeller OM, Li M, Roeder F, Eckel R, et al. Adjuvant radiotherapy after breast conserving surgery-a comparative effectiveness research study. Radiother Oncol 2014; 114: 28-34. doi: 10.1016/j.radonc.2014.08.027
Open DOI Search in Google Scholar Back to article
Cody HS, Urban JA. Internal mammary node status: a major prognosticator in axillary node-negative breast cancer. Ann Surg Oncol 1995; 2: 32-7. doi: 10.1007/BF02303699
Open DOI Search in Google Scholar Back to article
Poortmans PM, Collette S, Kirkove C, Limbergen EV, Budach V, Struikmans H, et al. Internal mammary and medial supraclavicular irradiation in breast cancer. N Engl J Med 2015; 373: 317-27. doi: 10.1056/NEJMoa1415369
Open DOI Search in Google Scholar Back to article
Taghian A, Jagsi R, Makris A, Goldberg S, Ceilley E, Grignon L, et al. Results of a survey regarding irradiation of internal mammary chain in patients with breast cancer: practice is culture driven rather than evidence based. Int J Radiat Oncol Biol Phys 2004; 60: 706-14. doi: 10.1016/j.ijrobp.2004.04.027
Open DOI Search in Google Scholar Back to article
Thorsen LB, Offersen BV, Dano H, Berg M, Jensen I, Pedersen AN, et al. DBCG-IMN: a population-based cohort study on the effect of internal mammary node irradiation in early node–positive breast cancer. J Clin Oncol 2016; 34: 314-20. doi: 10.1200/JCO.2015.63.6456
Open DOI Search in Google Scholar Back to article
Verma V, Vicini F, Tendulkar RD, Khan AJ, Wobb J, Edwards-Bennett S, et al. Role of internal mammary node radiation as a part of modern breast cancer radiation therapy: a systematic review. Int J Radiat Oncol Biol Phys 2016; 95: 617-31. doi: 10.1016/j.ijrobp.2016.01.058
Open DOI Search in Google Scholar Back to article
Marks LB, Yorke ED, Jackson A, Haken RKT, Constine LS, Eisbruch A, et al. The use of normal tissue complication probability models in the clinic. Int J Radiat Oncol Biol Phys 2010; 76: S10-S9. doi: 10.1016/j.ijrobp.2009.07.1754
Open DOI Search in Google Scholar Back to article
Fragkandrea I, Kouloulias V, Mavridis P, Zettos A, Betsou S, Georgolopoulou P, et al. Radiation induced pneumonitis following whole breast radiotherapy treatment in early breast cancer patients treated with breast conserving surgery: a single institution study. Hippokratia 2013; 17: 233-8. PMID: 24470733
Search in Google Scholar Back to article
Roychoudhuri R, Robinson D, Putcha V, Cuzick J, Darby S, Møller H, et al. Increased cardiovascular mortality more than fifteen years after radiotherapy for breast cancer: a population-based study. BMC Cancer 2007; 7: 9. doi: 10.1186/1471-2407-7-9
Open DOI Search in Google Scholar Back to article
Pierce SM, Recht A, Lingos TI, Abner A, Vicini F, Silver B, et al. Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer. Int J Radiat Oncol Biol Phys 1992; 23: 915-23. doi: 10.1016/0360-3016(92)90895-o
Open DOI Search in Google Scholar Back to article
Paszat LF, Mackillop WJ, Groome PA, Schulze K, Holowaty E. Mortality from myocardial infarction following postlumpectomy radiotherapy for breast cancer: a population-based study in Ontario, Canada. Int J Radiat Oncol Biol Phys 1999; 43: 755-62. doi: 10.1016/s0360-3016(98)00412-x
Open DOI Search in Google Scholar Back to article
Marks LB, Hebert ME, Bentel G, Spencer DP, Sherouse GW, Prosnitz LR. To treat or not to treat the internal mammary nodes: a possible compromise. Int J Radiat Oncol Biol Phys 1994; 29: 903-9. doi: 10.1016/03603016(94)90584-3
Open DOI Search in Google Scholar Back to article
Stranzl H, Zurl B, Langsenlehner T, Kapp KS. Wide tangential fields including the internal mammary lymph nodes in patients with left-sided breast cancer. Influence of respiratory-controlled radiotherapy (4D-CT) on cardiac exposure. Strahlenther Onkol 2009; 185: 155-60. doi: 10.1007/s00066-009-1939-2
Open DOI Search in Google Scholar Back to article
Popescu CC, Olivotto I, Patenaude V, Wai E, Beckham WA. Inverse-planned, dynamic, multi-beam, intensity-modulated radiation therapy (IMRT): a promising technique when target volume is the left breast and internal mammary lymph nodes. Med Dosim 2006; 31: 283-91. doi: 10.1016/j.meddos.2006.05.003
Open DOI Search in Google Scholar Back to article
Tyran M, Mailleux H, Tallet A, Fau P, Gonzague L, Minsat M, et al. Volumetric-modulated arc therapy for left-sided breast cancer and all regional nodes improves target volumes coverage and reduces treatment time and doses to the heart and left coronary artery, compared with a field-in-field technique. J Radiat Res 2015; 56: 927-37. doi: 10.1093/jrr/rrv052
Open DOI Search in Google Scholar Back to article
Pasler M, Lutterbach J, Björnsgard M, Reichmann U, Bartelt S, Georg D. VMAT techniques for lymph node-positive left sided breast cancer. Z Med Phys 2015; 25: 104-11. doi: 10.1016/j.zemedi.2014.03.008
Open DOI Search in Google Scholar Back to article
Yu PC, Wu CJ, Nien HH, Lui LT, Shaw S, Tsai YL. Tangent-based volumetric modulated arc therapy for advanced left breast cancer. Radiat Oncol 2018; 13: 236. doi: 10.1186/s13014-018-1167-y
Open DOI Search in Google Scholar Back to article
Caudrelier JM, Morgan SC, Montgomery L, Lacelle M, Nyiri B, Macpherson M. Helical tomotherapy for locoregional irradiation including the internal mammary chain in left-sided breast cancer: dosimetric evaluation. Radiol Oncol 2009; 90: 99-105. doi: 10.1016/j.radonc.2008.09.028
Open DOI Search in Google Scholar Back to article
Xu YJ, Wang JB, Hu ZH, Tian Y, Ma P, Li S, et al. Locoregional irradiation including internal mammary nodal region for left-sided breast cancer after breast conserving surgery: dosimetric evaluation of 4 techniques. Med Dosim 2019; 44: e13-e8. doi: 10.1016/j.meddos.2018.09.004
Open DOI Search in Google Scholar Back to article
Smyth G, Evans PM, Bamber JC, Bedford JL. Recent developments in non-coplanar radiotherapy. Br J Radiol 2019; 92: 20180908. doi: 10.1259/bjr.20180908
Open DOI Search in Google Scholar Back to article
Fogliata A, Clivio A, Nicolini, Vanetti E, Cozzi L. A treatment planning study using non-coplanar static fields and coplanar arcs for whole breast radiotherapy of patients with concave geometry. Radiother Oncol 2007; 85: 34654. doi: 10.1016/j.radonc.2007.10.006
Open DOI Search in Google Scholar Back to article
Yoo S, Blitzblau R, Yin FF, Horton JK. Dosimetric comparison of preoperative single-fraction partial breast radiotherapy techniques: 3D CRT, noncoplanar IMRT, coplanar IMRT, and VMAT. J Appl Clin Med Phys 2015; 16: 5126. doi: 10.1120/jacmp.v16i1.5126
Open DOI Search in Google Scholar Back to article
Xie Y, Bourgeois D, Guo B, Zhang R. Postmastectomy radiotherapy for left-sided breast cancer patients: comparison of advanced techniques. Med Dosim 2020; 45: 34-40. doi: 10.1016/j.meddos.2019.04.005
Open DOI Search in Google Scholar Back to article
Goldman UB, Wennberg B, Svane G, Bylund H, Lind P. Reduction of radiation pneumonitis by V20-constraints in breast cancer. Radiat Oncol 2010; 5: 99. doi: 10.1186/1748-717X-5-99
Open DOI Search in Google Scholar Back to article
Gagliardi G, Constine LS, Moiseenko V, Correa C, Pierce LJ, Allen AM, et al. Int J Radiat Oncol Biol Phys 2010; 76(Suppl 3): S77-85. doi: 10.1016/j.ijrobp.2009.04.093
Open DOI Search in Google Scholar Back to article
Paddick I, A simple scoring ratio to index the conformity of radiosurgical treatment plans. Technical note. J Neurosurg 2000; 93(Suppl 3): S219-22. doi: 10.3171/jns.2000.93.supplement
Open DOI Search in Google Scholar Back to article
Wang X, Zhang X, Dong L, Liu H, Gillin M, Ahamad A, Ang K, et al. Effectiveness of noncoplanar IMRT planning using a parallelized multiresolution beam angle optimization method for paranasal sinus carcinoma. Int J Radiat Oncol Biol Phys 2005; 63: 594-601. doi: 10.1016/j.ijrobp.2005.06.006
Open DOI Search in Google Scholar Back to article
Thorsen LBJ, Thomsen MS, Berg M, Jensen I, Josipovic M, Overgaard M, et al. CT-planned internal mammary node radiotherapy in the DBCG-IMN study: benefit versus potentially harmful effects. Acta Oncologica 2014; 53: 1027-34. doi: 10.3109/0284186X.2014.925579
Open DOI Search in Google Scholar Back to article
Poortmans PMP, Venselaar JLM, Struikmans H, Hurkmans CW, Davis JB, Huyskens D, et al. The potential impact of treatment variations on the results of radiotherapy of the internal mammary lymph node chain: a quality-assurance report on the dummy run of EORTC Phase III randomized trial 22922/10925 in Stage I–III breast cancer. Int J Radiation Oncology Biol Phys 2001; 49: 1399-408. doi: 10.1016/s0360-3016(00)01549-2
Open DOI Search in Google Scholar Back to article
Donovan E, Bleakley N, Denholm E, Evans P, Gothard L, Hanson J, et al. Randomised trial of standard 2D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy. Radiother Oncol 2007; 82: 254-64. doi: 10.1016/j.radonc.2006.12.008
Open DOI Search in Google Scholar Back to article
Clarke M, Collins R, Darby S, Davies C, Elphinstone P, Evans V, et al. 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 randomized trials. Lancet 2005; 366: 2087-106. doi: 10.1016/S0140-6736(05)67887-7
Open DOI Search in Google Scholar Back to article
Vallis KA, Pintilie M, Chong N, Holowaty E, Douglas PS, Kirkbride P, et al. Assessment of coronary heart disease morbidity and mortality after radiation therapy for early breast cancer. J Clin Oncol 2002; 20: 1036-42. doi: 10.1200/JCO.2002.20.4.1036
Open DOI Search in Google Scholar Back to article
Darby SC, Ewertz M, McGale P, Bennet AM, Blom-Goldman U, Brønnum D, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med 2013; 368: 987-98. doi: 10.1056/NEJMoa1209825
Open DOI Search in Google Scholar Back to article
Pham TT, Ward R, Latty D, Owen C, Gebski V, Chojnowski J, et al. Left-sided breast cancer loco-regional radiotherapy with deep inspiration breath-hold: does volumetric-modulated arc radiotherapy reduce heart dose further compared with tangential intensity-modulated radiotherapy? Radiat Oncol 2016; 60: 545-53. doi: 10.1111/1754-9485.12459
Open DOI Search in Google Scholar Back to article
Gagliardi G, Lax I, Ottolenghi A Rutqvist LE. Long-term cardiac mortality after radiotherapy of breast cancer – application of the relative seriality model. Br J Radiol 1996; 69: 839-46. doi: 10.1259/0007-1285-69-825-839
Open DOI Search in Google Scholar Back to article
Marks LB, Yu X, Prosnitz RG, Zhou SM, Hardenbergh PH, Blazing M. The incidence and functional consequences of RT-associated cardiac perfusion defects. Int J Radiat Oncol Biol Phys 2005; 63: 214-23. doi: 10.1016/j.ijrobp.2005.01.029
Open DOI Search in Google Scholar Back to article
Taylor CW, Nisbet A, McGale P, Darvy SC. Cardiac exposures in breast cancer radiotherapy: 1950s-1990s. Int J Radiat Oncol Biol Phys 2007; 69: 1484-95. doi: 10.1016/j.ijrobp.2007.05.034
Open DOI Search in Google Scholar Back to article
Jain V, Berman AT. Radiation pneumonitis: old problem, new tricks. Cancers 2018; 10: 222. doi: 10.3390/cancers10070222
Open DOI Search in Google Scholar Back to article
Lind PA, Svane G, Gagliardi G, Svensson C. Abnormalities by pulmonary regions studied with computer tomography following local or localregional-radiotherapy for breast cancer. Int J Radiat Oncol Biol Phys 1999; 43: 489-96. doi: 10.1016/s0360-3016(98)00414-3
Open DOI Search in Google Scholar Back to article
Wen G, Tan YT, Lan XW, He ZC, Huang JH, Shi JT, et al. New clinical features and dosimetric predictor identification for symptomatic radiation pneumonitis after tangential irradiation in breast cancer patients. J Cancer 2017; 8: 3795-802. doi: 10.7150/jca.21158
Open DOI Search in Google Scholar Back to article
Bongers EM, Botticella A, Palma DA, Haasbeek CJA, Warner A, Verbakel WFAR, et al. Predictive parameters of symptomatic radiation pneumonitis following stereotactic or hypofractionated radiotherapy delivered using volumetric modulated arcs. Radiother Oncol 2013; 109: 95-9. doi: 10.1016/j.radonc.2013.10.011
Open DOI Search in Google Scholar Back to article
Stovall M, Smith SA, Langholz BM, Jr Boice JD, Shore RE, Andersson M, et al. Dose to the contralateral breast from radiotherapy and risk of second primary breast cancer in the WECARE study. Int J Radiat Oncol Biol Phys 2008; 72: 1021-30. doi: 10.1016/j.ijrobp.2008.02.040
Open DOI Search in Google Scholar Back to article
Boice JD Jr, Harvey EB, Blettner M, Stovall M, Flannery JT. Cancer in the contralateral breast after radiotherapy for breast cancer. N Engl J Med 1992; 326: 781-5. doi: 10.1056/NEJM199203193261201
Open DOI Search in Google Scholar Back to article
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: 287-95. doi: 10.1016/j.ijrobp.2009.05.038
Open DOI Search in Google Scholar Back to article
Yamauchi R, Mizuno N, Itazawa T, Saitoh H, Kawamori J. Dosimetric evaluation of deep inspiration breath hold for left-sided breast cancer: analysis of patient-specific parameters related to heart dose reduction. J Radiat Res 2020; 61: 447-56. doi: 10.1093/jrr/rraa006
Open DOI Search in Google Scholar Back to article