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Evaluation of DIBH breast plan robustness against isocenter positioning uncertainties

I. Abstract
II. Introduction
A. PI: Breast treatment DIBH introduction, OAR toxicity possibilities (Reference:
Darby et al,1 Piroth et al2)
B. PII: DIBH explanation and AlignRT surface imaging (Reference: Conroy et al,3
Hayden et al,4 Latty et al,5 Bartlett et al,6 Xiao et al7)
C. PIII: Uncertainty sources (Reference: Mourik et al8)
D. PIV: Departmental threshold tolerances (Reference: Wiant et al9)
E. PV: Eclipse plan uncertainty tool (Reference: Warren et al10)
F. PVI: Problem, purpose, and hypotheses
1. Problem: The research problem is that patient positioning errors could be
shifting the isocenter resulting in an unplanned increase in cardiac dose
and decreased evaluation planning target volume (PTV Eval) dose
coverage for left sided breast patients treated with DIBH.
2. Purpose: The overall purpose of this study was to compare heart dose and
breast PTV Eval coverage for DIBH left breast patient plans using the plan
uncertainty feature in Eclipse to determine whether adjustments are
necessary for set up threshold tolerances.
3. Hypotheses: The research hypotheses were that by incorporating isocenter
shifts within the departmental setup tolerances of ±3mm in the X, Y, and
Z directions using the uncertainty tool would cause: <100% of patients
meeting all criteria for breast PTV and heart dose goals (H1), 10% of
whole heart dose receiving > 22 Gy (H2), mean heart dose receiving > 2.5
Gy (H3), 90% of breast PTV Eval dose receiving < 90% of the
prescription dose (H4), 100% of the breast boost dose of 39.6Gy covering
> 35% of breast PTV Eval (H5) and 50% of breast PTV Eval receiving >
38.3 Gy (H6). The null hypotheses were that by incorporating isocenter
shifts within the departmental setup margins of 3mm in the X, Y, and Z
directions using the uncertainty tool would not cause: 100% of patients
meeting all criteria for breast PTV and heart dose goals (H10), > 10% of
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the whole heart receiving > 22 Gy (H20), the mean heart dose > 2.5 Gy
(H30), 90% of the Breast PTV Eval receiving < 90% of the prescription
dose (H40), 100% of the boost prescribed dose of 39.6Gy covering > 35%
of the breast PTV Eval (H50), > 50% of the breast PTV Eval receiving
>38.3 Gy (H60).
III. Materials and Methods
A. PI-PII: Patient selection and setup
1. PI: Patient population
a. 19 patients
b. Inclusion criteria (Early stage left breast cancer)
c. Exclusion criteria (unqualified candidates for DIBH)
2. PII: Simulation procedures
B. PIII-PIV: Contours
1. PIII: Organs at risk (Reference: Poppe11)
2. PIV: Target volumes (Reference: Poppe11)
C. PV-PVI: Planning Procedures
1. PV: Planning parameters of equipment and systems
a. Treatment Planning System and algorithm
b. EZFluence optimization
c. Machine and image guidance information
d. November protocol (Reference: Poppe11)
e. Treatment scheme
2. PVI: Plan uncertainty tool implementation
a. Plan uncertainty tool introduction
b. Utilizing the plan uncertainty tool for treatment plans
c. Evaluating Dose Volume Histograms with uncertainty plans (Figure
1. DVH of uncertainty plans)
D. PVII: Statistical Analysis
1. P-value definition
2. P-value relating to criterion
a. P = 1 if none of the patients in the sample failed to meet the criterion
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b. P = 0 if one or more of the patients in the sample failed to meet the

criterion
IV. Results
A. PI: Overall Dose Criteria
1. 3mm + X, Y, Z isocenter shifts for all 5 dose criteria (H1)
a. Seventeen out of 19 patients passed all criteria (2 failed) (Table 1)
b. Reject null hypothesis (H10) at α= 0.05. (P=0)
B. PII: Dose to 10% of Heart
1. 3mm + X, Y, Z isocenter shifts and 10% whole heart dose (H2)
a. Whole heart dose D10% < 22Gy for all 19 patients
b. Whole heart dose = fail to reject null hypothesis (H20) at α= 0.05.
(P=1)
C. PIII: Mean Heart Dose
1. 3mm + X, Y, Z isocenter shifts and mean heart dose (H3)
a. Mean heart dose < 2.5Gy for all 19 patients
b. Mean heart dose = fail to reject null hypothesis (H30) at α= 0.05.
(P=1)
D. PIV: 90% Breast PTV Eval
1. 3mm + X, Y, Z isocenter shifts and 90% of breast PTV Eval dose (H4)
a. 90% of breast PTV Eval dose > 90% of the prescription dose
(30.78Gy) for all 19 patients
b. 90% breast PTV Eval dose = fail to reject null hypothesis (H40) at α=
0.05. (P=1)
E. PV: Breast PTV Eval Dose
1. 3mm + X, Y, Z isocenter shifts and 35% breast PTV Eval dose (H5)
a. 100% of breast boost dose (39.6Gy) < 35% of breast PTV Eval for
18 patients
b. 100% of breast boost dose (39.6Gy) > 35% of breast PTV Eval for 1
patient
i. –z direction
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c. 35% breast PTV Eval dose = Reject null hypothesis (H50) at α= 0.05.
(P=0)
F. PVI: 50% of Breast PTV Eval Dose
1. 3mm + X, Y, Z isocenter shifts and 50% breast PTV Eval dose (H6)
a. 50% of breast PTV Eval dose < 38.3Gy for 18 patients
b. 50% of breast PTV Eval dose > 38.3Gy for 1 patient
i. –x direction, +y direction, +z direction
c. 50% of breast PTV Eval dose = Reject null hypothesis (H60) at α=
0.05. (P=0)
V. Discussion
A. PI: Summarize all results
1. Setup threshold tolerance and length of treatment
2. Longer treatments result in more patient movement (Reference: Wiant et
al9)
B. PII: Summarize heart dose coverage results in relation to isocenter shifts
C. PIII: Summarize breast PTV Eval dose coverage results in relation to isocenter
shifts
D. PIV: Summarize all results in study to recap
VI. Conclusion
A. PI: Summarize the study
1. Problem: The problem is that patient positioning errors could be shifting
the isocenter resulting in an unplanned increase in cardiac dose and
decreased evaluation planning target volume (PTV Eval) dose coverage
for left sided breast patients treated with DIBH
2. Purpose: The purpose of this study was to compare heart dose and breast
PTV Eval coverage for DIBH left breast patient plans using the plan
uncertainty feature in Eclipse to determine whether adjustments are
necessary for set up threshold tolerances.
B. PII: Limitations/future research
1. Limitations: all patients were collected from 1 institution with the same
TPS and algorithm.
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2. Future research
a. Different TPS, linear accelerator, and/or surface image guidance
system
b. Apply different threshold tolerances
c. Apply this study using the plan uncertainty tool to a different
anatomical location
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References

1. Darby S, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after
radiotherapy for breast cancer. N Engl J Med. 2013;368(11):987–98.
http://doi.org/10.1056/NEJMoa1209825

2. Piroth MD, Baumann R, Budach W, et al. Heart toxicity from breast cancer radiotherapy.
Strahlenther Onkol. 2019;195(1):1-12. http://doi.org/10.1007/s00066-018-1378-z

3. Conroy L, Yeung R, Watt E, et al. Evaluation of target and cardiac position during visually
monitored deep inspiration breath-hold for breast radiotherapy. J Appl Clin Med Phys.
2016;17(4):25-36. http://doi.org/10.1120/jacmp.v17i4.6188
4. Hayden A, Rains M, Tiver K. Deep inspiration breath hold technique reduces heart dose
from radiotherapy for left sided breast cancer. J Med Imaging Radiat Oncol. 2012;56:464–
72. http://doi.org/10.1111/j.1754-9485.2012.02405.x
5. Latty D, Stuart KE, Wang W, Ahern V. Review of deep inspiration breath-hold techniques
for the treatment of breast cancer. J Med Radiat Sci. 2015;62(1):74-81.
http://doi.org/10.1002/jmrs.96
6. Bartlett F, Colgan R, Carr K, et al. The UK HeartSpare Study: Randomised evaluation of
voluntary deep inspiratory breathhold in women undergoing breast radiotherapy. Radiother
Oncol. 2013;108:242–7. http://doi.org/10.1016/j.radonc.2013.04.021
7. Xiao A, Crosby J, Malin M, et al. Single-institution report of setup margins of voluntary
deep-inspiration breath-hold (DIBH) whole breast radiotherapy implemented with real-time
surface imaging. J Appl Clin Med Phys. 2018;19(4):205-213.
http://doi.org/10.1002/acm2.12368
8. Mourik AV, Kranen SV, Hollander SD, Sonke J-J, Herk MV, Vliet-Vroegindeweij CV.
Effects of Setup Errors and Shape Changes on Breast Radiotherapy. Int J Radiat Oncol Biol
Phys. 2011;79(5):1557-1564. http://doi.org/10.1016/j.ijrobp.2010.07.032
9. Wiant DB, Wentworth S, Mauer JM, Vanderstraeten CL, Terrell JA, Sintay BJ. Surface
imaging-based analysis of intrafraction motion for breast radiotherapy patient. J Appl Clin
Med Phys. 2014;15(6):147-159. http://doi.org/10.1120/jacmp.v15i6.4957
10. Warren S, Partridge M, Bolsi A, et al. An Analysis of Plan Robustness for Esophageal
Tumors: Comparing Volumetric Modulated Arc Therapy Plans and Spot Scanning Proton
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Planning. Int J Radiat Oncol Biol Phys. 2016:95(1):199-207.

http://doi.org/10.1016/j.ijrobp.2016.01.044

11. Poppe M. Hypofractionated Radiation Therapy in Treating Patients With Stage 0-IIB Breast
Cancer (NOVEMBER). ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT03345420.
Updated May 8, 2020. Accessed July 23, 2020.
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Tables
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Figures

Figure 1. Dose Volume Histogram of the 7 plans using the uncertainty tool. Figure (A) displays the heart in
pink and the breast PTV eval in blue and Figure (B) displays the heart in a closer view to express the
differences of the plans.