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Evaluating dosimetric improvements after modification of a novel breast boost technique   

Authors: Caitlin Allen, BS, RT(T); Alexandra Rode, BA, RT(T); Tara Goffic BS,
RT(R)(T)(CT); Nishele Lenards PhD, CMD, R.T.(R)(T), FAAMD; Ashley Hunzeker MS, CMD;
Sabrina Zeiler MS, CMD, R.T.(T)
Affiliation: Medical Dosimetry Program, University of Wisconsin, La Crosse, WI   
  
Abstract  
The goal of breast cancer radiotherapy is to deliver conformal dose to the planning target volume
(PTV) while minimizing dose to the adjacent organs at risk (OAR). One technique for photon
breast boosts improves PTV conformality by introducing a dynamic conformal arc (DCA) to
tangent fields. The problem is that utilizing a DCA with wedged tangent fields for a free
breathing breast boost delivers more dose to the heart and ipsilateral lung. The purpose of this
retrospective study was to determine if modifications to this novel technique could increase
conformity to the boost PTV while achieving lower doses to the heart and ipsilateral lung for
left-sided breast cancers. Modifications studied included deep inspiration breath hold (DIBH),
field-in-field (FiF), and extending the length of the DCA between tangent fields. Ten post-
lumpectomy patients with free breathing (FB) and DIBH CT scans were selected from a single
institution. Patients were planned with 6 MV, 10 MV and/or 18 MV photons to a prescription
dose of 1000 cGy over 5 fractions. Doses to the PTVs and OAR were analyzed. The OAR
measurements included averages of maximum and mean dose to the heart and the volume of the
ipsilateral lung receiving 5 Gy (V5). The Radiation Therapy Oncology Group (RTOG)
conformity index (CI) for the PTV was also calculated. Researchers discovered a statistically
significant reduction in mean heart dose, but found changes in maximum heart dose, ipsilateral
V5, and RTOG CI to be statistically inconclusive.  
  
Keywords:   Left-sided breast cancer, dynamic conformal arc (DCA), cardiac toxicity, deep
inspiration breath hold (DIBH), boost technique 
  
Introduction  
Breast cancer is the most common malignancy diagnosed in women within the United
States. The standard of care for early-stage breast cancer is a lumpectomy followed by radiation
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therapy.1 As with all radiation treatments, delivering maximum dose to the planning target
volume (PTV) while sparing healthy tissue in and near the path of the beam is of utmost
importance. If healthy breast tissue is irradiated to higher than prescribed doses, there is an
increased risk of developing fibrosis.2 In addition, side effects such as radiation pneumonitis and
coronary events occur when nearby organs at risk (OAR), such as the lungs and heart, are within
the treatment field. Therefore, efforts must be made to maximize conformal dose distribution to
the PTV while limiting unnecessary dose to the OAR.   
A novel technique for treating breast lumpectomy cavities has been developed to improve
target conformity during boost treatments. This technique includes reduced tangents paired with
a dynamic conformal arc (DCA) to deliver a conformal dose to the PTV and reduce prescription
dose to unaffected breast tissue.2 This new technique effectively eliminates large dose areas of
105%, 100%, and 70% of the 1000 cGy prescription dose outside of the PTV and delivers
marked improvements to Radiation Therapy Oncology Group (RTOG) Conformity Index (CI).
However, the main disadvantage of this approach is increased dose to the heart due to exit dose
from the conformal arc.2   
Careful attention must be paid to the heart and ipsilateral lung when planning radiation
treatments to the left breast. Rare but relevant sequelae resulting from late cardiac toxicities
caused by radiotherapy to the breast, especially regarding the left side, has prompted research on
risk structure identification and definition of threshold doses to the heart and its subvolumes. 3
Rates of cardiac death and coronary events are both correlated with mean radiation heart dose.
Breast radiotherapy is shown to reduce the risks of cancer recurrence and death, but there is a
greater risk of heart disease caused by incidental irradiation of the heart. 4 To lower heart dose,
many clinics adopted the deep inspiration breath hold (DIBH) technique for patients with left-
sided breast cancer. This technique allows a larger separation between the heart and chest wall
which minimizes the amount of dose that can reach the heart through tangent fields. Bergom et
al5 reported that patients planned with free breathing (FB) had an increased mean heart dose of
25-67% when compared to those planned utilizing DIBH. For physically able patients, DIBH is
recommended to reduce cardiac risks.  
In addition to heart toxicity, one of the most predominant early and late effects of breast
irradiation is lung toxicity.6,7 An abundance of research has been conducted to determine at what
dose these effects occur and which techniques decrease these risks. Brownlee et al 6 completed an
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analysis of breast cancer management and reported breast patients receiving 3-dimensional (3D)
conformal radiation therapy received a mean lung dose (MLD) of 5.7 Gy, citing secondary
malignancies in the lung as a result of dose received. Radiation pneumonitis (RP) is another risk
related to incidental lung irradiation.7 Gokula et al7 performed a meta-analysis of multiple
databases over a 16-year period with more than 500 female breast cancer patients receiving a
total dose of 50-60 Gy of 3D radiation therapy to the chest wall or intact breast. The incidence of
RP in breast cancer patients using different treatment techniques was evaluated which revealed a
strong association between RP and dose volume histogram (DVH) factors such as total lung
volume irradiated and mean lung dose (MLD).7 The authors concluded that keeping the
ipsilateral lung volume receiving 20 Gy (V20) below 24% and MLD < 15 Gy without
compromising breast coverage decreases RP and suggested the use of other techniques when this
is not achievable.7 With the constantly evolving field of radiation oncology, advancements
including 3D imaging and planning, as well as target delineation and conformal field shaping
have improved the ability to conform to the target and avoid excessive lung dose.  
Modern radiotherapy techniques could increase OAR sparing without sacrificing local
control.5,6 In a retrospective breast boost plan study of 54 patients, Pearson et al 2 discovered the
addition of a DCA to the reduced tangents significantly improved conformity to the lumpectomy
cavity and reduced hotspots in surrounding healthy breast tissue. The problem is that the addition
of a DCA to wedged tangent fields introduced more dose to the heart and ipsilateral lung. This
was due to the exit dose from the DCA. The purpose of the current study was to determine if
modifications to this existing treatment technique would increase conformity to the boost PTV
and reduce dose to the heart and ipsilateral lung. Researchers hypothesized that utilizing DIBH,
FiF, and an extended arc distance between tangents would reduce maximum (H 1) and mean dose
(H2) to the heart, lower the volume of the ipsilateral lung receiving 5 Gy (V 5) (H3), and increase
PTV conformity (H4).  
Methods and Materials  
Patient selection and setup  
Ten patients from a single institution were selected for this retrospective study. All
patients had undergone a lumpectomy procedure and were candidates for external beam radiation
therapy to the left breast. For CT simulation, patients had their upper bodies supported by a
Civco Vac-Lok bag that was placed on an inclined breastboard. A cushioned knee support was
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used in each setup. These treatment devices were used for comfort and to aid in immobilization
and reproducibility of position.  Nine patients had both arms up with their hands holding
handlebars. One patient was positioned with their right arm by their side and left arm up.
Patients' heads were rotated to their right. A gating box was placed on their abdomen to measure
the breath-hold amplitude and evaluate its consistency with Varian’s Real-time Position
Management (RPM) system for the DIBH scans. Each patient had 2.5 mm helical scans on a GE
Discovery CT scanner: 1 FB scan and 1 DIBH scan. The 2 scans were transferred to the
treatment planning system (TPS).   
Contouring  
After CT simulation was complete, patient information was imported to Varian Eclipse
TPS version 13.6 (Varian Medical Systems, Palo Alto, CA). A medical dosimetrist contoured
OAR which included the left and right lungs, heart, spinal cord, and esophagus. The radiation
oncologist contoured the lumpectomy cavity and added a margin to create a PTV. Margins
ranged from 1.25-2.0 cm, and the PTV was cropped from the body contour by 0.2 cm.  
Treatment Planning  
Patients were planned for treatment on a Varian TrueBeam linear accelerator using 6
MV, 10 MV, and 18 MV photons. The prescription dose for the boost plans was 1000 cGy over
5 fractions. Retrospective boost plans were created using tangent gantry angles to minimize dose
through the ipsilateral lung and heart, and a DCA to improve conformity. For every patient, the
DCA extended from the medial tangent angle to the lateral tangent angle (Figure 1). The tangent
fields had multi-leaf collimators (MLCs) shaped around the PTV with a margin of 1.0 cm. The
MLCs in the DCA were shaped to fit the PTV with a 0.75 cm margin. Plans were normalized to
a reference point. Two boost plans were created for each patient: a FB plan and a DIBH plan. All
plans utilized FiF. Plan hot spots were restricted to < 107% of the prescription dose.   
Plan Comparison & Analysis  
For each boost plan, doses to the PTVs and OAR were recorded. The calculations used
for analysis included: averages of maximum and mean doses to the heart, V 5 of the ipsilateral
lung, averages of PTV maximum doses, and the RTOG CI. Conformity of the treatment volume
was calculated using the RTOG CI.   
RTOG CI = Prescription isodose volume / PTV volume  
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The ideal RTOG CI for treatment is 1.0. Values greater than 1.0 have prescription dose beyond
the PTV volume, while values less than 1.0 do not have prescription dose that completely covers
the PTV volume. The p-values were calculated by using a paired t-test for the maximum heart
dose, mean heart dose, ipsilateral lung V5, and the RTOG CI to determine the statistical
significance. Values were considered significant if p < 0.05.  
Results  
Maximum and Mean Heart Dose  
The average maximum heart dose was 195.65 cGy for the FB plans and 163.72 cGy for
the DIBH plans (Table 1). Though the average maximum heart dose was improved with the use
of DIBH FiF over FB FiF, the paired t-test showed that the difference was not statistically
significant (Table 2); therefore, the first null hypothesis (H1 0) failed to be rejected. Similarly, the
mean heart dose for the DIBH plans was lower at 22.21 cGy, while the FB plans had a higher
mean heart dose of 33.27 cGy (Table 1). The resulting p-value of the paired t-test was 0.002
which provided enough evidence to conclude that the heart mean dose using FB is statistically
higher than the heart mean dose using DIBH. Therefore, the second null hypothesis (H2 0) was
rejected (Table 2). 
Ipsilateral Lung V5 Dose  
The mean percentage of ipsilateral V5 dose for the DIBH plans was higher than the mean
percentage of ipsilateral V5 dose using FB, 0.639 and 0.165, respectively (Table 1). The paired t-
test provided insufficient evidence (p=0.994) that the ipsilateral V5 dose was reduced by adding
DIBH with FiF tangents and an extended conformal arc (Table 2). Therefore, the third null
hypothesis (H30) failed to be rejected.  
PTV RTOG CI  
The mean result for the RTOG CI on the FB treatment plans was 1.380, whereas the
mean result for DIBH treatment plans was 1.434 (Table 1). To determine if the RTOG CI would
improve with the DIBH plans compared to the FB plans, a paired t-test was implemented. The
resulting p-value of the paired t-test was 0.841 (Table 2) which was not enough evidence to
support that using DIBH with FiF tangents and DCA would statistically increase PTV CI
compared to the FB plans. Therefore, the fourth null hypothesis (H4 0) failed to be rejected.  
Discussion  
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Sparing healthy tissue while delivering prescription dose to the PTV is imperative.
Pearson et al2 developed a novel boost technique of wedged tangents with the addition of a DCA
which improved conformity to the prescribed volume. However, the researchers reported
increased dose to the heart and ipsilateral lung when compared to wedged tangent-only plans. 2 In
the current study, the authors modified the technique and tested the hypotheses that with the
addition of DIBH, FiF, and an extended arc distance between tangents, OAR sparing and PTV
conformity would improve.  
Researchers in the current study measured differences in heart dose between FB and
DIBH plans. The modified DIBH technique showed a decrease in both mean and maximum heart
dose compared with the FB plan, with the mean heart dose being statistically significant.
Previously, Janowski et al8 discovered the risk of a major cardiac event increased by 7.4% per
Gy of mean heart dose for patients receiving radiotherapy to the breast. Pearson et al 2
demonstrated a notable increase in maximum heart dose due to the exit of the DCA when
compared to the tangents-only plan. Since their technique posed an even greater cardiac risk than
conventional techniques, the decreased mean and maximum heart doses achieved with the
modified technique is a promising improvement for reduction of cardiac toxicities.  
Another OAR considered for breast irradiation is the ipsilateral lung. While the effects of
high dose in the lungs have been a focus of research in radiation therapy treatments, studies of
low dose spillage (V5) of the ipsilateral lung in breast cancer patients are not as prevalent.
However, in lung cancer patients, the V5 has shown to be an important predictor of lymphocyte
nadir and consequently, radiation induced lymphopenia is associated with poor survival. 9 Chen et
al9 studied radiation induced lymphopenia in breast cancer patients and found that the treatment
technique was the most important factor between patients with lymphopenia versus nadir.
Although values for the V5 of the ipsilateral lung were not calculated by Pearson et al, 2
researchers documented an average increase of 46.8 cGy in maximum dose to the ipsilateral lung
when a DCA was added to the tangent fields. The findings of the current study showed an
increase in the ipsilateral lung V5 when using DIBH instead of FB. A major contributor to
ipsilateral lung dose was the exit dose produced by the addition of the DCA. Researchers
hypothesized the modified technique would lower the volume of lung receiving dose; however,
results of final beam weighting between the tangent and DCA beams to maintain PTV
conformity inhibited significant reduction of exit dose into the ipsilateral lung.  
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Since high dose to healthy breast tissue may lead to fibrosis and poor cosmesis, 10 Pearson
et al2 aimed to improve PTV conformity. By implementing a DCA with the tangent fields on
breast patients, Pearson et al2 noted significant improvement in dose conformity with less than
105%, 107%, and 70% isodose outside of the PTV. When measured with the RTOG CI, this
technique improved conformity from 3.67 for the tangent without DCA plans to 1.42 in the
tangents with DCA plans.2 Similarly, researchers in the current study aimed to maintain a RTOG
CI close to 1.0. The FB and DIBH plans had an average RTOG CI within 0.054 of each other
(Table 1) which was similar to the results of the Pearson et al 2 study. The results from the current
study suggest that the respiration technique may not be as important compared to the treatment
plan technique utilized when considering PTV conformity. 
Conclusion  
The addition of DCA to reduced tangents has been shown to significantly improve
conformity to the lumpectomy cavity while minimizing hotspots in surrounding healthy breast
tissue.2 However, the problem is that utilizing a DCA with wedged tangent fields for a FB
photon breast boost delivers more dose to the heart and ipsilateral lung. The purpose of this
retrospective study was to determine if modifications, including DIBH, FiF, and extending the
length of the conformal arc between the tangents could increase conformity to the boost PTV
while simultaneously achieving lower maximum and mean heart doses and lower V 5 to the
ipsilateral lung. By utilizing these modifications, the authors found that the average changes in
maximum heart dose, ipsilateral lung V5, and the RTOG CI were not statistically significant.
Statistical significance was achieved for the DIBH mean heart dose when compared to FB.  
There were limitations of this study such as a small sample size of 10 patients. Metrics of
data collection omitted from this study included cardiac sub-volumes such as left ventricle and
left anterior descending artery. Suggestions for future research would be to include a larger
sample size, potentially across multiple institutions, and include use of 15 MV and evaluation of
specific cardiac structures during planning.   
Acknowledgements  
The authors would like to thank Dr. Sherwin Toribio at the UW-La Crosse Statistical
Consulting Center for his assistance with analysis and interpretation of statistical data; however,
any errors of fact or interpretation remain the sole responsibility of the authors.
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References
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http://doi.org/10.22034/APJCP.2018.19.10.2929
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Figures
 

 
Figure 1. An example of beam arrangements and dose distribution to the PTV. 
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Tables

Table 1.  Mean comparison between free breathing field-in-field (FiF) tangents and dynamic
conformal arc (DCA) plans versus the deep inspiration breath hold (DIBH) FiF tangents and
DCA plans.  
    Free breathing               DIBH  
Maximum heart dose (cGy)    195.65    163.72   
Mean heart dose (cGy)    33.27    22.21   
Ipsilateral lung V5Gy (%)    0.165    0.639   
PTV maximum dose (cGy)    1061.76    1057.49   
RTOG Conformity Index    1.380    1.434  
cGy = centigray; PTV = planning target volume; V5Gy = volume of the ipsilateral lung  
receiving 5 Gy; RTOG = Radiation Therapy Oncology Group 
 
Table 2. Results of the paired t-test applied to the free breathing and deep inspiration breath hold
(DIBH) plans of 10 patients.
Standard Degrees of One-sided Two-sided
   t-test  
deviation   freedom   p   p  
Maximum
72.69   1.389   9   .099   .198  
heart dose  
Mean heart
8.79   3.979   9   .002   .003  
dose  
Ipsilateral
0.43482   -3.447   9   .994   .007  
lung V5Gy  
RTOG
-1.057   .841  
Conformity 0.1639   9   .318  
       
Index  
V5Gy = volume of the ipsilateral lung receiving 5 Gy; RTOG= Radiation Therapy Oncology Group