Background Adjuvant radiotherapy is the standard treatment after breast-conserving surgery. According to meta-analyses, adjuvant 3d-conventional irradiation reduces the risk of local recurrence and thereby improves long-term survival by 5–10%. However, there is an unintended exposure of organs such as the heart, lungs and contralateral breast. Irradiation of the left breast has been related to long-term effects like increased rates of coronary events as well as second cancer induction. Modern radiotherapy techniques such as tangential intensity modulated radiotherapy (t-IMRT) and tangential volumetric modulated arc therapy (t-VMAT) and particularly deep inspiration breath hold (DIBH) technique have been developed in order to improve coverage of target volume and to reduce dose to normal tissue. The aim of this study was to compare t-IMRT-plans with t-VMAT-plans in DIBH position for left-sided breast irradiation in terms of normal tissue exposure, i.e. of lungs, heart, left anterior descending coronary artery (LADCA), as well as homogeneity (HI) and conformity index (CI) and excess absolute risk (EAR) for second cancer induction for organs at risk (OAR) after irradiation. Methods Twenty patients, diagnosed with left-sided breast cancer and treated with breast-preserving surgery, were included in this planning study. For each patient DIBH-t-IMRT plan using 5 to 7 beams and t-VMAT plan using four rotations were generated to achieve 95% dose coverage to 95% of the volume. Data were evaluated on the basis of dose-volume histograms: Cardiac dose and LADCA (mean and maximum dose, D25% and D45%), dose to ipsilateral and contralateral lung (mean, D20%, D30%), dose to contralateral breast (mean dose), total monitor units, V5% of total body and normal tissue integral dose (NTID). In addition, homogeneity index and conformity index, as well as the excess absolute risk (EAR) to estimate the risk of second malignancy were calculated. Results T-IMRT showed a significant reduction in mean cardiac dose of 26% ( p = 0.002) compared to t-VMAT, as well as a significant reduction in the mean dose to LADCA of 20% ( p = 0.03). Following t-IMRT, mean dose to the left lung was increased by 5% ( p = 0.006), whereas no significant difference was found in the mean dose to the right lung and contralateral breast between the two procedures. Monitor units were 31% ( p = 0.000004) lower for t-IMRT than for t-VMAT. T-IMRT technique significantly reduced normal tissue integral dose (NTID) by 19% ( p = 0.000005) and the V5% of total body by 24% ( p = 0.0007). In contrast, t-VMAT improved CI and HI by 2% ( p = 0.001) and 0.4% ( p = 0.00001), respectively. EAR with t-IMRT was significantly lower, especially for contralateral lung and contralateral breast (2–5/10...

Left-sided breast irradiation is best performed in the DIBH position, since a considerable dose sparing to the heart and LADCA can be achieved by using either IMRT or VMAT techniques. A significant additional decrease in heart and LADCA dose by IMRT in both FB and DIBH irradiation was seen compared with VMAT.

The Occupied Territories of Palestine (OtP) consists of the non-contiguous West Bank including East Jerusalem, and the Gaza Strip. Political and economic tensions and its dense populations compound the impact of drug abuse and addiction in the home. A qualitative study using four focus groups (n = 42) was conducted in West Bank and Gaza Strip explored the experiences of professionals working with Palestinian families and children affected by substance use and addiction in the home. Data were analysed using thematic analysis (TA), and four themes emerged. These were 'The rising and shifting problem of drug use in Palestine'; 'Psychosocial causal factors of drug use in Palestine'; 'The consequences for children and families living with drug use'; and 'Potential solutions to the problem are complex and multi-faceted.' The study paints a concerning picture of how drug abuse impacts on Palestinian families subjected to multiple pressures, stigmas, risks and harms relating to their situation.