Abdominal DIBH reduces the cardiac dose even further: a prospective analysis

Abstract

BackgroundDeep inspiration breath hold (DIBH) can be performed using different breathing maneuvers, such as DIBH with a thoracic breathing maneuver (T-DIBH) and DIBH with an abdominal breathing maneuver (A-DIBH). Dosimetric benefits of A-DIBH were investigated in the treatment of left-sided breast cancer radiotherapy (RT) with both 3-Dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) techniques.MethodsTwenty-two patients with left-sided breast cancer were enrolled in this study. 3D-CRT and IMRT plans were generated for each patient with three different CT scans of free breathing (FB), T-DIBH and A-DIBH. There were total of six treatment plans generated for each patient: FB_3D-CRT; TDIBH_3D-CRT; ADIBH_3D-CRT; FB-IMRT; TDIBH-IMRT; ADIBH-IMRT. Doses to the heart, left anterior descending coronary artery (LADCA), and ipsilateral lung were evaluated and compared using the Wilcoxon signed-rank test.ResultsThe mean doses to the heart, LADCA and ipsilateral lung in 3D-CRT plans generated from 3D-CRT with FB, T-DIBH and A-DIBH were (2.89 ± 1.30), (1.67 ± 0.90) and (1.34 ± 0.43) Gy (all P < 0.05), respectively, with FB; (29.08 ± 16.72), (13.94 ± 14.74) and (10.22 ± 10.30) Gy (all P < 0.05), respectively, with T-DIBH; and (7.77 ± 2.71), (7.32 ± 1.42) and (6.90 ± 1.60) Gy (all P < 0.05), respectively, with A-DIBH. The mean doses to the heart, LADCA and ipsilateral lung in IMRT plans were generated from IMRT with FB, T-DIBH and A-DIBH were (1.96 ± 2.25), (1.37 ± 0.44) and (1.18 ± 0.26) Gy (all P < 0.05), respectively, with FB; (16.10 ± 7.45), (8.6 ± 6.60) and (7.35 ± 5.42) Gy (all P < 0.05), respectively, with T-DIBH; and (5.90 ± 2.24), (5.65 ± 1.58) and (5.62 ± 1.05) Gy (all P > 0.05), respectively, with A-DIBH.ConclusionsThis study indicates that both 3D-CRT and IMRT plans with A-DIBH achieved lower cardiac and LADCA doses than plans with FB and T-DIBH; 3D-CRT plans with A-DIBH achieved lower ipsilateral lung doses than plans with FB and T-DIBH; and IMRT plans with A-DIBH had better outcomes than 3D-CRT plans with A-DIBH with respect to the mean dose to the heart, LADCA and ipsilateral lung. IMRT plans with A-DIBH should be incorporated into the daily routine for left-sided breast RT.

Immobilization-assisted abdominal deep inspiration breath-hold in post-mastectomy radiotherapy of left-sided breast cancer with internal mammary chain coverage

“…This study compared the dosimetric results obtained from six treatment plans (FB 3D-CRT , FB IMRT , FB VMAT , aDIBH 3D-CRT , aDIBH IMRT , and aDIBH VMAT ) for left-sided breast cancer patients undergoing IMC-inclusive PMRT. We found that with aDIBH, the doses to the heart and LAD were substantially decreased regardless of the treatment plan (3D-CRT, IMRT, and VMAT), which is consistent with our previous study we first proposed using aDIBH to reduce the cardiac dose further (18).…”

“…Understandably, one study reported significant movement of the lymph node areas due to DIBH, which implies a larger internal target volume (ITV) is needed to compensate for the movement (17). Our previous study found that by reducing the thoracic proportion as much as possible, aDIBH could further decrease the cardiac dose (18) because the significantly lowered heart position keeps it further away from the clinical target volume (CTV).…”

Dosimetry and Feasibility Studies of Volumetric Modulated Arc Therapy With Deep Inspiration Breath-Hold Using Optical Surface Management System for Left-Sided Breast Cancer Patients

“…Regarding the OAR, the heart, all dosimetric parameters (including the mean dose, D2%, V 5 , and V 10 ) showed a better performance with DIBH-VMAT than with FB-VMAT, similar to a previous study ( 32 , 33 ). As early as 2005, Korreman et al ( 34 ) published a result about nine left-sided breast cancer patients with RT, showing that DIBH substantially reduced the doses to the heart and lung.…”

The dosimetric benefit of in‐advance respiratory training for deep inspiration breath holding is realized during daily treatment in left breast radiotherapy: A comparative retrospective study of serial surface motion tracking

“…9,[14][15][16] While it has been recognized that a learning curve exists for patients to acquire the complex physical and cognitive skills to perform DIBH manoeuvres well, 17 only very few studies have explored alternative preparatorytraining approaches to boost patients' DIBH performance and tolerance. 13,[18][19][20][21] Logistically the timing of respiratory training can be expanded farther into the pre-radiation therapy phase, enabling earlier, preparatory and thereby more intensified DIBH training regimens that provide longer time for patients to practice and improve their DIBH skills. Results of these very few studies show promise that a strategy of early preparatory DIBH training and practice, implemented well in advance of the first DIBH performance at the simulation procedure, can measurably decrease procedure time spent in CT simulation, 13 lengthen the sustained DIBH 19,20 and broaden the range of breath-hold manoeuvres performed.…”

“…Results of these very few studies show promise that a strategy of early preparatory DIBH training and practice, implemented well in advance of the first DIBH performance at the simulation procedure, can measurably decrease procedure time spent in CT simulation, 13 lengthen the sustained DIBH 19,20 and broaden the range of breath-hold manoeuvres performed. 21 Among these investigations, our previous comparison study was the first to demonstrate that cardiac dose can be further reduced by in-advance preparatory DIBH training and practice. 18 Patients who received preparatory DIBH coaching, training and home practice for 1-2 weeks before the CT simulation, had significantly lower cardiac dose (max dose: 13.1 vs. 19.5 Gy, P = 0.004) than those with conventional immediate pre-procedure instruction, based on dosimetry from CT simulation imaging.…”