Six-year Experience Routinely Using Moderate Deep Inspiration Breath-hold for the Reduction of Cardiac Dose in Left-sided Breast Irradiation for Patients With Early-stage or Locally Advanced Breast Cancer

Abstract

Purpose/Objectives Moderate Deep Inspiration Breath-hold (mDIBH), utilizing an Active breathing Control (ABC) device has been used in our clinic since 2002 to reduce cardiac dose for patients receiving left-sided breast irradiation. We report our routine use of the mDIBH technique in clinically localized breast cancer, treated to the intact breast, reconstructed breast, or chest wall. Materials/Methods Ninety-nine patients with left sided breast cancer were evaluated for ABC treatment, of which, 87 patients were treated with mDIBH. Plans for both the free-breathing (FB) and mDIBH CT scans were evaluated. Dose volume histograms (DVHs) were analyzed for the heart and ipsilateral lung, comparing results for mDIBH vs FB plans. Results Eighty-seven patients are included for analysis. Of those, 66% received adjuvant chemotherapy with cardiotoxic agents. The mean dose to the whole breast was 47.6 Gy. There was a statistically significant decrease in all DVH parameters evaluated, favoring the delivery of mDIBH over FB plans. mDIBH plans significantly reduced cardiac mean dose (4.23 Gy vs. 2.54 Gy; p<0.001), a relative reduction of 40%. As well, there were significant reductions in all other heart parameters evaluated (i.e volume of heart treated, V30, V25, V20, V15, V10, and V5). mDIBH also significantly reduced lung dose, including a reduction of the left lung mean dose (9.08 Gy vs. 7.86 Gy; p<0.001), a relative reduction of 13%, as well as significant reduction of all lung DVH parameters evaluated. Conclusions To date, this series represents the largest experience utilizing mDIBH to reduce cardiac irradiation during left-sided breast cancer treatment. Statistically significant reductions in all heart and lung DVH parameters were achieved with mDIBH over FB plans. mDIBH, for the treatment of left sided breast cancer, is a proven technique for reducing cardiac dose that may lead to reduced cardiotoxicity and can be routinely integrated into the clinic.

Monitoring deep inspiration breath hold for left‐sided localized breast cancer radiotherapy with an in‐house developed laser distance meter system

“…2. The results are consistent with what others have presented previously 6, 9, 10. Anzai Medical has just released a system utilizing a distance laser measurer similar to the in‐house system we report clinical data on 26.…”

“…Excluding the heart from the field might compromise the dose to the target, but by means of the deep inspiration breath hold (DIBH) technique it is possible to reduce the cardiopulmonary doses while maintaining the prescribed dose to the breast 6, 7. The method is well established and several groups have previously reported beneficial results using DIBH 6, 8, 9, 10, 11, 12, 13, 14. Since DIBH is capable of decreasing dose to the heart; it is also assumed that the long‐term risk of developing cardiac damage is reduced.…”

Dosimetric effect due to the motion during deep inspiration breath hold for left‐sided breast cancer radiotherapy

“…Since the heart can be displaced medially, inferiorly, and posterior (i.e., away from the left breast) during deep inspiration in most patients, one approach to reduce incidental cardiac irradiation is to treat patients specifically during this portion of the respiratory cycle (e.g., using DIBH). This approach allows one to typically maintain coverage of the target tissues yet markedly reduce the degree of incidental cardiac irradiation 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 …”

Should breathing adapted radiotherapy also be applied for right-sided breast irradiation?

“…A common practice nowadays to reduce the cardiac dose and therefore the risk of cardiac injury is to apply breath-hold techniques for locally and locoregionally irradiated left-sided breast cancer patients [8][9][10][11]. Different methods are used to monitor and control respiratory motion (e.g.…”