Spot-scanning proton therapy for early breast cancer in free breathing versus deep inspiration breath-hold

Authors

  • Line Bjerregaard Stick Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
  • Louise Lærke Nielsen The Education of Radiography, University College Lillebælt, Svendborg, Denmark
  • Cecilia Bui Trinh The Education of Radiography, University College Lillebælt, Svendborg, Denmark
  • Ihsan Bahij Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
  • Maria Fuglsang Jensen Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
  • Camilla Jensenius Skovhus Kronborg Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
  • Stine Elleberg Petersen Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
  • Linh My Hoang Thai Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
  • May-Lin Martinsen The Education of Radiography, University College Lillebælt, Svendborg, Denmark
  • Helle Precht Health Sciences Research Center, University College Lillebælt, Svendborg, Denmark; Institute of Regional Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Radiology, Lillebælt University Hospital of Southern Denmark, Kolding, Denmark
  • Birgitte Vrou Offersen Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark; Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark

DOI:

https://doi.org/10.2340/1651-226X.2024.28591

Keywords:

Breast cancer, proton therapy, deep inspiration breath-hold, comparative treatment planning, heart dose

Abstract

Background and purpose: Proton therapy for breast cancer is usually given in free breathing (FB). With the use of deep inspiration breath-hold (DIBH) technique, the location of the heart is displaced inferiorly, away from the internal mammary nodes and, thus, the dose to the heart can potentially be reduced. The aim of this study was to explore the potential benefit of proton therapy in DIBH compared to FB for highly selected patients to reduce exposure of the heart and other organs at risk. We aimed at creating proton plans with delivery times feasible with treatment in DIBH.

Material and methods: Sixteen patients with left-sided breast cancer receiving loco-regional proton therapy were included. The FB and DIBH plans were created for each patient using spot-scanning proton therapy with 2–3 fields, robust and single field optimization. For the DIBH plans, minimum monitor unit per spot and spot spacing were increased to reduce treatment delivery time.

Results: All plans complied with target coverage constraints. The median mean heart dose was statistically significant reduced from 1.1 to 0.6 Gy relative biological effectiveness (RBE) by applying DIBH. No statistical significant difference was seen for mean dose and V17Gy RBE to the ipsilateral lung. The median treatment delivery time for the DIBH plans was reduced by 27% compared to the FB plans without compromising the plan quality.

Interpretation: The median absolute reduction in dose to the heart was limited. Proton treatment in DIBH may only be relevant for a subset of these patients with the largest reduction in heart exposure.

Downloads

Download data is not yet available.

References

Taylor C, Dodwell D, McGale P, et al. Radiotherapy to regional nodes in early breast cancer: an individual patient data meta-analysis of 14 324 women in 16 trials. Lancet. 2023 Nov;402(10416):1991–2003.

Thorsen LBJ, Overgaard J, Matthiessen LW, et al. Internal mammary node irradiation in patients with node-positive early breast cancer: fifteen-year results from the Danish Breast Cancer Group Internal Mammary Node Study. J Clin Oncol. 2022;40(36):4198–207. https://doi.org/10.1200/JCO.22.00044 DOI: https://doi.org/10.1200/JCO.22.00044

Poortmans PM, Weltens C, Fortpied C, et al. Internal mammary and medial supraclavicular lymph node chain irradiation in stage I–III breast cancer (EORTC 22922/10925): 15-year results of a randomised, phase 3 trial. Lancet Oncol. 2020 Dec;21(12):1602–10. https://doi.org/10.1016/S1470-2045(20)30472-1 DOI: https://doi.org/10.1016/S1470-2045(20)30472-1

Whelan TJ, Olivotto IA, Parulekar WR, et al. Regional nodal irradiation in early-stage breast cancer. N Engl J Med. 2015;373(4):307–16. https://doi.org/10.1056/NEJMoa1415340 DOI: https://doi.org/10.1056/NEJMoa1415340

Darby SC, 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. https://doi.org/10.1056/NEJMoa1209825 DOI: https://doi.org/10.1056/NEJMoa1209825

Van Den Bogaard VAB, Ta BDP, Van Der Schaaf A, et al. Validation and modification of a prediction model for acute cardiac events in patients with breast cancer treated with radiotherapy based on three-dimensional dose distributions to cardiac substructures. J Clin Oncol. 2017;35(11):1171–8. https://doi.org/10.1200/JCO.2016.69.8480 DOI: https://doi.org/10.1200/JCO.2016.69.8480

Lorenzen EL, Rehammar JC, Jensen M-B, Ewertz M, Brink C. Radiation-induced risk of ischemic heart disease following breast cancer radiotherapy in Denmark, 1977–2005. Radiother Oncol. 2020 Nov;152:103–10. https://doi.org/10.1016/j.radonc.2020.08.007 DOI: https://doi.org/10.1016/j.radonc.2020.08.007

Milo MLH, Thorsen LBJ, Johnsen SP, et al. Risk of coronary artery disease after adjuvant radiotherapy in 29,662 early breast cancer patients: a population-based Danish Breast Cancer Group study. Radiother Oncol. 2021 Apr;157:106–13. https://doi.org/10.1016/j.radonc.2021.01.010 DOI: https://doi.org/10.1016/j.radonc.2021.01.010

Grantzau T, Thomsen MS, Væth M, Overgaard J. Risk of second primary lung cancer in women after radiotherapy for breast cancer. Radiother Oncol. 2014;111(3):366–73. https://doi.org/10.1016/j.radonc.2014.05.004 DOI: https://doi.org/10.1016/j.radonc.2014.05.004

Taylor C, Duane FK, Dodwell D, et al. Estimating the risks of breast cancer radiotherapy: evidence from modern radiation doses to the lungs and heart and from previous randomized trials. J Clin Oncol. 2017;35(15):1641–9. https://doi.org/10.1200/JCO.2016.72.0722 DOI: https://doi.org/10.1200/JCO.2016.72.0722

Ranger A, Dunlop A, Hutchinson K, et al. A dosimetric comparison of breast radiotherapy techniques to treat locoregional lymph nodes including the internal mammary chain. Clin Oncol. 2018;30(6):346–53. https://doi.org/10.1016/j.clon.2018.01.017 DOI: https://doi.org/10.1016/j.clon.2018.01.017

Patel SA, Lu HM, Nyamwanda JA, et al. Postmastectomy radiation therapy technique and cardiopulmonary sparing: a dosimetric comparative analysis between photons and protons with free breathing versus deep inspiration breath hold. Pract Radiat Oncol. 2017;7(6):e377–84. https://doi.org/10.1016/j.prro.2017.06.006 DOI: https://doi.org/10.1016/j.prro.2017.06.006

Stick LB, Yu J, Maraldo MV, et al. Joint estimation of cardiac toxicity and recurrence risks after comprehensive nodal photon versus proton therapy for breast cancer. Int J Radiat Oncol Biol Phys. 2017;97(4):754–61. https://doi.org/10.1016/j.ijrobp.2016.12.008 DOI: https://doi.org/10.1016/j.ijrobp.2016.12.008

Mutter RW, Choi JI, Jimenez RB, et al. Proton therapy for breast cancer: a consensus statement from the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol. 2021 Oct;111(2):337–59. https://doi.org/10.1016/j.ijrobp.2021.05.110 DOI: https://doi.org/10.1016/j.ijrobp.2021.05.110

Fuglsang Jensen M, Stick LB, Høyer M, et al. Proton therapy for early breast cancer patients in the DBCG proton trial: planning, adaptation, and clinical experience from the first 43 patients. Acta Oncol. 2022 Feb;61(2):223–30. https://doi.org/10.1080/0284186X.2021.1986229 DOI: https://doi.org/10.1080/0284186X.2021.1986229

Stick LB, Lorenzen EL, Yates ES, et al. Selection criteria for early breast cancer patients in the DBCG proton trial – the randomised phase III trial strategy. Clin Transl Radiat Oncol. 2021 Mar;27:126–31. https://doi.org/10.1016/j.ctro.2021.01.012 DOI: https://doi.org/10.1016/j.ctro.2021.01.012

Offersen BV, Boersma LJ, Kirkove C, et al. ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage breast cancer. Radiother Oncol. 2015;114(1):3–10. https://doi.org/10.1016/j.radonc.2014.11.030 DOI: https://doi.org/10.1016/j.radonc.2014.11.030

Milo MLH, Offersen BV, Bechmann T, et al. Delineation of whole heart and substructures in thoracic radiation therapy: national guidelines and contouring atlas by the Danish Multidisciplinary Cancer Groups. Radiother Oncol. 2020;150:121–7. https://doi.org/10.1016/j.radonc.2020.06.015 DOI: https://doi.org/10.1016/j.radonc.2020.06.015

Danish Breast Cancer Group (DBCG). Postoperativ strålebehandling af brystkræft [Internet]. 2023. Available from: https://www.dmcg.dk/siteassets/kliniske-retningslinjer---skabeloner-og-vejledninger/kliniske-retningslinjer-opdelt-pa-dmcg/dbcg/dbcg_postop_stralebh_brystkraft_v.3.0_admgodk_10032023.pdf [cited 23 november 2023]

Poulsen PR, Nyström H, Skyt PS, Jensen MF. PH-0241: a simulator of proton pencil beam scanning delivery. Radiother Oncol. 2020 Nov;152:S124–5. https://doi.org/10.1016/S0167-8140(21)00265-6 DOI: https://doi.org/10.1016/S0167-8140(21)00265-6

Nielsen AWM, Spejlborg H, Lutz CM, Rugaard Poulsen P, Offersen BV. Difference between planned and delivered radiotherapy dose to the internal mammary nodes in high-risk breast cancer patients. Phys Imaging Radiat Oncol. 2023 Jul;27:100470. https://doi.org/10.1016/j.phro.2023.100470 DOI: https://doi.org/10.1016/j.phro.2023.100470

Li H, Dong L, Bert C, et al. AAPM Task Group Report 290: respiratory motion management for particle therapy. Med Phys. 2022 Apr;49(4):e50–81. https://doi.org/10.1002/mp.15470 DOI: https://doi.org/10.1002/mp.15470

Klaassen L, Petoukhova AL, Habraken SJM, et al. Effect of breathing motion on robustness of proton therapy plans for left-sided breast cancer patients with indication for locoregional irradiation. Acta Oncol. 2021;60(2):222–8. https://doi.org/10.1080/0284186X.2020.1825800 DOI: https://doi.org/10.1080/0284186X.2020.1825800

Stick LB, Jensen MF, Kronborg CJS, et al. PD-0231 impact of respiratory motion for breast cancer proton therapy in free breathing. Radiother Oncol. 2022 May;170:S191–2. https://doi.org/10.1016/S0167-8140(22)02786-4 DOI: https://doi.org/10.1016/S0167-8140(22)02786-4

Downloads

Additional Files

Published

2024-02-26

How to Cite

Stick, L. B., Nielsen, L. L., Trinh, C. B., Bahij, I., Jensen, M. F., Kronborg, C. J. S., … Offersen, B. V. (2024). Spot-scanning proton therapy for early breast cancer in free breathing versus deep inspiration breath-hold. Acta Oncologica, 63(1), 56–61. https://doi.org/10.2340/1651-226X.2024.28591

Issue

Vol. 63 (2024): Acta Oncologica

Section

Short report

Categories

License

Copyright (c) 2024 Line Bjerregaard Stick, Louise Lærke Nielsen, Cecilia Bui Trinh, Ihsan Bahij, Maria Fuglsang Jensen, Camilla Jensenius Skovhus Kronborg, Stine Elleberg Petersen, Linh My Hoang Thai, May-Lin Martinsen, Helle Precht, Birgitte Vrou Offersen

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.