Retrospective evaluation of a robust hybrid planning technique established for irradiation of breast cancer patients with included mammary internal lymph nodes

Dose comparison between hybrid volumetric modulated arc therapy, volumetric modulated arc therapy, and three-dimensional conformal radiotherapy for breast/chest wall irradiation, including regional lymph node irradiation using deep inspiration breath-hold technique

PURPOSE

Breast radiation treatment has been linked to complications such as pneumonitis and cardiac toxicity, necessitating dose optimization. This study aims to determine the optimal integration plan of volumetric modulated arc therapy (VMAT) and three-dimensional conformal radiotherapy (3DCRT) in a deep inspiration breath-hold regimen.

MATERIALS AND METHODS

CT imaging data from twenty patients with breast or chest wall cancer, either right or left-sided, and with supraclavicular and internal mammary chain lymph nodes were retrieved. The CT data planned with a hybrid VMAT of three different weighting proportions: 30 % using 3DCRT and 70 % using VMAT, 50 % using 3DCRT and 50 % using VMAT, and 70% using 3DCRT and 30 % using VMAT and compared with full 3DCRT and full VMAT plan (classic and five arc design).

RESULTS

The homogeneity and conformity indices were better in the hybrid VMAT plans than in plans using VMAT or 3DCRT alone (P<0.005). Results of all hybrid VMAT plans showed a considerable drop of volumes receiving more than 4Gy, 8Gy or 16Gy in the ipsilateral lung compared to the full VMAT plan (P<0.001). There was a noticeable decrease in the mean dose to the heart and the dose in 5% of the contralateral breast in the plan using 70 % 3DCRT and 30 % VMAT compared to full VMAT (P<0.001). The plan using 70 % 3DCRT and 30% VMAT achieved a balance between the target and surrounding areas, compared to using only 3DCRT or VMAT.

CONCLUSION

A hybrid plan using 70 % 3DCRT contribution achieved a balanced outcome for breast or chest wall irradiation, considering both planning target volume and organs at risk. Utilizing our VMAT arc design, incorporating one shortened arc can significantly reduce doses to organs at risk further. It is important to consider the patient's anatomy when making this decision.

Interfractional variation in whole-breast VMAT irradiation: a dosimetric study with complementary SGRT and CBCT patient setup

BACKGROUND

The dosimetric effect of setup uncertainty and tissue deformations in left-sided whole-breast irradiation with complementary surface-guided radiotherapy (SGRT) and cone-beam computed tomography (CBCT) setup was evaluated.

METHOD

Treatment courses of 40.05 Gy prescribed dose in 15 fractions were simulated for 29 patients by calculating the dose on deformed CT images, that were based on daily CBCT images, and deforming and accumulating the dose onto the planning CT image. Variability in clinical target volume (CTV) position and shape was assessed as the 95% Hausdorff distance (HD95) between the planning CTV and deformed CTV structures. DVH metrics were evaluated between the planned and simulated cumulative dose distributions using two treatment techniques: tangential volumetric modulated arc therapy (tVMAT) and conventional 3D-conformal radiotherapy (3D-CRT).

RESULTS

Based on the HD95 values, the variations in CTV shape and position were enclosed by the 5 mm CTV-PTV margin in 85% of treatment fractions using complementary CBCT and SGRT setup. A residual error of 8.6 mm was observed between the initial SGRT setup and CBCT setup. The median CTV V95% coverage was 98.1% (range 93.1-99.8%) with tVMAT and 98.2% (range 84.5-99.7%) with 3D-CRT techniques with CBCT setup. With the initial SGRT-only setup, the corresponding coverages were 96.3% (range 92.6-99.4%) and 96.6% (range 84.2-99.4%), respectively. However, a considerable bias in vertical residual error between initial SGRT setup and CBCT setup was observed. Clinically relevant changes between the planned and cumulative doses to organs-at-risk (OARs) were not observed.

CONCLUSIONS

The CTV-to-PTV margin should not be reduced below 5 mm even with daily CBCT setup. Both tVMAT and 3D-CRT techniques were robust in terms of dose coverage to the target and OARs. Based on the shifts between setup methods, CBCT setup is recommended as a complementary method with SGRT.

Hybrid VMAT-3DCRT as breast cancer treatment improvement tool

Radiation therapy is an important tool in the treatment of breast cancer and can play a crucial role in improving patient outcomes. For breast cancer, if the technique has been for a long time the use of 3DCRT, clinicians have seen the management evolve greatly in recent years. Field-in-field and IMRT approaches and more recently dynamic arctherapy are increasingly available. All of these approaches are constantly trying to improve tumour coverage and to preserve organs at risk by minimising the doses delivered to them. If arctherapy allows a considerable reduction of high doses received by healthy tissues, no one can deny that it also leads to an increase of low doses in tissues that would not have received any with other techniques. We propose a hybrid approach combining the robustness of the 3DCRT approach and the high technicality and efficiency of arctherapy. Statistical tests (ANOVA, Wilcoxon, determination coefficient, ROC, etc.) allow us to draw conclusions about the possibility of using the hybrid approach in certain cases (right breast, BMI [Formula: see text], age [Formula: see text], target volume [Formula: see text] cc, etc.). Depending on the breast laterality and patients morphological characteristics, hybridization may prove to be a therapeutic tool of choice in the management of breast cancer in radiotherapy.

Comparative Study of Plan Robustness for Breast Radiotherapy: Volumetric Modulated Arc Therapy Plans with Robust Optimization versus Manual Flash Approach

A previous study investigated robustness of manual flash (MF) and robust optimized (RO) volumetric modulated arc therapy plans for breast radiotherapy based on five patients in 2020 and indicated that the RO was more robust than the MF, although the MF is still current standard practice. The purpose of this study was to compare their plan robustness in terms of dose variation to clinical target volume (CTV) and organs at risk (OARs) based on a larger sample size. This was a retrospective study involving 34 female patients. Their plan robustness was evaluated based on measured volume/dose difference between nominal and worst scenarios (ΔV/ΔD) for each CTV and OARs parameter, with a smaller difference representing greater robustness. Paired sample t-test was used to compare their robustness values. All parameters (except CTV ΔD98%) of the RO approach had smaller ΔV/ΔD values than those of the MF. Also, the RO approach had statistically significantly smaller ΔV/ΔD values (p < 0.001-0.012) for all CTV parameters except the CTV ΔV95% and ΔD98% and heart ΔDmean. This study's results confirm that the RO approach was more robust than the MF in general. Although both techniques were able to generate clinically acceptable plans for breast radiotherapy, the RO could potentially improve workflow efficiency due to its simpler planning process.

An evaluation of isocentre shift magnitude and treatment site on image-guided radiation therapy online decision analysis times

INTRODUCTION

The ability to capture more anatomical detail in cone-beam computed tomography (CBCT) imaging compared to kilovoltage (kV) and megavoltage (MV) imaging, has seen a documented shift towards CBCT image verification and staff adopting more extensive image analysis processes. The timeframe associated with assessing online CBCT images, termed the online decision analysis time, if drawn out, can affect treatment efficiency and accuracy. This study aimed to determine the current CBCT online decision analysis time at Radiation Oncology Princess Alexandra Ipswich Road (ROPAIR) and investigate the influence of isocentre shift magnitude and treatment site considerations on this timeframe.

METHODS

This retrospective clinical audit collected treatment parameters from 202 CBCT images over 2 treatment days. The online decision analysis time was calculated by subtracting the image acquisition timestamp from the image verification shift application timestamp. The quantitative data were analysed using mean, standard deviation, and range in the following categories: all CBCTs, CBCTs grouped by isocentre shift magnitude and CBCTs grouped by treatment site. Content analysis was performed on staff comments made during image analysis.

RESULTS

The average online decision analysis time was 2:37 ± 1:28 min. On average approximately, head and neck, spine and extremity treatment sites measured 1 min, pelvis, breast, and chest measured 2-3 min with abdomen measuring 4 min. Common categories reported in staff comments included anatomical changes, repositioning, and organs at risk size.

CONCLUSION

The results provide baseline online decision analysis times. Further refinement is required to determine if the image match method, treatment site considerations, and rotational discrepancies influence this timeframe.