Assessment of planning reproducibility in three-dimensional field-in-field radiotherapy technique for breast cancer: impact of surgery-simulation interval

Abstract

The three-dimensional field-in-field (3-D FIF) technique for radiotherapy is an advanced, state-of-the-art method that uses multileaf collimators to generate a homogeneous and conformal dose distribution via segmental subfields. The purpose of this study is to evaluate the dosimetric reproducibility of 3-D FIF plans using the original simulation computed tomography (iCT) scans and re-simulation CT (rCT) scans for whole breast irradiation (WBI) schedule. This study enrolled a total of 34 patients. The study population underwent iCT scans for standard WBI and took rCT scans after 45 Gy of WBI for cone down boost plans. The dosimetric parameters (V_105%, V_103%, V_100%, V_98%, V_95%, V_90%, V_50%), plan quality indices (conformity index, homogeneity index) and clinical parameters (isocenter-breast axis, isocenter-lung axis, soft tissue volumes within radiation field, lung volumes within radiation field) were assessed. The median time interval from surgery to iCT was 33 days and from iCT to rCT was 35 days. All dosimetric parameters exhibited statistically significant differences between iCT and rCT among cohorts with a surgery-iCT interval of < 60 days. Homogeneity index showed a statistically significant increase from iCT to rCT among all cohorts. Soft tissue volumes (p = 0.001) and isocenter-breast axis (p = 0.032) exhibited statistically significant differences among cohorts with surgery-iCT interval < 60 days. Regarding the reproducibility of the 3-D FIF WBI plans, significant changes were observed in dosimetric and clinical factors, particularly in study cohorts with a surgery-simulation interval < 60 days. The main contributing factor of these transitions seemed to be the changes in volume of the soft tissue within the WBI field. Further confirmative studies are necessary to determine the most suitable timing and technique for WBI.

Figure 1

Representative illustration cases. A-1: 103% isodose lines at iCT in patient 1 (axial image), A-2: 103% isodose lines at rCT in patient 1 (axial image), A-3: 103% isodose lines at iCT in patient 1 (coronal image), A-4: 103% isodose lines at rCT in patient 1 (coronal image), A-5: 103% isodose lines at rCT in patient 1 (sagittal image), A-6: 103% isodose lines at rCT in patient 1 (sagittal image), B-1: 95% isodose lines at iCT in patient 2 (axial image), B-2: 95% isodose lines at rCT in patient 2 (axial image), B-3: 95% isodose lines at iCT in patient 2 (coronal image), B-4: 95% isodose lines at rCT in patient 2 (coronal image), B-5: 95% isodose lines at iCT in patient 2 (sagittal image), B-6: 95% isodose lines at rCT in patient 2 (sagittal image).

Figure 2

Autocontoured structures in the thorax (produced by Mirada RTx 1.8 and Workflow Box 1.4, Mirada Medical Ltd., Oxford, UK, https://mirada-medical.com/radiation-oncology/) and 3-dimensional rendered images (produced by ECLIPSE™, version 10; Varian Medical Systems, Palo Alto, CA, USA, https://www.varian.com/products/radiosurgery/treatment-planning/eclipse). A: Autocontoured structures in the thorax area, B: 3-dimensional rendered images.

Figure 3

Measurement of clinical and dosimetric parameters. A: Isocenter–Breast axis, B: Isocenter–Lung axis, C: V_103%, D: V_100%, E: V_98%, F: V_95%, G: V_90%, H: V_50% (pink color) and lung (within RT field) volume (white color), I: Soft tissue (within RT field) volume.