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. 2023 Apr;199(4):389-395.
doi: 10.1007/s00066-023-02047-z. Epub 2023 Feb 24.

Low doses to the heart in daily practice for treating left-sided breast cancer using accelerated partial-breast irradiation by multicatheter brachytherapy and deep-inspiration breath-hold using a SIB

Stefan Knippen  1   2 , Sven Schönherr  3 , Michael Schwedas  3 , Tobias Teichmann  3 , Simon Howitz  3   4 , Matthias Mäurer  3 , Andrea Wittig-Sauerwein  3 , Marciana-Nona Duma  3   5   6
Affiliations

Low doses to the heart in daily practice for treating left-sided breast cancer using accelerated partial-breast irradiation by multicatheter brachytherapy and deep-inspiration breath-hold using a SIB

Stefan Knippen et al. Strahlenther Onkol. 2023 Apr.

Abstract

Purpose: The aim of this study was to analyze the heart dose for left-sided breast cancer that can be achieved during daily practice in patients treated with multicatheter brachytherapy (MCBT) accelerated partial-breast irradiation (APBI) and deep-inspiration breath-hold (DIBH) whole-breast irradiation (WBI) using a simultaneous integrated tumor bed boost (SIB)-two different concepts which nonetheless share some patient overlap.

Materials and methods: We analyzed the nominal average dose (Dmean) to the heart as well as the biologically effective dose (BED) and the equivalent dose in 2‑Gy fractions (EQD2) for an α/β of 3 in 30 MCBT-APBI patients and 22 patients treated with DIBH plus SIB. For further dosimetric comparison, we contoured the breast planning target volume (PTV) in each of the brachytherapy planning CTs according to the ESTRO guidelines and computed tangential field plans. Mean dose (Dmean), EQD2 Dmean, and BED Dmean for three dosing schemes were calculated: 50 Gy/25 fractions and two hypofractionated regimens, i.e., 40.05 Gy/15 fractions and 26 Gy/5 fractions. Furthermore, we calculated tangential field plans without a boost for the 22 cases treated with SIB with the standard dosing scheme of 40.05 Gy/15 fractions.

Results: MCBT and DIBH radiation therapy both show low-dose exposure of the heart. As expected, hypofractionation leads to sparing of the heart dose. Although MCBT plans were not optimized regarding dose to the heart, Dmean differed significantly between MCBT and DIBH (1.28 Gy vs. 1.91 Gy, p < 0.001) in favor of MCBT, even if the Dmean in each group was very low. In MCBT radiation, the PTV-heart distance is significantly associated with the dose to the heart (p < 0.001), but it is not in DIBH radiotherapy using SIB.

Conclusion: In daily practice, both DIBH radiation therapy as well as MCBT show a very low heart exposure and may thus reduce long term cardiac morbidity as compared to currently available long-term clinical data of patients treated with conventional tangential field plans in free breathing. Our analysis confirms particularly good cardiac sparing with MCBT-APBI, so that this technique should be offered to patients with left-sided breast cancer if the tumor-associated eligibility criteria are fulfilled.

Keywords: APBI; Brachytherapy; Breast cancer; DIBH; Heart; SIB; Simultaneous integrated boost.

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Conflict of interest statement

S. Knippen, S. Schönherr, M. Schwedas, T. Teichmann, S. Howitz, M. Mäurer, A. Wittig-Sauerwein, and M.-N. Duma declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Tangential field treatment plan in a brachytherapy planning CT: 1 demarks the brachytherapy PTV (red); 2 the mammary gland; 3 the EBRT PTV, the red arrow shows the air within a brachytherapy single leader catheter; 4 the measure of the PTV–heart distance (white arrows) for WB
Fig. 2
Fig. 2
Heart EQD2 Dmean in MCBT and DIBH SIB
Fig. 3
Fig. 3
Scatterplot heart distance in mm/heart, Dmean MCBT
See this image and copyright information in PMC

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