CC BY-NC-ND 4.0 · Senologie - Zeitschrift für Mammadiagnostik und -therapie 2020; 17(01): 14-23
DOI: 10.1055/a-0849-0524
Scientific Discussion/Wissenschaftliche Arbeit

5 years of experience with DIBH (Deep inspiration breath-hold) combined with SGRT (Surface-Guided Radiation Therapy) in left-sided breast cancer

Artikel in mehreren Sprachen: English | deutsch
Claudia Steffal
Institut für Radioonkologie, Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef-Spital und Geriatriezentrum Favoriten, Vienna, Austria
,
Annemarie U. Schratter-Sehn
Institut für Radioonkologie, Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef-Spital und Geriatriezentrum Favoriten, Vienna, Austria
,
Karin Brinda-Raitmayr
Institut für Radioonkologie, Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef-Spital und Geriatriezentrum Favoriten, Vienna, Austria
,
Thomas Kann
Institut für Radioonkologie, Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef-Spital und Geriatriezentrum Favoriten, Vienna, Austria
,
Daniela Mailat
Institut für Radioonkologie, Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef-Spital und Geriatriezentrum Favoriten, Vienna, Austria
,
Jochen Reiterer
Institut für Radioonkologie, Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef-Spital und Geriatriezentrum Favoriten, Vienna, Austria
,
Günther Tremmel
Institut für Radioonkologie, Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef-Spital und Geriatriezentrum Favoriten, Vienna, Austria
› Institutsangaben

Abstract

Background Radiation treatment to the left breast is associated with increased cardiac morbidity as well as mortality. Deep inspiration breath-hold (DIBH) technique with Surface Guided Radiation Therapy (SGRT) could have dosimetric advantages over the free breathing technique (NB, normal breathing) in cardiac (heart and LAD) and ipsilateral lung sparing in patients with left-sided breast cancer after surgery. Therefore this technique was implemented in 2013 at the institute of radiooncology at the KFJ/SMZ-South – Hospital Vienna.

Methods From Oct 2013 – December 2018 548 patients were referred to radiotherapy following conservative operation of left-sided invasive breast cancer. All patients gave their informed consent and underwent training sessions for the DIBH-technique independent of age or breathing activity or respiratory disorders. Patients who turned out to be unfit for DIBH were enrolled for NB. The relative reduction in Dmean heart and left lung dose was compared between the two cohorts. Acute radiation induced side effects were classified according to the Radiation Therapy Oncology Group/The European Organisation for Research (RTOG) [37]; late toxicity rates according to the Common Terminology Criteria for Adverse Events (CTCAE Version 4.03)

Results The median age of the DIBH-patients was 58 years (27–90), of the NB-patients 65 (30–80) years. Follow-up was obtained until June 2019. The median follow-up was 52 months (range 7–73 m). The average coverage of Dmean left lung was 6.91 Gy (1.44 Gy – 12.4 Gy). The average coverage of Dmean heart was 1.17 Gy (0.12 Gy – 3.19 Gy) in the DIBH-cohort. The NB – plans had a Dmean of 8.92 Gy (5.23–16.9 Gy) at the ipsilateral lung and a Dmean of 2.31 Gy (0.71–4.21 Gy) at the heart. This shows that the DIBH-technique halved the Dmean of the heart. The amount of acute side effects was comparable between the two groups: RTOG 1: 70.8 % vs. 64 %, RTOG 3 6.6 % vs. 5.6 %, no reaction 3.2 % vs. 1.4 %. There were more CTCAE 1-late events in the NB-group (51.6 % vs. 12.67 %).

Conclusion Deep inspiration breath-hold (DIBH) technique with Surface Guided Radiation Therapy (SGRT) is a rather simple, reproducable method with a high acceptance of the patients who can actively participate in the whole treatment process. The mean dose at the heart and the left lung can be reduced, at the heart even by as much as 50 %.



Publikationsverlauf

Artikel online veröffentlicht:
09. März 2020

© .

© Georg Thieme Verlag KG
Stuttgart · New York

 
  • References

  • 1 Corradini S, Ballhausen H, Weingandt H. et al Left-sided breast cancer and risks of secondary lung cancer and ischemic heart disease. Strahlenther Onkol 2018; 194: 196-205
  • 2 Conway JL, Conroy L, Harper L. et al Deep inspiration breath-hold produces a clinically meaningful reduction in ipsilateral lung dose during locoregional radiation therapy for some women with right-sided breast cancer. Pract Radiat Oncol 2017; 7: 147-153
  • 3 Darapu A, Balakrishnan R, Sebastian P. et al Is the Deep Inspiration Breath-Hold Technique Superior to the Free Breathing Technique in Cardiac and Lung Sparing while treating both Left-Sided Post-Mastectomy Chest Wall and Supraclavicular Regions. Case rep Oncol 2017; 10: 37-51
  • 4 Lawler G, Leech M. Dose Sparing Potential of Deep Inspiration Breath-hold Technique for Left Breast Cancer Radiotherapy Organs-at-risk. Anticancer Res 2017; 37: 883-890
  • 5 Jensen CA, Skottner N, Frengen J. et al Development of a deep inspiration breath-hold system for radiotherapy utilizing a laser distance measurer. J Appl Clin Med Phys 2017; 18: 260-264
  • 6 Koivumäki T, Tujunen J, Virén T. et al Geometrical uncertainty of heart position in deep-inspiration breath hold radiotherapy of left-sided breast cancer patients. Acta Oncol 2017; 56: 879-883
  • 7 Rice L, Goldsmith C, Grenne MMI. et al An effective deep-inspiration breath-hold radiotherapy technique for left-breast cancer: impact of post-mastectomy treatment, nodal coverage, and dose schedule on organs at risk. Breast Cancer 2017; 9: 437-446
  • 8 Sakka M, Kunzelmann L, Metzger M. et al Cardiac dose-sparing effects of deep-inspiration breath-hold in left breast irradiation. Strahlenther Onkol 2017; 193: 800-811
  • 9 Hepp R, Ammerpohl M, Morgenstern C. et al Deep inspiration breath-hold (DIBH) radiotherapy in left-sided breast cancer. Strahlenther Onkol 2015; 191: 710-716
  • 10 Latty D, Stuart KE, Wang W. et al Review of deep inspiration breath-hold techniques for the treatment of breast cancer. J Med Radiat Sci 2015; 62: 74-81
  • 11 Rice L, Harris S, Green MML. et al Deep inspiration breath-hold (DIBH) technique applied in right breast radiotherapy to minimize liver radiation. BJR case reports 2015; 1: 20150038
  • 12 Whelan TJ, Olivotto IA, Parulekar WR. et al Regional nodal irradiation in early-stage breast cancer. N Engl J Med 2015; 373: 307-316
  • 13 Thorsen LBJ, Berg M, Brodersen HJ. et al Improved survival with internal mammary node irradiation: a prospective study on 3072 breast cancer patients. Radiother Oncol 2014; 111: 67-68
  • 14 Bruzzaniti V, Abate A, Pinnarò P. et al Dosimetric and clinical advantages of deep inspiration breath-Hold (DIBH) during radiotherapy of breast cancer. J Exp Clin Cancer Res 2013; 32: 88
  • 15 Nissen HD, Appelt AL. Improved heart, lung and target dose with deep inspiration breath hold in a large clinical series of breast cancer patients. Radiother Oncol 2013; 106: 28-32
  • 16 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: 987-998
  • 17 Haviland JS, Owen JR, Dewar JA. et al The UK Standardisation of Breast, Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-yearfollow-up results of two randomised controlled trials. Lancet Oncol 2013; 14: 1086-1094
  • 18 Bouillon K, Haddy N, Delaloge S. et al Long-term cardiovascular mortality after radiotherapy for breast cancer. J Am Coll Cardiol 2011; 57: 445-452
  • 19 Whelan TJ, Pignol JP, Levine MN. et al Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med 2010; 362: 513-520
  • 20 Stranzl H, Zurl B. Postoperative irradiation of left-sided breast cancer patients and cardiac toxicity. Dose deep inspiration breath-hold (DIBH) technique protect the heart?. Strahlenth Onkol 2008; 184: 354-358
  • 21 Taylor CW, Nisbet A, McGale P. et al Cardiac exposures in breast cancer radiotherapy 1950s-1990s. IJRBP 2007; 69: 1484-1495
  • 22 Correa CR, Litt HI, Hwang WT. et al Coronary artery findings after left-sided compared with right-sided radiation treatment for early stage breast cancer. JCO 2007; 25: 3031-3037
  • 23 Clarke M, Collins R, Darby S. et al Early Breast cancer Trialists’ Collabortaive Group (EBCTCG): Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomized trials. Lancet 2005; 366: 2087-2106
  • 24 Rutqvist LE, Johansson H. Mortality by laterality of the primary tumour among 55000 breast cancer patients from the Swedish Cancer Registry. Br J Cancer 1990; 61: 866-868
  • 25 Schratter-Sehn AU, Schurawitzki H, Zach M. et al High-resolution computed tomography of the lungs in irradiated breast cancer patients. RadiotherOncol 1993; 27: 198-202
  • 26 https://www.varian.com/de/products/radiotherapy/real-time-tracking-motion-management/real-time-position-management
  • 27 C-RAD. Catalyst HD. Im Internet (Stand: 19.12.2019): https://c-rad.se/product/catalyst-hd
  • 28 http://embed.widencdn.net/pdf/view/varian/02uaz1vhfj/PerfectPitch6DOF_ProductBrief_10264B_1013.pdf?u=wefire
  • 29 START Trialists’ Group. et al The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet 2018; 371: 1098-1107
  • 30 Doyen J, Giraud P, Belkacemi Y. Normal tissue tolerance to external beam radiation therapy: cardiac structures. Cancer Radiother 2010; 14: 319-326
  • 31 Thill M, Liedtke C, Müller V. et al AGO Recommendations for the Diagnosis and Treatment of Patients with Advanced and Metastatic Breast Cancer: Update 2018. Breast Care (Basel) 2018; 13: 209-215 . doi:10.1159/000489331
  • 32 AWMF. S3-Leitlinie Früherkennung, Diagnostik, Therapie und Nachsorge des Mammakarzinoms (Version 4.1, 20189). Im Internet (Stand: 19.12.2019): https://www.awmf.org/leitlinien/detail/ll/032-045OL.html
  • 33 White J, Tai A, Arthur D. Breast Cancer Atlas for Radiation Therapy Planning: Consensus Definitions RTOG (Radiation Therapy Oncology Group). www.rtog.org/CoreLab/ContouringAtlases
  • 34 Darby S, McGael P, Correa C. et al Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis qof individual patient data for 10801 women in 17 randomised trials. Lancet 2011; 378: 1707-1716
  • 35 Bentzen SM, Agrawal RK, Aird EGA. et al The UK Standardisation of Breast Radiotherapy (START) trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet 2008; 371: 1098-1107
  • 36 Bentzen SM, Agrawal RK, Aird EGA. et al The UK Standardisation of Breast Radiotherapy (START) trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet Oncol 2008; 9: 331-341
  • 37 Lopez E, Núnez MI, Guerrero MR. et al Breast Cancer Acute Radiotherapy Morbidity Evaluated by Different Scoring Systems. Breast Cancer Res Treat 2002; 73: 127-134
  • 38 Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. Published: May 28, 2009 (v4.03: June 14, 2010). Im Internet (Stand: 19.12.2019): https://www.eortc.be/services/doc/ctc/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf
  • 39 Yeung R, Conroy L, Long K. et al Cardiac dose reduction with deep inspiration breath hold for left-sided breast cancer radiotherapy patients with and without regional nodal irradiation. Radiol Oncol 2015; 10: 200 . doi:10.1186/s13014-015-0511-8
  • 40 Mamounas EP, Bandos H, White JR. et al NRG Oncology/NSABP B-51/RTOG 1304: Phase III trial to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to whole breast RT post breast-conserving surgery (BCS) reduces invasive breast cancer recurrence-free interval (IBCR-FI) in patients (pts) with pathologically positive axillary (PPAx) nodes who are ypN0 after neoadjuvant chemotherapy (NC). JCO.2019.37.15_suppl.TPS600
  • 41 Hayden AJ, Rains M, Tiver K. Deep inspiration breath hold technique reduces heart dose from radiotherapy for left-sided breast cancer with deep breath-holding. J Med Imaging Radiat Oncol 2012; 56: 464-472
  • 42 Bergom C, Currey A, Desai N. et al Deep Inspiration Breath Hold: Techniques and Advantages for Cardiac Sparing During Breast Cancer Irradiation. Front Oncol 2018; 8: 87 . doi:10.3389/fonc.2018.00087
  • 43 Bradley JA, Dagan R, Ho MW. et al Initial report of a prospective dosimetric and clinical feasibility trial demonstrates the potential of protons to increase the therapeutic ratio in breast cancer compared with photons. Int J Radiat Oncol Biol Phys 2016; 95: 411-421
  • 44 Lin LL, Vennarini S, Dimofte A. et al Proton beam versus photon beam dose to the heart and left anterior descending artery for left-sided breast cancer. Acta Oncol 2015; 54: 1032-1039
  • 45 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: e377-e384
  • 46 MacDonald SM. Proton therapy for breast cancer: getting to the heart of the matter. Int J Radiat Oncol Biol Phys 2016; 95: 46-48
  • 47 Tanguturi SK, Lyatskaya y, Chen Y. et al Prospective assessment of deep inspiration breath-hold using 3-dimensional surface tracking for irradiation of left-sided breast cancer. Pract Radiat Oncol 2015; 5: 358-365
  • 48 Henson KE, McGale P, Taylor C. et al Radiation-related mortality from heart disease and lung cancer more than 20 years after radiotherapy for breast cancer. Br J Cancer 2013; 108: 179-182
  • 49 Mill WB, Baglan RJ, Kurichety P. et al Symptomatic radiation-induced pericarditis in Hodgkin’s disease. Int J Radiat Oncol Biol Phys 1984; 10: 2061-2065
  • 50 Aleman BM, van den Belt-Dusebout AW, Klokman WJ. et al Long-term cause-specific mortality of patients treated for Hodgkin’s disease. J Clin Oncol 2003; 21: 3431-3439
  • 51 Schultz-Hector S, Trott KR. Radiation-induced cardiovascular diseases: is the epidemiologic evidence compatible with the radiobiologic data?. Int J Radiat Oncol Biol Phys 2007; 67: 10-18
  • 52 Nitsche M, Pahl R, Huber K. et al Cardiac Toxicity after Radiotherapy for Breast Cancer: Myths and Facts. Breast Care (Basel) 2015; 10: 131-135
  • 53 Wang K, Eblan MJ, Deal AM. et al Cardiac Toxicity After Radiotherapy for Stage III Non-Small-Cell Lung Cancer: Pooled Analysis of Dose-Escalation Trials Delivering 70 to 90 Gy. J Clin Oncol 2017; 35: 1387-1394
  • 54 Ming X, Feng Y, Yang C. et al Radiation-induced heart disease in lung cancer radiotherapy – A dosimetric update. Medicine (Baltimore) 2016; 95: e5051
  • 55 Piroth MD, Baumann R, Budach W. et al Heart toxicity from breast cancer radiotherapy. Strahlenther Onkol 2019; 195: 1-12
  • 56 Taylor CW, Nisbet A, McGale P. et al Cardiac doses from Swedish breast cancer radiotherapy since the 1950s. Radiother Oncol 2009; 90: 127-135
  • 57 Taylor CW, Povall JM, McGale P. et al Cardiac dose from tangential breast cancer radiotherapy in the year 2006. Int J Radiat Oncol Biol Phys 2008; 72: 501-507
  • 58 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: 1171-1178
  • 59 Hahn E, Jiang H, Ng A. et al Late Cardiac Toxicity After Mediastinal Radiation Therapy for Hodgkin Lymphoma: Contributions of Coronary Artery and Whole Heart Dose-Volume Variables to Risk Prediction. Int J Radiat Oncol Biol Phys 2017; 98: 1116-1123
  • 60 Veiga LHS, Curtis RE, Morton LM. et al Combined effect of radiotherapy and anthracyclines on risk of breast cancer among female childhood cancer survivors: A report from the Childhood Cancer Survivor Study (CCSS). Im Internet (Stand: 19.12.2019): https://ascopubs.org/doi/abs/10.1200/JCO.2019.37.15_suppl.10053
  • 61 Feijen EAML, Font-Gonzalez A, van der Pal HJH. et al Risk and Temporal Changes of Heart Failure Among 5‐Year Childhood Cancer Survivors: a DCOG‐LATER Study. J Am Heart Assoc 2019; 8: e009122
  • 62 Berry GJ, Jorden M. Pathology of radiation and anthracycline cardiotoxicity. Pediatric Blood and Cancer 2005; 44: 630-637
  • 63 Upadhrasta S, Elias H, Patel K. et al Managing cardiotoxicity associated with immune checkpoint inhibitors. Chronic Dis Transl Med 2019; 5: 6-14
  • 64 Varricchi G, Galdiero MR, Marone G. et al Cardiotoxicity of immune checkpoint inhibitors. ESMO Open 2017; 2: e000247
  • 65 Tajiri K, Ieda M. Cardiac Complications in Immune Checkpoint Inhibition Therapy. Front Cardiovasc Med 2019; 6: 3
  • 66 Chang HM, Okwuosa TM, Scarabelli T. et al Cardiovascular Complications of Cancer Therapy: Best Practices in Diagnosis, Prevention, and Management. J Am Coll Cardiol 2017; 70: 2552-2565
  • 67 Perez EA. Cardiac Toxicity of ErbB2-Targeted Therapies: What Do We Know?. Clinical Breast Cancer 2008; 8 (Suppl. 03) 114-120