title: Reduction of cardiac and lung complication probabilities after breast irradiation using conformal radiotherapy with or without intensity modulation.
abstract: OBJECTIVE
  The main purpose of this work is to reduce the cardiac and lung dose by applying conformal tangential beam irradiation of the intact left breast with and without intensity modulation, instead of rectangular tangential treatment fields. The extension of the applicability of the maximum heart distance (MHD) to conformal tangential fields as a simple patient selection criterion, identifying patients for which rectangular and conformal tangential fields without intensity modulation will result in unacceptable normal tissue complication probability (NTCP) values for late cardiac mortality (e.g. >2%), was also investigated.
  
  
  METHODS
  Three-dimensional treatment planning was performed for 17 left-sided breast cancer patients. Three different tangential beam techniques were compared: (1) optimized wedges without blocks, (2) optimized wedges with conformal blocks and (3) intensity modulation. Plans were evaluated using dose-volume histograms (DVHs) for the planning target volume (PTV), the heart and the lungs. NTCPs for radiation pneumonitis and late cardiac mortality were calculated using the DVH data. The MHD was measured for all rectangular (MHD(rectangular)) and conformal (MHD(conformal)) treatment plans.
  
  
  RESULTS
  For all patients, on average, part of the PTV receiving a dose between 95 and 107% of the prescribed dose of 50Gy in 25 fractions of 2Gy was 90.8% (standard deviation (SD): 5.0%), 92.8% (SD: 3.5%) and 92.8% (SD: 3.6%) for the intensity modulation radiation therapy (IMRT), conformal and rectangular field treatment techniques, respectively. The NTCP for radiation pneumonitis was 0.3% (SD: 0.1%), 0.4% (SD: 0.4%) and 0.5% (SD: 0.6%) for the IMRT, conformal and rectangular field techniques, respectively. The NTCP for late cardiac mortality was 5.9% (SD: 2.2%) for the rectangular field technique. This value was reduced to 4.0% (SD: 2.3%) with the conformal technique. A further reduction to 2.0% (SD: 1.1%) could be accomplished with the IMRT technique. The NTCP for late cardiac mortality could be described as a second order polynomial function of the MHD. This function could be described with a high accuracy and was independent of the technique for which the MHD was determined (r(2)=0.88). In order to achieve a NTCP value for late cardiac mortality below 1, 2 or 3%, the MHD should be equal to or smaller than 11, 17 or 23 mm, respectively. If such a maximum complication probability cannot be accomplished, a treatment using the IMRT technique should be considered.
  
  
  CONCLUSIONS
  The use of conformal tangential fields decreases the NTCP for late cardiac toxicity on average by 30% compared to using rectangular fields, while the tangential IMRT technique can further reduce this value by an additional 50%. The MHD can be used to estimate the NTCP for late cardiac mortality if rectangular or conformal tangential treatment fields are used.
authors.affiliation: Department of Radiotherapy, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
authors.forename: Coen W
authors.initials: CW
authors.lastname: Hurkmans
authors.forename: B C John
authors.initials: BC
authors.lastname: Cho
authors.forename: Eugene
authors.initials: E
authors.lastname: Damen
authors.forename: Lambert
authors.initials: L
authors.lastname: Zijp
authors.forename: Ben J
authors.initials: BJ
authors.lastname: Mijnheer
mesh_terms: D001943:Breast Neoplasms / Q000532:radiotherapy*; D005260:Female; D006331:Heart Diseases / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D008171:Lung Diseases / Q000209:etiology / Q000517:prevention & control*; D011832:Radiation Injuries / Q000209:etiology / Q000517:prevention & control*; D011879:Radiotherapy Dosage; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects / Q000379:methods; D020266:Radiotherapy, Conformal / Q000009:adverse effects*; D014022:Tissue Survival