title: Breathing adapted radiotherapy for breast cancer: comparison of free breathing gating with the breath-hold technique.
abstract: OBJECTIVE
  Adjuvant radiotherapy after breast-conserving surgery for breast cancer implies a risk of late cardiac and pulmonary toxicity. This is the first study to evaluate cardiopulmonary dose sparing of breathing adapted radiotherapy (BART) using free breathing gating, and to compare this respiratory technique with voluntary breath-hold.
  
  
  METHODS
  17 patients were CT-scanned during non-coached breathing manoeuvre including free breathing (FB), end-inspiration gating (IG), end-expiration gating (EG), deep inspiration breath-hold (DIBH) and end-expiration breath-hold (EBH). The Varian Real-time Position Management system (RPM) was used to monitor respiratory movement and to gate the scanner. For each breathing phase, a population based internal margin (IM) was estimated based on average chest wall excursion, and incorporated into an individually optimised three-field mono-isocentric wide tangential photon field treatment plan for each scan. The target included the remaining breast, internal mammary nodes and periclavicular nodes.
  
  
  RESULTS
  The mean anteroposterior chest wall excursion during FB was 2.5mm. For IG and EG, the mean excursions within gating windows were 1.1 and 0.7 mm, respectively, whereas for DIBH and EBH the excursions were 4.1 and 2.6mm, respectively. For patients with left-sided cancer, the median heart volume receiving more than 50% of the prescription dose was reduced from 19.2% for FB to 2.8% for IG and 1.9% for DIBH, and the median left anterior descending (LAD) coronary artery volume was reduced from 88.9% to 22.4% for IG and 3.6% for DIBH. Simultaneously, the median ipsilateral relative lung volume irradiated to >50% of the prescribed target dose for both right- and left-sided cancers was reduced from 45.6% for FB to 29.5% for IG and 27.7% for DIBH. For EBH and EG, both the irradiated heart, LAD and lung volumes increased compared to FB.
  
  
  CONCLUSIONS
  This is the first study to demonstrate the dosimetric benefits of free breathing gated breast cancer radiotherapy. IG compared favourably with DIBH, substantially reducing cardiac doses simultaneous with significant pulmonary tissue sparing.
authors.affiliation: Department of Radiation Oncology, Rigshospitalet, Copenhagen, Denmark. stine.k@rh.dk
authors.forename: Stine S
authors.initials: SS
authors.lastname: Korreman
authors.forename: Anders N
authors.initials: AN
authors.lastname: Pedersen
authors.forename: Trine Jakobi
authors.initials: TJ
authors.lastname: Nøttrup
authors.forename: Lena
authors.initials: L
authors.lastname: Specht
authors.forename: Håkan
authors.initials: H
authors.lastname: Nyström
mesh_terms: D000368:Aged; D001943:Breast Neoplasms / Q000532:radiotherapy* / Q000601:surgery; D019583:Dose Fractionation, Radiation; D005260:Female; D006321:Heart / Q000528:radiation effects*; D006801:Humans; D008168:Lung / Q000528:radiation effects*; D008875:Middle Aged; D009068:Movement; D011187:Posture; D011832:Radiation Injuries / Q000517:prevention & control*; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects; D012119:Respiration; D012307:Risk Factors; D035441:Thoracic Wall / Q000528:radiation effects; D014057:Tomography, X-Ray Computed