title: Changes in breast cancer risk associated with different volumes, doses, and techniques in female Hodgkin lymphoma patients treated with supra-diaphragmatic radiation therapy.
abstract: OBJECTIVE
  The contribution of thoracic radiation in increasing secondary breast cancer (BC) risk in female Hodgkin lymphoma patients is well known, and recent changes in radiation therapy volumes, doses and techniques are supposed to minimize it. In this study, we compared different radiation therapy solutions in terms of secondary BC induction risk with the aim of selecting which could be considered the most protective.
  
  
  METHODS
  In 10 female patients under 30 years old we estimated breast cancer risk for different combined treatment solutions (involved field vs involved nodal radiation therapy [IFRT vs INRT], 30 Gy vs 20 Gy, 3-dimensional conformal radiation therapy vs volumetric modulated arc therapy [3DCRT vs VMAT]). The organ equivalent dose (OED) method was used for dose calculation, as OED is directly related to the excess risk. Estimated OED mean values for all options in all patients were then analyzed and compared.
  
  
  RESULTS
  INRT was significantly associated with a lower OED, regardless of total dose and technique (0.43 vs 1.15, P < .0001). The relative OED reduction from IFRT to INRT was approximately 60%. The dose of 20 Gy resulted in a significant reduction of OED, approximately 25% (0.68 vs 0.9, P < .01). VMAT did not show significantly higher OED when compared with 3DCRT (0.84 vs 0.74, P = .15). The combination of INRT and 20 Gy lead to a decrease in OED of approximately 70% if compared with IFRT 30 Gy.
  
  
  CONCLUSIONS
  The INRT approach substantially reduces OED, independent of dose and technique; the dose reduction from 30 Gy to 20 Gy also has a significant impact, and as expected INRT-20 Gy resulted to be the solution at lowest risk. No differences were observed when comparing different techniques (3DCRT vs VMAT). The combination of these innovative approaches might lead to a substantial reduction in secondary breast cancer risk in this patient population.
authors.affiliation: University of Torino, Department of Oncology, Radiation Oncology Unit, Torino, Italy. Electronic address: andreariccardo.filippi@unito.it.
authors.forename: Andrea Riccardo
authors.initials: AR
authors.lastname: Filippi
authors.affiliation: University of Torino, Department of Oncology, Radiation Oncology Unit, Torino, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Ragona
authors.affiliation: University of Torino, Department of Oncology, Radiation Oncology Unit, Torino, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Fusella
authors.affiliation: University of Torino, Department of Oncology, Radiation Oncology Unit, Torino, Italy.
authors.forename: Angela
authors.initials: A
authors.lastname: Botticella
authors.affiliation: University of Torino, Department of Oncology, Radiation Oncology Unit, Torino, Italy.
authors.forename: Christian
authors.initials: C
authors.lastname: Fiandra
authors.affiliation: University of Torino, Department of Oncology, Radiation Oncology Unit, Torino, Italy.
authors.forename: Umberto
authors.initials: U
authors.lastname: Ricardi