title: Minimizing late effects for patients with mediastinal Hodgkin lymphoma: deep inspiration breath-hold, IMRT, or both?
abstract: OBJECTIVE
  Hodgkin lymphoma (HL) survivors have an increased risk of cardiovascular disease (CD), lung cancer, and breast cancer. We investigated the risk for the development of CD and secondary lung, breast, and thyroid cancer after radiation therapy (RT) delivered with deep inspiration breath-hold (DIBH) compared with free-breathing (FB) using 3-dimensional conformal RT (3DCRT) and intensity modulated RT (IMRT). The aim of this study was to determine which treatment modality best reduced the combined risk of life-threatening late effects in patients with mediastinal HL.
  
  
  METHODS
  Twenty-two patients with early-stage mediastinal HL were eligible for the study. Treatment plans were calculated with both 3DCRT and IMRT on both DIBH and FB planning computed tomographic scans. We reported the estimated dose to the heart, lung, female breasts, and thyroid and calculated the estimated life years lost attributable to CD and to lung, breast, and thyroid cancer.
  
  
  RESULTS
  DIBH lowered the estimated dose to heart and lung regardless of delivery technique (P<.001). There was no significant difference between IMRT-FB and 3DCRT-DIBH in mean heart dose, heart V20Gy, and lung V20Gy. The mean breast dose was increased with IMRT regardless of breathing technique. Life years lost was lowest with DIBH and highest with FB.
  
  
  CONCLUSIONS
  In this cohort, 3DCRT-DIBH resulted in lower estimated doses and lower lifetime excess risks than did IMRT-FB. Combining IMRT and DIBH could be beneficial for a subgroup of patients.
authors.affiliation: Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Faculty of Sciences, Niels Bohr Institute, and Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark. Electronic address: marianne.camille.aznar@regionh.dk.
authors.forename: Marianne C
authors.initials: MC
authors.lastname: Aznar
authors.affiliation: Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Maja V
authors.initials: MV
authors.lastname: Maraldo
authors.affiliation: Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Schut
authors.affiliation: Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Faculty of Sciences, Niels Bohr Institute, and Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Michael
authors.initials: M
authors.lastname: Lundemann
authors.affiliation: Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Institute of Onco-Physics, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York.
authors.forename: N Patrik
authors.initials: NP
authors.lastname: Brodin
authors.affiliation: Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Ivan R
authors.initials: IR
authors.lastname: Vogelius
authors.affiliation: Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Anne K
authors.initials: AK
authors.lastname: Berthelsen
authors.affiliation: Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Lena
authors.initials: L
authors.lastname: Specht
authors.affiliation: Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Petersen
mesh_terms: D001940:Breast / Q000528:radiation effects; D001943:Breast Neoplasms / Q000209:etiology; D062485:Breath Holding; D002318:Cardiovascular Diseases / Q000209:etiology; D005260:Female; D006321:Heart / Q000000981:diagnostic imaging / Q000528:radiation effects; D006689:Hodgkin Disease / Q000401:mortality / Q000532:radiotherapy*; D006801:Humans; D001239:Inhalation; D015993:Life Tables; D008168:Lung / Q000000981:diagnostic imaging / Q000528:radiation effects; D008175:Lung Neoplasms / Q000209:etiology; D008297:Male; D008479:Mediastinal Neoplasms / Q000401:mortality / Q000532:radiotherapy*; D009381:Neoplasms, Radiation-Induced; D016609:Neoplasms, Second Primary / Q000209:etiology*; D058958:Organs at Risk / Q000000981:diagnostic imaging / Q000528:radiation effects*; D011859:Radiography; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D020266:Radiotherapy, Conformal / Q000009:adverse effects / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects / Q000379:methods*; D012119:Respiration; D013961:Thyroid Gland / Q000000981:diagnostic imaging / Q000528:radiation effects; D013964:Thyroid Neoplasms / Q000209:etiology