Abstract
Background and purpose: The clinical benefit of irradiating the intact breast after lumpectomy must be weighted
against the risk of severe toxicity. We present a study on cardiac and pulmonary dose-volume
data and the related complication probabilities of tangential breast irradiation having
the following objectives: (1) to quantify the sparing of the organs at risk (ORs),
the heart and the lung, achieved by three-dimensional (3-D) conformal tangential irradiation
(CTI) as compared to standard tangential irradiation (STI); (2) to elucidate the uncertainty
in radiation tolerance data; and (3) to analyse the relation between the amount of
OR irradiated and the resulting morbidity risk.
Material and methods: Computed tomography (CT)-based 3-D treatment plans of 26 patients prescribed to
CTI of the intact breast were applied. Contour-based STI has been our routine treatment,
and was reconstructed for all patients. Dose–volume data and normal tissue complication
probability (NTCP) predictions from the probit and relative seriality models with
several cardiac and pulmonary tolerance parameterizations were analysed and compared.
Results and conclusions: A significant amount of normal tissues can be spared from radiation by using CT-based
CTI, resulting in a 50% reduction of the average excess cardiac mortality risk in
the left-sided cases. The risks for pericarditis and pneumonitis were too low to reveal
any clinically significant difference between the treatments. For the STI set-up,
a regression analysis showed that the excess cardiac mortality risk increased when
larger parts of the heart were inside the fields. However, the different excess cardiac
mortality and pneumonitis tolerance parameters resulted in statistically significant
different NTCPs, which precluded the ability to accurately predict absolute NTCPs
after tangential breast irradiation. Despite this uncertainty the different series
of cardiac and pulmonary risk predictions were in relatively good agreement when small
volumes of the ORs were irradiated. From the present data and without consideration
of patient or organ motion, it therefore appears that tangential breast irradiation
with less than 1 cm of the heart and 2–2.5 cm of the lung included inside the treatment
fields will cause at most 1‰ risk for cardiac mortality and pulmonary morbidity. CT-based
CTI should be considered, in particular for the left-sided cases, if these requirements
cannot be met.
Keywords
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References
- Dosimetric improvements following 3D planning of tangential breast irradiation.Int J Radiat Oncol Biol Phys. 2000; 48: 1569-1574
- Fitting of normal tissue tolerance data to an analytic function.Int J Radiat Oncol Biol Phys. 1991; 21: 123-135
- Effects of radiotherapy and surgery in early breast cancer. An overview of the randomized trials.N Engl J Med. 1995; 333: 1444-1455
- Tolerance of normal tissue to therapeutic irradiation.Int J Radiat Oncol Biol Phys. 1991; 21: 109-122
- Long-term cardiac mortality following radiation therapy for Hodgkin's disease: analysis with the relative seriality model.Radiother Oncol. 2000; 55: 153-162
- Normal tissue complication probabilities: how well do the models work?.Phys Med. 2001; 17: 24-35
- Cardiac doses in postoperative breast irradiation.Radiother Oncol. 1992; 25: 19-24
- Modelling heart and lung complication data in radiation therapy of the breast. Thesis. Department of Medical Radiation Physics, Stockholm University, Stockholm1998
- Radiation pneumonitis after breast cancer irradiation: analysis of the complication probability using the relative seriality model.Int J Radiat Oncol Biol Phys. 2000; 46: 373-381
- Long-term cardiac mortality after radiotherapy of breast cancer - application of the relative seriality model.Br J Radiol. 1996; 69: 839-846
- Evaluation of irradiated heart volumes in stage I breast cancer patients treated with postoperative adjuvant radiotherapy.J Clin Oncol. 1997; 15: 1348-1353
- Histologic multifocality of Tis, T1–2 breast carcinomas. Implications for clinical trials of breast-conserving surgery.Cancer. 1985; 56: 979-990
- Cardiac and lung complication probabilities after breast cancer irradiation.Radiother Oncol. 2000; 55: 145-151
- Variability in target volume delineation on CT scans of the breast.Int J Radiat Oncol Biol Phys. 2001; 50: 1366-1372
- Calculation of complication probability factors for nonuniform normal tissue irradiation: the effective volume method.Int J Radiat Oncol Biol Phys. 1989; 16: 1623-1630
- Treatment planning for primary breast cancer: a patterns of care study.Int J Radiat Oncol Biol Phys. 1996; 36: 731-737
- Radiation pneumonitis as a function of mean lung dose: an analysis of pooled data of 540 patients.Int J Radiat Oncol Biol Phys. 1998; 42: 1-9
- Tumor and normal tissue responses to fractionated non-uniform dose delivery.Int J Radiat Biol. 1992; 62: 249-262
- Cardiac avoidance in breast radiotherapy: a comparison of simple shielding techniques with intensity-modulated radiotherapy.Radiother Oncol. 2001; 60: 247-255
- The role of radiotherapy in breast conserving treatment.Acta Oncol. 1995; 34: 675-680
- Complication probability as assessed from dose volume histograms.Radiat Res. 1985; 104: S13-S19
- A bayesian sequential model for updating radiobiological parameters in radiation therapy (abstract).in: Second European conference on highly structured stochastic systems. 1999: 180-181
- Fraction size and dose parameters related to the incidence of pericardial effusions.Int J Radiat Oncol Biol Phys. 1998; 40: 155-161
- Can dose response models predict reliable normal tissue complication probabilities in radical radiotherapy of urinary bladder cancer? The impact of alternative radiation tolerance models and parameters.Int J Radiat Oncol Biol Phys. 2001; 50: 627-637
- Invited review: tangential breast irradiation – rationale and methods for improving dosimetry.Br J Radiol. 1994; 67: 1149-1154
- Correlation of breast dose heterogeneity with breast size using 3D CT planning and dose–volume histograms.Radiother Oncol. 1995; 34: 210-218
- Calculation of normal tissue complication probability and dose-volume histogram reduction schemes for tissues with a critical element structure.Radiother Oncol. 1991; 20: 166-176
- Modeling of normal tissue response to radiation: the critical volume model.Int J Radiat Oncol Biol Phys. 1993; 25: 135-145
- Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b trial.N Engl J Med. 1997; 337: 949-955
- Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial.Lancet. 1999; 353: 1641-1648
- Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer.N Engl J Med. 1997; 337: 956-962
- Cardiovascular mortality in a randomized trial of adjuvant radiation therapy versus surgery alone in primary breast cancer.Int J Radiat Oncol Biol Phys. 1992; 22: 887-896
- Calculation of the uncertainty in complication probability for various dose-response models, applied to the parotid gland.Int J Radiat Oncol Biol Phys. 2001; 50: 147-158
- Radiation injury to the heart.Int J Radiat Oncol Biol Phys. 1995; 31: 1205-1211
- Adjuvant radiotherapy for breast cancer significantly improves overall survival: the missing link.Radiother Oncol. 2000; 55: 263-272
- An assessment of the number of CT slices necessary to plan breast radiotherapy.Radiother Oncol. 1999; 52: 179-183
- Treatment volume and tissue tolerance.Int J Radiat Oncol Biol Phys. 1988; 14: 751-759
- Quantification of the response of heterogeneous tumours and organized normal tissues to fractionated radiotherapy. Thesis. Department of Medical Radiation Physics, Stockholm University, Stockholm1995
Article info
Publication history
Accepted:
October 15,
2001
Received in revised form:
September 26,
2001
Received:
March 6,
2001
Identification
Copyright
© 2002 Elsevier Science Ireland Ltd. Published by Elsevier Inc. All rights reserved.
