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Epworth HealthCare
Intensity-Modulated Radiotherapy versus Three-
Dimensional Conformal Radiotherapy; a retrospective
study
Epworth Radiation Oncology
Emma Fitzgerald
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Overview
• Literature search into Breast Intensity-Modulated Radiation Therapy (IMRT)
• Challenging Planning Target Volumes (PTV)
• Breast IMRT solution
• Critical review of technique
• Identify the clinical indicators
• Future direction of technique
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History
• Radiation Therapy remains integral to the management of Breast Cancer (1-6)
• Dosimetric Improvements from Two-Dimensional to Three-Dimensional Conformal Radiation Therapy (3DCRT)
• Are further improvements possible?
• Does IMRT have a role to play?
• If so, what are the indicators?
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Literature – Breast IMRT
• Retrospective studies question feasibility (1-3, 6, 8, 9, 10, 11)
• Increased trend to use IMRT for breast but no
detailed specific clinical scenarios (Lisa, A 2011)
• IMRT is dependent upon technique (2, 6-7, 12)
PositivesPositives NegativesNegatives
Improved HomogeneityImproved Homogeneity ↑ ↑ IIntegral Dosentegral Dose
BetterBetter PTV conformity indexPTV conformity index ↑ Heart↑ Heart MeanMean DoseDose
↓ Ipsilateral Lung V20 Gy↓ Ipsilateral Lung V20 Gy ↑ Contralateral Breast Dose↑ Contralateral Breast Dose
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Clinical Example
• Comparison of 2 different IMRT plans 6 FLDs Tan Approach Vs 9 FLDs ~30⁰ apart
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Background
• Field-In-Field PTV based approach is standard
• Acknowledge IMRT is resource intensive
• Limited benefit to replace as standard (11)
• However, real role to specific clinical scenarios (7, 9, 13, 10)
– Internal Mammary Chain (IMC)
– Complex volumes close to Organs At Risk (OARs)
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PTV & OAR
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PTV & OAR
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PTV & OAR
Right Coronary Artery (RCA) Planning Risk Volume (PRV)
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4.2cm
PTV & OAR
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PTV & OAR
• Left Anterior Descending (LAD) Coronary Artery Delineation
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The Clinical Decision
• Radiation Oncologist Driven
• Higher concern for IMC recurrence than Chronic toxicity
– LAD dose <30 Gy (14)
– RCA dose <35 Gy
• Application of Evidence Based Dose Constraints (14, 16)
• Extensive IMRT planning and treatment experience
• Collaboration with other sites
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Method
• 9 field Beam Arrangement:
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Method
• Supraclavicular Fossa (SCF) and Axilla Beam Arrangement:
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Method
• SCF/Axilla Beam Arrangement:
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Method
• Target Structures for IMRT Optimisation:
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Method
• Target Structures for IMRT Optimisation:
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Method
• Target Structures for IMRT Optimisation:
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Method
• Target Structures for IMRT Optimisation:
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Method
• 3DCRT - Wide Field Tangents & SCF/Axilla:
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Results
Isodose Range 47.5 Gy IMRT Vs 3DCRT
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Results
Isodose Range 47.5 Gy IMRT Vs 3DCRT
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Results
Isodose Range 25 Gy IMRT Vs 3DCRT
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Results
Isodose Range 5 Gy IMRT Vs 3DCRT
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Results
• Dose Volume Comparison – IMRT Vs 3DCRT IMRT (Gy)IMRT (Gy) 3DCRT (Gy)3DCRT (Gy) Goal (Gy)Goal (Gy)
PTV D 98%PTV D 98% 47.047.0 47.8 47.8 4747.5.5
PTV D 2 %PTV D 2 % 52.852.8 54.254.2 53.553.5
Right Lung V20Right Lung V20 30.030.0 46.046.0 < 15% (7.5)< 15% (7.5)
Heart MeanHeart Mean 7.27.2 2.32.3 < 5< 5
Heart MaxHeart Max 39.339.3 46.846.8 < 50< 50
PRV RCA MaxPRV RCA Max 38.538.5 46.546.5 < 35< 35
LADLAD N/AN/A N/AN/A < 30 Max< 30 Max
Brachial PlexusBrachial Plexus 51.1051.10 51.951.9 < 52 Max< 52 Max
Contra Breast MaxContra Breast Max 11.2 11.2 47.247.2 < 5 ***< 5 ***
Contra Lung MeanContra Lung Mean 2.92.9 0.30.3 < 5< 5
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Results
• Dose Volume Comparison – IMRT Vs 3DCRT IMRT (Gy)IMRT (Gy) 3DCRT (Gy)3DCRT (Gy) Goal (Gy)Goal (Gy)
PTV D 98%PTV D 98% 47.047.0 47.8 47.8 4747.5.5
PTV D 2 %PTV D 2 % 52.852.8 54.254.2 53.553.5
Right Lung V20Right Lung V20 30.030.0 46.046.0 < 15% (7.5)< 15% (7.5)
Heart MeanHeart Mean 7.27.2 2.32.3 < 5< 5
Heart MaxHeart Max 39.339.3 46.846.8 < 50< 50
PRV RCA MaxPRV RCA Max 38.538.5 46.546.5 < 35< 35
LADLAD N/AN/A N/AN/A < 30 Max< 30 Max
Brachial PlexusBrachial Plexus 51.1051.10 51.951.9 < 52 Max< 52 Max
Contra Breast MaxContra Breast Max 11.2 11.2 47.247.2 < 5 ***< 5 ***
Contra Lung MeanContra Lung Mean 2.92.9 0.30.3 < 5< 5
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Discussion
• PTV depth to cover IMC is a challenge
• IMRT advantages over 3DCRT;
– Improved Conformity of dose to PTV – Lower dose to most OARs.
• IMRT disadvantages over 3DCRT;
– Increased mean dose to heart and contralat lung – Higher integral dose
• Accurate delineation of OAR required
– Pre & Post Contrast CT for LAD (RO)
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Discussion
• Limitations of this study
– Comparison of only one 3DCRT approach – ???Junctional electron technique
• Future Direction
– 11 patients treated with IMRT for breast cancer to date
– RapidArc and Respiratory Gating – IGRT match results trend review – Clinical use of breast drapes
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Conclusion
• IMRT improves PTV coverage
• IMRT reduces OAR dose at expense of higher integral dose
• Wide field 3DCRT cannot achieve comparable results
• Careful selection of suitable cases is recommended
• IMRT has become the standard of care for complex
breast cancer cases
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Acknowledgements
Jim Frantzis Paul Fenton
Professor Chris Hamilton Robert Lumsden
Staff at Epworth Radiation Oncology
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References
1. Hurkmans W, Cho B, Damen E, Zijp L, Mijnheer B. Reduction of cardiac and lung complication probabilities after breast irradiation using conformal radiotherapy with or without intensity modulation. J of Radiotherapy & Oncology 2002; 62: 163-171. 2. Landau D, Adams E, Webb S, Ross G. Cardiac avoidance in breast radiotherapy: a comparison of simple shielding techniques with intensity-modulated radiotherapy. J of Radiotherapy & Oncology 2001; 60: 247-255. 3. Lohr F, El-Haddad M, Dobler B, Grau R, Wertz H-J, Kraus-Tiefenbacher U, Steil V, Madyan Y, Wenz F. Potential effect of robust and simple IMRT approach for left-sided breast cancer on cardiac mortality. Int. J Radiation Oncology Biol. Phys. 2008; 74: 73-80. 4. Meei The A, Walsh L, Purdie T, Mosseri A, Xu W, Levin W, Koch C, Fyles A, Liu F-F, Cho B. Concomitant intensity modulated boost during whole breast hypofractionated radiotherapy – A feasibiity and toxicity study. J of Radiotherapy & Onocology 2012; 102: 89-95. 5. Toscas J, Linero D, Rubio I, Hidalgo A, Arnalte R, Escude L, Cozzi L, Fogliata A, Miralbell R. Boosting the tumor bed from deep-seated tumors in early-stage breast cancer: A planning study between electron, photon and proton beams. J of Radiotherapy & Oncology 2010; 96: 192-198. 6. Stille A, Kron T, Herschtal A, Hornby C, Cramb J, Sullivan K, Chua B. Does inverse-planned intenstiy-modulated radiation therapy have a role in the treatment of patients with left-sided breast cancer? J of Medical Imaging and Radiation Oncology 2011; 55: 311-319. 7. Beckham W, Popescu C, Patenaude V, Wai E, Olivotto I. Is multibeam IMRT better than standard treatment for patients with left-sided breast cancer? Int. J. Radiation Oncology Biol. Phys. 2007; 69: 918-924.
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References
8. Abeyaratne D. Can intensity modulated radiation therapy reduce cardiac dose in left-sided breast patients? The Radiographer 2010; 57: 40. 9. Thilmann C, Sroka-Perez G, Krempien R, Hoess A, Wannenmacher M, Debus J. Inversely planned intensity modulated radiotherapy of the breast including the internal mammary chain: a plan comparison study. Technol Cancer Res Treat 2004; 3: 69-75. 10. Dogan N. Cuttino L. Lloyd R. Bump E. Arthur D. Optimized Dose Coverage of Regional Lymph Nodes in Breast Cancer: The Role of Intensity-Modulated Radiotherapy. Int. J. of Radiation Oncology Biol. Phys. 2007; 68: 1238-1250. 11. Dayes I, Rumble R, Bowen J, Dixon P, Warde P. Intensity-Modulated Radiotherapy in the Treatment of Breast Cancer. Clinical Oncology 2012; 24: 488-498. 12. Jagsi R, Moran J, Marsh R, Masi K, Griffith K, Pierce L. Evaluation of Four Techniques Using Intensity-Modualted Radiation Therapy for Comprehensive Locoregional Irradiation of Breast Cancer. Int. J of Radiation Oncology Biol. Phys. 2010; 78: 1594-1603. 13. Jin JY, Klein EE, Kong FM, Li Z. An improved internal mammary irradiation technique in radiation treatment of locally advanced breast cancers. J Appl Clin Med Phys 2005; 6: 84-93. 14. Taylor C, Povall J. McGale P. Nisbet A. Dodwell D. Smith J. Darby S. Cardiac Dose From Tangential Breast Cancer Radiotherapy in the year 2006. Int. J. of Radiation Oncology. Biol. Phys. 2008; 72: 501-507. 15. Louise Richter. Dose to the LAD associated with 3DCRT vs IMRT for Left sided breast irradiation. Powerpoint Presentation. 2011. 16. ICRU 83 Report.
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Thank you