Original paper| Volume 45, P82-87, January 2018

Download started.


Dosimetric evaluation of modern radiation therapy techniques for left breast in deep-inspiration breath-hold


      • TomoDirect, RapidArc, Elekta VMAT and FinF plans compared for breast irradiation.
      • TomoDirect, RapidArc and Elekta VMAT achieve highest dose coverage.
      • TomoDirect, RapidArc and Elekta VMAT spare the organs in the vicinity of the PTV.
      • FinF has the lowest dose on contralateral organs.
      • FinF has the shortest treatment delivery time.



      The dosimetric differences between four radiation therapy techniques for left sided whole breast irradiation were evaluated side by side in the same patient population.


      Radiotherapy treatment plans were retrospectively created with Accuray TomoDirect (TD), Elekta Volumetric Modulated Arc Therapy (E-VMAT), Varian RapidArc (RA) and Field-in-field (FinF) technique for 20 patients, who had received left breast irradiation during deep-inspiration breath-hold. Dose characteristics of planning target volume and organs at risk were compared.


      The E-VMAT, TD and RA treatment plans had higher target coverage (V95%) than FinF plans (97.7–98.3% vs. 96.6%). The low-dose spillage to contralateral breast and lung was smaller with FinF and TD (mean 0.1 and 0.3 Gy) compared to E-VMAT and RA (mean 0.6 and 0.9 Gy). E-VMAT, RA and TD techniques were more effective than FinF in sparing left anterior descending artery (mean 4.0, 4.2 and 4.7 Gy vs. 6.1 Gy, respectively).


      In whole breast irradiation TD, E-VMAT and RA plans generated in this study achieved higher dose coverage and sparing of organs from the high dose in the vicinity of the PTV. The advantage of calculated FinF plans is the lowest dose on contralateral organs. The choice of the technique used should be weighted by each institution taking into account the dose characteristics of each technique and its fit with patient anatomy bearing in mind the increased workload of using modulated techniques and the increased beam on time.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Physica Medica: European Journal of Medical Physics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Clarke M.
        • Collins R.
        • Darby S.
        • et al.
        Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials.
        Lancet. 2005; 366: 2087-2106
        • Osman S.O.S.
        • Hol S.
        • Poortmans P.M.
        • Essers M.
        Volumetric modulated arc therapy and breath-hold in image-guided locoregional left-sided breast irradiation.
        Radiother Oncol. 2014; 112: 17-22
        • Viren T.
        • Heikkilä J.
        • Myllyoja K.
        • Koskela K.
        • Lahtinen T.
        • Seppälä J.
        Tangential volumetric modulated arc therapy technique for left-sided breast cancer radiotherapy.
        Radiat Oncol. 2015; 10: 79
        • Johansen S.
        • Cozzi L.
        • Olsen D.R.
        A planning comparison of dose patterns in organs at risk and predicted risk for radiation induced malignancy in the contralateral breast following radiation therapy of primary breast using conventional, IMRT and volumetric modulated arc treatment techniques.
        Acta Oncol. 2009; 48: 495-503
        • Coon A.B.
        • Dickler A.
        • Kirk M.C.
        • et al.
        Tomotherapy and multifield intensity-modulated radiotherapy planning reduce cardiac doses in left-sided breast cancer patients with unfavorable cardiac anatomy.
        Int J Radiat Oncol Biol Phys. 2010; 78: 104-110
        • Shiau A.C.
        • Hsieh C.H.
        • Tien H.J.
        • et al.
        Left-sided whole breast irradiation with hybrid-IMRT and helical Tomotherapy dosimetric comparison.
        Biomed Res Int. 2014; : 741326
        • Reynders T.
        • Tournel K.
        • De Conick P.
        • et al.
        Dosimetric assessment of static and helical TomoTherapy in the clinical implementation of breast cancer treatments.
        Radiother Oncol. 2009; 93: 71-79
        • Mast M.E.
        • van Kempen-Harteveld L.
        • Heijenbrok M.W.
        • et al.
        Left-sided breast cancer radiotherapy with and without breath-hold: does IMRT reduce the cardiac dose even further?.
        Radiother Oncol. 2013; 108: 248-253
        • Franco P.
        • Zeverino M.
        • Migliaccio F.
        • et al.
        Intensity-modulated and hypofractionated simultaneous integrated boost adjuvant breast radiation employing statics ports of tomotherapy (TomoDirect): a prospective phase II trial.
        J Cancer Res Clin Oncol. 2014; 104: 167-177
        • Franco P.
        • Zeverino M.
        • Migliaccio F.
        • et al.
        Intensity-modulated adjuvant whole breast radiation delivered with static angle tomotherapy (TomoDirect): a prospective case series.
        J Cancer Res Clin Oncol. 2013; 139: 1927-1936
        • Darby S.C.
        • Ewertz M.
        • McGale P.
        • et al.
        Risk of ischemic heart disease in women after radiotherapy for breast cancer.
        N Eng J Med. 2013; 368: 987-998
        • Brahme A.
        • Nyman P.
        • Skatt B.
        4D laser camera for accurate patient positioning, collision avoidance, image fusion and adaptive approaches during diagnostic and therapeutic procedures.
        Med Phys. 2008; 35: 1670
        • Wang Y.
        • Vidan E.
        • Bergman G.W.
        Cardiac motion of coronary arteries: variability in the rest period and implications for coronary MR angiography.
        Radiology. 1999; 213: 751-758
        • Correa C.R.
        • Litt H.I.
        • Hwang W.T.
        • Ferrari V.A.
        • Solin L.J.
        • Harris E.E.
        Coronary artery findings after left-sided compared with right-sided radiation treatment for early-stage breast cancer.
        J Clin Oncol. 2007; 25: 3031-3037
        • Nilsson G.
        • Holmberg L.
        • Garmo H.
        • et al.
        Distribution of coronary artery stenosis after radiation for breast cancer.
        J Clin Oncol. 2012; 30: 380-386
      1. Radiation therapy oncology group. Breast cancer atlas for radiation therapy planning: Consensus definitions. Cited 2015 Jun 16. Available:

        • START trialists’ group
        The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial.
        Lancet. 2008; 371: 1098-1107
        • Gonzales
        • et al.
        Evaluation of two tomotherapy-based techniques for the delivery of whole-breast intensity-modulated radiation therapy.
        Int J Radiat Oncol Biol Phys. 2006; 65: 284-290
        • Nicolini G.
        • Fogliata A.
        • Clivio A.
        • Vanetti E.
        • Cozzi L.
        Planning strategies in volumetric modulated arc therapy for breast.
        Med Phys. 2011; 38: 4025-4031
        • Tortorelli G.
        • Di Murro L.
        • Barbarino R.
        • et al.
        Standard or hypofractionated radiotherapy in the postoperative treatment of breast cancer: a retrospective analysis of acute skin toxicity and dose inhomogeneities.
        BMC Cancer. 2013; 13: 230
        • Yarnold J.
        • Bentzen S.M.
        • Coles C.
        • Haviland J.
        Hypofractionated whole-breast radiotherapy for women with early breast cancer: myths and realities.
        Int J Radiat Oncol Biol Phys. 2011; 79: 1-9
        • Nilsson G.
        • Holmberg L.
        • Garmo H.
        • et al.
        Distribution of coronary artery stenosis after radiation for breast cancer.
        J Clin Oncol. 2012; 30: 380-386
        • Chung E.
        • Corbett J.R.
        • Moran J.M.
        • et al.
        Is there a dose-response relationship for heart disease with low-dose radiation therapy?.
        Int J Radiat Oncol Biol Phys. 2013; 85: 959-964
        • Goldman U.B.
        • Wennberg B.
        • Svane G.
        • Bylund H.
        • Lind P.
        Reduction of radiation pneumonitis by V20-constraints in breast cancer.
        Radiat Oncol. 2010; 5: 99
        • Hurkmans C.W.
        • Cho B.C.J.
        • Damen E.
        • Zijp L.
        • Mijnheer B.J.
        Reduction of cardiac and lung complication probabilities after breast irradiation using conformal radiotherapy with or without intensity modulation.
        Radiother Oncol. 2002; 62: 163-171
        • Hong L.
        • Hunt M.
        • Chui C.
        • et al.
        Intensity-modulated tangential beam irradiation of the intact breast.
        Int J Radiat Oncol Biol Phys. 1999; 44: 1155-1164
        • Nicolini G.
        • Clivio A.
        • Fogliata A.
        • Vanetti E.
        • Cozzi L.
        Simultaneous integrated boost radiotherapy for bilateral breast: a treatment planning and dosimetric comparison for volumetric modulated arc and fixed field intensity modulated therapy.
        Radiat Oncol. 2009; 4: 27
        • Popescu C.C.
        • Olivotto I.A.
        • Beckham W.A.
        • et al.
        Volumetric modulated arc therapy improves dosimetry and reduces treatment time compared to conventional intensity-modulated radiotherapy for locoregional radiotherapy of left-sided breast cancer and internal mammary nodes.
        Int J Radiat Oncol Biol Phys. 2010; 76: 287-295
        • Borst G.R.
        • et al.
        Clinical results of image-guided deep inspiration breath hold breast irradiation.
        Int J Radiat Oncol Biol Phys. 2010; 78: 1345-1351
        • Vikström J.
        • Hjelstuen M.H.B.
        • Mjaaland I.
        • Dybvik K.I.
        Cardiac and pulmonary dose reduction for tangentially irradiated breast cancer, utilizing deep inspiration breath-hold with audio-visual guidance, without compromising target coverage.
        Acta Oncol. 2011; 50: 42-50
        • Nissen D.H.
        • Appelt A.L.
        Improved heart, lung and target dose with deep inspiration breath hold in a large clinical series of breast cancer patients.
        Radiother Oncol. 2013; 106: 28-32
        • Péguret N.
        • et al.
        Apnea-like suppression of respiratory motion: first evaluation in radiotherapy.
        Radiother Oncol. 2016; 118: 220-226
        • Howell R.M.
        • Scarboro S.B.
        • Kry S.F.
        • Yaldo D.Z.
        Accuracy of out-of-field dose calculations by a commercial treatment planning system.
        Phys Med Biol. 2010; 55: 6999-7008
        • Thompson C.M.
        • Weston S.J.
        • Cosgrove V.C.
        • Thwaites D.I.
        A dosimetric characterization of a novel linear accelerator collimator.
        Med Phys. 2014; 41: 031713
        • Kim J.O.
        • Siebers J.V.
        • Keall P.J.
        • Arnfield M.R.
        • Mohan R.
        A Monte Carlo study of radiation transport through multileaf collimators.
        Med Phys. 2001; 28: 2497-2506
        • Joosten A.
        • Bochud F.
        • Baechler S.
        • Levi F.
        • Mirimanoff R.-O.
        • Moeckli R.
        Variability of a peripheral dose among various linac geometries for second cancer risk assessment.
        Phys Med Biol. 2011; 56: 5131-5151
        • Koivumäki T.
        • Heikkilä J.
        • Väänänen A.
        • Koskela K.
        • Sillanmäki S.
        • Seppälä J.
        Flattening filter free technique in breath-hold treatments of left-sided breast cancer: the effect on beam-on time and dose distributions.
        Radiother Oncol. 2016; 118: 194-198
        • Fogliata A.
        • et al.
        Dosimetric trade-offs in breast treatment with VMAT technique.
        Br J Radiol. 2017; 1070: 20160701