Twice as nice.

Top Line: Not much makes achieving acceptable heart and lung dosimetry during breast irradiation more challenging than synchronous bilateral cancers.

The Study: Here is a retrospective review from Mayo of intensity modulated proton therapy (IMPT) plans delivered to 11 patients with synchronous bilateral breast cancer requiring adjuvant regional nodal irradiation: 9 after bilateral mastectomies and 2 after bilateral breast-conserving surgeries. The clinical target volumes (CTV) differed from the RTOG guidelines in a few ways: it stopped at anterior (not posterior) surface of ribs), excluded 3 mm from surface for chest wall and 5 mm for intact breast, and supraclavicular nodal volumes stopped at lateral (not medial) border of internal carotid artery). When comparing delivered bilateral IMPT plans to best achievable bilateral VMAT photon plans, CTV coverage was excellent either way with 90% receiving a median of 99.9% and 97.6% of prescription dose (50Gy/25), respectively. A more notable discrepancy emerged in doses to organs at risk: there were significant reductions with IMPT in mean heart dose (0.7 v 7.2 Gy), mean total lung dose (7.8 v 17.3 Gy), and the volume of total lung receiving ≥20 Gy (13.0% v 27.4%). Important to note here is that no patients required deep inspiratory breath hold (DIBH) with IMPT given the inherent stopping power of protons, and only 3 patients had DIBH scans available for VMAT comparison plans. Also interesting to note is that 5 of 11 patients were treated with arms down, which is apparently a feasible and often more comfortable set-up option when treating with IMPT.


TBL: Intensity modulated proton therapy offers excellent organ-at-risk sparing when delivering adjuvant breast radiation to bilateral regional nodal regions for synchronous breast cancers. | Garda, Adv Radiat Oncol 2022

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