Cardiac substructure exposure in breast radiotherapy: a comparison between intensity modulated proton therapy and volumetric modulated arc therapy

Abstract

Introduction Proton therapy for breast cancer treatment reduces cardiac radiation exposure. Left-sided breast cancer patients with indication for internal mammary chain (IMC) irradiation are most at risk of radiation-induced cardiotoxicity. This study aims to evaluate in this situation the potential dosimetric benefit of intensity modulated proton therapy (IMPT) over volumetric modulated arc therapy (VMAT) at the cardiac substructure level. Materials and methods Cardiac substructures were retrospectively delineated according to ESTRO guidelines on the simulation CT scans of fourteen left-sided breast cancer patients having undergone conserving surgery and adjuvant locoregional free-breathing (FB-) or deep inspiration breath-hold (DIBH-) VMAT with internal mammary chain irradiation. IMPT treatment was re-planned on the simulation CT scans. Mean doses to cardiac substructures were retrieved and compared between VMAT treatment plans and IMPT simulation plans. Pearson correlation coefficients were calculated between mean doses delivered to cardiac substructures using these two techniques. Results Mean doses to all cardiac substructures were significantly lower with IMPT than with VMAT. Regardless of the irradiation technique, the most exposed cardiac substructure was the mid segment of the left anterior descending coronary artery (LADCA). Pearson correlation coefficients between mean doses to cardiac substructures were usually weak and statistically non-significant for IMPT; mean heart dose (MHD) only correlated with mean doses delivered to the right ventricle, to the mid segment of the right coronary artery (RCA) and, to a lesser extent, to the LADCA. Conclusion The dosimetric benefit of IMPT over conformal photon therapy was consistently observed for all cardiac substructures. MHD may not be a reliable dosimetric parameter for precise cardiac exposure evaluation when planning IMPT.