Comparison of Dosimetric Parameters of Three- Dimensional Conformal Radiotherapy and Intensity- Modulated Radiotherapy in Breast Cancer Patients Undergoing Adjuvant Radiotherapy after Modified Radical Mastectomy

Abstract

Introduction Adjuvant radiotherapy has an important role in preventing locoregional recurrences. But radiation-induced late sequelae have become an important area of concern. The ideal postmastectomy radiotherapy technique is an area of controversy. The present study was designed to compare two widely practiced conformal techniques, three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT), in terms of dosimetry. Material and Methods A total of 50 postmodified radical mastectomy patients were selected and were randomized to treatment either by 3DCRT or IMRT technique. Two opposing tangential beams were used in 3DCRT plans whereas five to seven tangential beams were used for IMRT plans. The prescribed dose was 50 Gy in 25 fractions over 5 weeks. The dosimetric parameters were compared for planning target volume (PTV), lungs, heart, and left ventricle, opposite breast and esophagus. Results The dosimetric parameters of PTV in terms of D95%, D90%, D50%, and Dmean showed no significant difference among both techniques. The IMRT technique had significantly better mean values of Dnear-min/D98% (45.56 vs. 37.92 Gy; p = 0.01) and Dnear-max/D2% (51.47 vs. 53.65 Gy; p < 0.001). Also, conformity index (1.07 vs. 1.29; p = 0.004) and homogeneity index (0.22 vs. 0.46; p = 0.003) were significantly better in IMRT arm. The dosimetric parameters of ipsilateral lung were significantly higher in IMRT arm in terms of mean dose (19.92 vs. 14.69 Gy; p < 0.001) and low/medium dose regions (V5, V10, V13, V15, V20; p < 0.05). However, high-dose regions (V40) were significantly higher in 3DCRT arm (15.57 vs. 19.89 Gy; p = 0.02). In contralateral lung also, mean dose was significantly higher in IMRT technique (3.63 vs. 0.53 Gy; p < 0.0001) along with low-dose regions (V5, V10, V13, V15; p < 0.05) while V20 was comparable between both the arms. In left-sided patients, the heart dose favored 3DCRT technique in terms of mean dose (17.33 vs. 8.51 Gy; p = 0.003), low/medium dose regions (V5, V10, V20; p < 0.05), and doses to partial/whole volumes (D33, D67, D100). But the high-dose regions (V25, V30, V40) were comparable between both the arms. The dosimetry of left ventricle also showed significantly lesser values of mean dose and V5 in 3DCRT technique (p < 0.0001). The opposite breast also showed higher mean dose with IMRT technique (2.60 vs. 1.47 Gy; p = 0.009) along with higher V5 (11.60 vs. 3.83 Gy; p = 0.001). The dosimetric parameters of esophagus showed higher mean dose in IMRT technique (10.04 vs. 3.24 Gy; p < 0.0001) but the high-dose regions V35 and V50 were comparable between both the arms. Conclusion A clear advantage could not be demonstrated with any of the techniques. The IMRT technique led to more conformal and homogenous dose distribution with reduction in high-dose regions in ipsilateral lung while the 3DCRT technique showed lesser mean dose to organs at risk (OARs). The exposure of large volumes of OARs to low doses in IMRT technique may translate to increased long-term radiation-induced complications. The shortcomings of 3DCRT technique can be overcome by using multiple subfields within tangential fields.