Session Item

In 2014, our institution implemented a Patient-Specific Heart Constraint (PSHC) and a mean heart dose (MHD) constraint of 4Gy for patients receiving breast RT with a simultaneous boost (SIB). The PSHC uses a calculation method for determining MHD before optimising IMRT fields. The aim of this study was to determine whether the introduction of a PSHC would reduce MHD, whilst maintaining optimally-dosed treatment plans.

Consecutive patients who received BCS and whole breast with SIB adjuvant RT were retrospectively identified and divided into two cohorts, pre- and post-implementation of the PSHC. Patients were simulated in the supine position. Prescribed dose to the breast PTV was 50Gy in 25 fractions; the SIB PTV was 57Gy in 25 fractions. Plans were generated using a hybrid IMRT technique, where 30Gy was delivered through a static tangential field arrangement, and the remaining 27Gy was delivered through IMRT fields. The calculation of the PSHC used the formula: MHD (open tangent fields) x 2. The following values were collected: D95% SIB PTV, RTOG conformity index (CI), homogeneity index (HI); MHD, V25Gy and V5Gy for heart, left anterior descending coronary artery (LAD) and ipsilateral lung mean doses.

Data from 264 patients treated between June 2013 and July 2015 were collected. There were 138 patients in the pre-PSHC cohort and 126 patients post-PSHC. The plans showed no difference in the CI of the SIB PTV D95% (pre-PSHC mean 1.82 (±0.56), post-PSHC 1.79 (±0.45), p=0.634 (95% CI -0.09-0.15); HI was slightly worse post-PSHC but not clinically relevant (pre-PSHC 6.1 (±1.35), post-PSHC 6.46 (±1.5), p=0.04 (95% CI -0.7, -0.01). The SIB D95% coverage was reduced post-PSHC but was above the 54.15Gy limit (pre-PSHC 55.64Gy (±0.59) post-PSHC 55.31Gy (±0.48) p<0.001 (95% CI 0.19-0.45)). Organ at risk dose comparisons are displayed in Table 1. The PSHC benefit was enhanced further with DIBH for heart V5Gy (p=0.034; 95%CI 0.42-9.85), but not for other parameters. IMRT fields contributed less to MHD post-PSHC (Figure 1).

Figure 1: Contribution to MHD from IMRT fields per patient in chronological order, for women receiving whole breast with SIB irradiation. This is based on the formula: Total MHD/(Open MHD x 1.67), where Total MHD is the sum of both the Open and IMRT components of heart dose received. The Open MHD component (representing MHD from the 30Gy delivered tangentially) is multiplied by 1.67 to predict MHD50 should 50Gy be delivered tangentially. The factor of 1.2 takes into account the boost contribution (57/50 = 1.14) with added buffer up to 60Gy (60/50 = 1.2)

Introduction of a PHSC has led to a decrease in MHD for patients receiving RT with SIB to the breast whilst maintaining optimally-dosed plans.