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We report on a comparative dosimetrical study between deep inspiration breath hold (DIBH) and shallow breathing (SB) in prone crawl position for photon and proton radiotherapy of whole breast (WB) and locoregional lymph node regions, including the internal mammary chain (LN_MI). We investigate the dosimetrical effects of DIBH in prone crawl position on organs-at-risk for both photon and proton plans. For each modality, we further estimate the effects of lung and heart doses on the mortality risks of different risk profiles of patients. Thirty-one patients with invasive carcinoma of the left breast and pathologically confirmed positive lymph node status were included in this study. DIBH significantly decreased dose to heart for photon and proton radiotherapy. DIBH also decreased lung doses for photons, while increased lung doses were observed using protons because the retracting heart is displaced by low-density lung tissue. For other organs-at-risk, DIBH resulted in significant dose reductions using photons while minor differences in dose deposition between DIBH and SB were observed using protons. In patients with high risks for cardiac and lung cancer mortality, average thirty-year mortality rates from radiotherapy-related cardiac injury and lung cancer were estimated at 3.12% (photon DIBH), 4.03% (photon SB), 1.80% (proton DIBH) and 1.66% (proton SB). The radiation-related mortality risk could not outweigh the ~ 8% disease-specific survival benefit of WB + LN_MI radiotherapy in any of the assessed treatments.

Prone positioning for whole-breast irradiation (WBI) reduces dose to organs at risk, but reduces set-up speed, precision, and comfort. We aimed to improve these problems by placing patients in prone crawl position on a newly developed crawl couch (CrC). A group of 10 right-sided breast cancer patients requiring WBI were randomized in this cross-over trial, comparing the CrC to a standard prone breastboard (BB). Laterolateral (LL), craniocaudal (CC) and anterioposterior (AP) set-up errors were evaluated with cone beam CT. Comfort, preference and set-up time (SUT) were assessed. Forty left and right-sided breast cancer patients served as a validation group. For BB versus CrC, AP, LL and CC mean patient shifts were - 0.8 ± 2.8, 0.2 ± 11.7 and - 0.6 ± 4.4 versus - 0.2 ± 3.3, - 0.8 ± 2.5 and - 1.9 ± 5.7 mm. LL shift spread was reduced significantly. Nine out of 10 patients preferred the CrC. SUT did not differ significantly. The validation group had mean patient shifts of 1.7 ± 2.9 (AP), 0.2 ± 3.6 (LL) and - 0.2 ± 3.3 (CC) mm. Mean SUT in the validation group was 1 min longer (P < 0.05) than the comparative group. Median SUT was 3 min in all groups. The CrC improved precision and comfort compared to BB. Set-up errors compare favourably to other prone-WBI trials and rival supine positioning.

Introduction: In view of the limited incremental benefit between whole breast irradiation (WBI), accelerated partial breast irradiation (APBI) and omission of radiotherapy in favorable early-stage breast cancer (ESBC), APBI can only be justified if it combines adequate target coverage with the lowest achievable toxicity. Interobserver exercises demonstrated the difficulty of precise target delineation, especially in prone position; information on accuracy is even scarcer. We tested the impact of inserting an additional indicator clip, marking the depth of the tumor in the breast, and the added value of a preoperative CT in treatment position on precision and accuracy., Material and Methods: In 12 patients, tumor bed delineation was performed by four radiation oncologists, with CTV standard (clinical target volume) based on standard delineation guidelines, CTV clip resulting from a 1-2-cm symmetrical expansion with the indicator clip as center and CTV clip&#95;CT expanding from the midpoint between the indicator clip and preoperative gross tumor volume (GTV) as center. Precision was measured as the mean pairwise Jaccard index (JI pairs ) between observers, accuracy as the mean overlap between GTV and respective CTVs., Results: JI pairs was 0.38 for CTV standard , 0.75 for CTV clip and 0.59 for CTV clip&#95;CT . Overlap rate of GTV with CTVs was respectively 0.48, 0.67 and improved further to 0.88 for CTV clip&#95;CT . High-dose coverage of GTV (D95 and D90) improved with an indicator clip, but the most optimal result was reached when preoperative CT was added., Conclusions: If EB-APBI in prone position is aimed for, an indicator clip intended to mark the depth of the tumor increases the probability of accurate target coverage, but cannot entirely replace the added value of a preoperative CT in treatment position. Avoiding the cost and effort of such CT implies a risk of missing the target, especially when small volumes are aimed for. Increasing target volumes to reduces this risk, questions the concept of APBI.

Background and Purpose: The safety of a simultaneous integrated boost (SIB) in combination with prone hypofractionated whole-breast irradiation (WBI) was investigated., Materials and Methods: 167 patients were randomized between WBI with a sequential boost (SeB) or SIB. All patients were treated in prone position to 40.05Gy in 15 fractions to the whole breast. In the control arm, a SeB of 10Gy in 4 fractions (negative surgical margins) or 14.88Gy in 6 fractions (transsection) was prescribed. In the experimental arm a SIB of 46.8 or 49.95Gy (negative and positive surgical margins, respectively) was prescribed., Results: Patient age was the only significantly different parameter between treatment arms with patients in the SIB arm being slightly older. In both arms, 6/83 patients developed moist desquamation. Grade 2/3 dermatitis was significantly more frequent in the SeB arm (38/83vs 24/83 patients, p=0.037). In the SIB and SeB arm, respectively, 36 patients (43%) and 51 patients (61%) developed pruritus (p=0.015). The incidence of oedema was lower in the SIB arm (59vs 68 patients), but not statistically significant (p=0.071)., Conclusions: The primary endpoint, moist desquamation, was not significantly different between treatment arms., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To report the 2-year cosmetic outcome of a randomized trial comparing prone and supine whole-breast irradiation in large-breasted patients., Methods and Materials: One hundred patients with a (European) cup size ≥C were included. Before and 2 years after radiation therapy, clinical endpoints were scored and digital photographs were taken with the arms alongside the body and with the arms elevated 180°. Three observers rated the photographs using the 4-point Harvard cosmesis scale. Cosmesis was also evaluated with the commercially available Breast Cancer Conservation Treatment.cosmetic results (BCCT.core) software., Results: Two-year follow-up data and photographs were available for 94 patients (47 supine treated and 47 prone treated). Patient and treatment characteristics were not significantly different between the 2 cohorts. A worsening of color change occurred more frequently in the supine than in the prone cohort (19/46 vs 10/46 patients, respectively, P=.04). Five patients in the prone group (11%) and 12 patients in the supine group (26%) presented with a worse scoring of edema at 2-year follow-up (P=.06). For retraction and fibrosis, no significant differences were found between the 2 cohorts, although scores were generally worse in the supine cohort. The cosmetic scoring by 3 observers did not reveal differences between the prone and supine groups. On the photographs with the hands up, 7 patients in the supine group versus none in the prone group had a worsening of cosmesis of 2 categories using the BCCT.org software (P=.02)., Conclusion: With a limited follow-up of 2 years, better cosmetic outcome was observed in prone-treated than in supine-treated patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Deep inspiration breath hold in the prone position causes a caudal shift of the heart away from the nearly unmodified breast and internal mammary lymph node region, suggesting better heart protection for left-sided whole breast irradiation with or without regional nodal radiotherapy., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background and Purpose: Comparison of acute toxicity of whole-breast irradiation (WBI) in prone and supine positions., Materials and Methods: This non-blinded, randomized, prospective, mono-centric trial was undertaken between December 29, 2010, and December 12, 2012. One hundred patients with large breasts were randomized between supine multi beam (MB) and prone tangential field (TF) intensity modulated radiotherapy (IMRT). Dose-volume parameters were assessed for the breast, heart, left anterior descending coronary artery (LAD), ipsilateral lung and contralateral breast. The primary endpoint was acute moist skin desquamation. Secondary endpoints were dermatitis, edema, pruritus and pain., Results: Prone treatment resulted in: improved dose coverage (p<0.001); better homogeneity (p<0.001); less volumes of over-dosage (p=0.001); reduced acute skin desquamation (p<0.001); a 3-fold decrease of moist desquamation p=0.04 (chi-square), p=0.07 (Fisher's exact test)); lower incidence of dermatitis (p<0.001), edema (p=0.005), pruritus (p=0.06) and pain (p=0.06); 2- to 4-fold reduction of grades 2-3 toxicity; lower ipsilateral lung (p<0.001) and mean LAD (p=0.007) dose; lower, though statistically non-significant heart and maximum LAD., Conclusions: This study provides level I evidence for replacing the supine standard treatment by prone IMRT for whole-breast irradiation in patients with large breasts. A confirmatory trial in a multi-institutional setting is warranted., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Purpose To quantify the influence on heart dose metrics of prone left-sided whole-breast irradiation in an end-inspiratory phase (Pr IN ) versus an end-expiratory phase (Pr EX ). Patients and methods Twenty patients underwent CT-simulation in Pr IN and Pr EX . Dynamic intensity-modulated radiotherapy was planned for whole-breast irradiation with a median prescription dose of 40.05 Gy in 15 fractions and maximal sparing of the organs at risk. Dose–volume parameters were analyzed for heart, left anterior descending coronary artery, ipsilateral lung and both breasts. Results Pr IN consistently reduced ( P < 0.001) heart and left anterior descending coronary artery dose metrics compared to Pr EX . Population averages for maximum and mean heart dose were 6.2 Gy and 1.3 Gy for Pr IN versus 21.4 Gy and 2.5 Gy for Pr EX , respectively. Moreover, a maximum heart dose less than 10 Gy was achieved in 80% of patients for Pr IN . Target dose distribution, ipsilateral lung and contralateral breast sparing by radiation dose were similar for both procedures. Conclusions Inspiratory gating consistently reduced heart dose metrics pointing to a possible benefit of breathing-adapted radiotherapy for prone left-sided whole-breast irradiation. [ABSTRACT FROM AUTHOR]