Abstract P3-19-02: Should deep inspiration breath hold scans be standardly acquired for right-sided breast/chestwall and regional nodal irradiation?
Authors: Jhawar Sachin R , Lindsey Kylee , Kuhn Karla , Tedrick Kayla , Zoller Ian , Taylor William , Cochran Eric , Healy Erin , Beyer Sasha , White Julia , Bazan Jose G 
Published: March 2022

Abstract
Background: Adjuvant regional nodal irradiation (RNI) after breast conserving surgery or mastectomy is supported by clinical trials for patients with node-positive breast cancer. RNI results in increased radiation dose to organs-at-risk (OARs) such as the heart and lungs. While regular acquisition of both free breathing (FB) and deep inspiration breath hold (DIBH) scans has been widely adopted for left-sided breast cancers (LBCs) as a cardiac-sparing technique, DIBH scans are not routinely acquired for right-sided breast cancers (RBCs). Therefore, when OAR constraints cannot be met with 3D conformal radiation therapy (3DCRT) planning on the FB scan, the only option is intensity modulated radiation therapy (IMRT), with its inherent increased cost, resource utilization, and requirement for insurance authorization. Given these challenges, we have regularly acquired FB and DIBH scans for right-sided RNI since 2018. We hypothesized that acquisition of DIBH scans would result in a reduced need for IMRT and reduced dose to OARs. Methods: We retrospectively identified patients who were treated with right-sided RNI who had both FB and DIBH scans. All patients had target volumes (breast or chest wall and regional lymph nodes [undissected axillary, supraclavicular, and internal mammary nodes]) prospectively contoured on the FBCT scan based upon the RTOG Breast Atlas. This initiated a treatment planning algorithm that began with creating a FB 3DCRT plan and changed to DIBH 3DCRT then FB IMRT when OAR constraints could not be met while maintaining acceptable planning target volume (PTV) coverage. For patients who did not have contours available on the DIBH scan, the treating physician retrospectively completed the PTV contours. For each patient, three total plans were created for comparison using our institutional target coverage and OAR metrics: FB 3DCRT, FB IMRT, and DIBH 3DCRT. We compared PTV coverage and doses to multiple OARs including the contralateral breast, esophagus, heart, lungs (left, right, total lung dose), and liver. PTV coverage and OAR doses were evaluated by a one-way ANOVA followed by Bonferroni comparison. A p &lt; 0.05 was considered statistically significant.Results: We identified 38 patients in whom FB and DIBH scans were acquired. Only 32% (N=12) were treated with the standard FB 3DCRT. Of the remaining 26 patients 73% (N=19) were treated DIBH 3DCRT, and only 27% (N=7) were treated with FB IMRT, resulting in a FB IMRT rate of 18% overall. Without DIBH scans, 68% (N=19) would have advanced to FB IMRT. Dosimetric comparison across these 38 patients (N=114 plans) demonstrated that DIBH 3DCRT had at least equivalent OAR metrics as compared to FB 3DCRT, with significant improvement in max heart dose (9.6 Gy vs. 14.9 Gy; p = 0.034), right lung V20 (32.1% vs 37.8%; p &lt; 0.01), mean total lung dose (8.9 Gy vs. 10.5 Gy; p &lt; 0.01), and mean liver dose (1.8 Gy vs. 4.0 Gy; p &lt; 0.01). FB IMRT plans resulting in significantly lower right lung V20 (26.3% FB IMRT vs. 37.8% FB 3DCRT vs. 32.1% DIBH 3DCRT), but resulted in higher dose to the heart and contralateral breast: mean heart dose (2.2 Gy FB IMRT vs. 1.0 Gy FB 3DCRT vs. 0.9 Gy DIBH 3DCRT; p &lt; 0.01), maximum heart dose (16.4 Gy FB IMRT vs. 14.9 Gy FB 3DCRT vs. 9.6 Gy DIBH 3DCRT; p &lt; 0.01) and contralateral breast D5% (5.0 Gy FB IMRT vs. 2.9 Gy FB 3DCRT vs. 3.0 Gy DIBH 3DCRT; p &lt; 0.01).Conclusions: We found that acquiring DIBH scans for RBC patients receiving RNI reduced the need for FB IMRT from 68% to 18%. As compared to FB 3DCRT, DIBH 3DCRT resulted in in equivalent target coverage with significantly lower lung and liver doses. FB IMRT is useful to keep the right lung V20 within acceptable limits at the expense of higher dose to other OARs. Our data support the routine acquisition of DIBH scans in RBC patients undergoing RNI in order to decrease the proportion of patients that require FB IMRT.
Citation Format: Sachin R Jhawar, Kylee Lindsey, Karla Kuhn, Kayla Tedrick, Ian Zoller, William Taylor, Eric Cochran, Erin Healy, Sasha Beyer, Julia White, Jose G Bazan. Should deep inspiration breath hold scans be standardly acquired for right-sided breast/chestwall and regional nodal irradiation? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-02.