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Deep inspiration breath hold (DIBH) radiotherapy is used routinely for cardiac avoidance in patients with left-sided breast cancer. Reports on the value of DIBH for those with right-sided breast cancer (RBC) remain conflicting with some suggesting that the use of modern planning techniques negates much of the benefit of DIBH for organs at risk (OARs) in RBC.  As the delivery of DIBH can be resource and time-consuming, departmental policies for DIBH in RBC should be based on evidence of benefit. This computer-based study quantified the potential benefit that would accrue from DIBH – in addition to a modern planning technique -in a specific subgroup of those with RBC requiring RT to the breast and all regional nodal levels-I-IV-in addition to the internal mammary chain nodes (IMC).

The study database was formed from corresponding free breathing (FB) and Deep inspiration breath hold (DIBH) Computed Tomography (CT) datasets of 10 randomly selected patients, who had previously received surface-guided, DIBH radiotherapy for RBC. All targets and OARs were re-contoured, in both corresponding sets, using ESTRO guidelines. These included the ipsilateral breast, tumour bed, and regional node levels I-IV and IMC in addition to the total lung, ipsilateral lung, contralateral breast, heart, liver, head of the right humerus (HH), spinal cord, and thyroid. Plans were generated using a dynamic MLC, inverse planning technique, reviewed and results analysed statistically.

The total lung V20, V10 and V5   and the Ipsilateral Lung V17 all had statistically significant reductions in DIBH when compared to FB (p=0.005, p=0.005, p=0.001 & p=0.005) resulting in absolute decreases of 5%. The mean lung dose did not change.  The mean heart dose was also statistically significantly reduced but was already below 2Gy in both FB and DIBH: 1.4Gy vs 0.9Gy. The heart V2 reduced from 8.9% to 5.9% with DIBH (p=0.008) and the maximum dose to the heart was halved from 16.8Gy to 9.78Gy p=0.02 by DIBH. The mean dose to liver was not significantly different but the maximum dose to the liver was reduced by 25% and V20 and V10 also improved with the use of DIBH (p=0.005) The mean dose to the HH increased by 2Gy with DIBH: 10.8Gy vs 12.9Gy, p=0.03.   None of the following parameters were reduced by DIBH when compared to FB: the maximum dose to the cord, the maximum, mean and V20 of the thyroid and mean dose to the contralateral breast.

This preliminary study suggests that modern planning techniques in FB may achieve target coverage with equal toxicity when compared to DIBH, in this specific subgroup of RBC. Further expansion of the study to look at this and the impact of other factors e.g. addition of tumour bed boost should be considered. The correlation between clinical toxicity and the reduction in dose parameters to OARs by DIBH should be undertaken e.g. dose to the liver in those who require hypo-fractionated, 1 week courses.