Evaluation of a mixed beam therapy for postmastectomy breast cancer patients: Bolus electron conformal therapy combined with intensity modulated photon radiotherapy and volumetric modulated photon arc therapy.

PURPOSE: The purpose of this study was to assess the potential benefits and limitations of a mixed beam therapy, which combined bolus electron conformal therapy (BECT) with intensity modulated photon radiotherapy (IMRT) and volumetric modulated photon arc therapy (VMAT), for left-sided postmastectomy breast cancer patients.

METHODS: Mixed beam treatment plans were produced for nine postmastectomy radiotherapy (PMRT) patients previously treated at our clinic with VMAT alone. The mixed beam plans consisted of 40 Gy to the chest wall area using BECT, 40 Gy to the supraclavicular area using parallel opposed IMRT, and 10 Gy to the total planning target volume (PTV) by optimizing VMAT on top of the BECT + IMRT dose distribution. The treatment plans were created in a commercial treatment planning system (TPS), and all plans were evaluated based on PTV coverage, dose homogeneity index (DHI), conformity index (CI), dose to organs at risk (OARs), normal tissue complication probability (NTCP), and secondary cancer complication probability (SCCP). The standard VMAT alone planning technique was used as the reference for comparison.

RESULTS: Both techniques produced clinically acceptable PMRT plans but with a few significant differences: VMAT showed significantly better CI (0.70 vs 0.53, P < 0.001) and DHI (0.12 vs 0.20, P < 0.001) over mixed beam therapy. For normal tissues, mixed beam therapy showed better OAR sparing and significantly reduced NTCP for cardiac mortality (0.23% vs 0.80%, P = 0.01) and SCCP for contralateral breast (1.7% vs 3.1% based on linear model, and 1.2% vs 1.9% based on linear-exponential model, P < 0.001 in both cases), but showed significantly higher mean (50.8 Gy vs 49.3 Gy, P < 0.001) and maximum skin doses (59.7 Gy vs 53.3 Gy, P < 0.001) compared with VMAT. Patients with more tissue (minimum distance between the distal PTV surface and lung approximately > 0.5 cm and volume of tissue between the distal PTV surface and heart or lung approximately > 250 cm3 ) between distal PTV surface and lung may benefit the most from mixed beam therapy.

CONCLUSION: This work has demonstrated that mixed beam therapy (BECT + IMRT:VMAT = 4:1) produces clinically acceptable plans having reduced OAR doses and risks of side effects compared with VMAT. Even though VMAT alone produces more homogenous and conformal dose distributions, mixed beam therapy remains as a viable option for treating postmastectomy patients, possibly leading to reduced normal tissue complications.