Voluntary breath-holding for breast cancer radiotherapy is consistent and stable

Objective: To evaluate breath-hold stability and constancy for a voluntary breath-hold (VBH) technique in a retrospective analysis. Methods: Movie loop sequences of electronic portal image data from multiple breath holds in a cohort of 19 patients were used to assess within and between breath-hold stability. In vivo dosimetry data based on electronic portal imaging (EPI) were analysed for 31 VBH patients plus a cohort of free-breathing (FB) patients to provide a reference. A phantom experiment simulated the impact on dose of FB, breath hold and unplanned release of breath hold. Results: 165/174 (93%) movie loop data sets had no detectable displacement. For the remaining 12, median displacement = 1.5 mm and maximum displacement = 3 mm (one patient on one fraction). In vivo dosimetry data analysis showed a median dose difference measured to planned of 20.2% (VBH) and -0.1% (FB). Dose distribution evaluation (gamma) pass rates were 84% (VBH) and 91% (FB) including the lung region; 93% and 96% with a lung override. Unplanned release of phantom breath-hold position changed median dose by <= 1% and degraded g pass rates to 79-62%. Failing regions were mostly in the periphery of the treated volume. Conclusion: The data confirmed that multiple VBHs using visual monitoring are stable; in vivo dose verification via EPI was within expected and acceptable levels. Advances in knowledge: These data provide further reassurance that VBH is a safe technique for cardiac sparing breast radiotherapy and support its rapid, widespread implementation.