Dosimetric evaluation of different radiotherapy techniques in mastectomized left-sided breast cancer

Context: Inclusion of internal mammary lymph nodes in mastectomized left breast cancer radiotherapy may lead to high dose receiving risk of the heart, lung, and contralateral breast. Aim: The aim of this study is to compare the dosimetric differences of field-in-field (FIF), volumetric-modulated arc therapy (VMAT), seven-field intensity-modulated radiotherapy (7F-IMRT), and helical tomotherapy (HT) planning techniques for mastectomized left breast cancer. Materials and Methods: Computed tomography images of ten patients treated with the FIF technique were used to compare four different treatment planning techniques. Planning target volume (PTV) included chest wall and regional lymph nodes. The heart, left anterior descending coronary artery (LAD), left and whole lung, thyroid, esophagus, and contralateral breast were identified as organs-at-risks (OARs). Except for HT, a single isocenter in PTV and bolus of thickness 0.3 cm on the chest wall was used. Complete and directional blocks were applied in HT, and the dosimetric parameters of PTV and OARs for four different techniques were analyzed using the Kruskal-Wallis test. Results: 7F-IMRT, VMAT, and HT were superior to the FIF technique in providing homogeneous dose distribution covering the PTV (P < 0.0001). Mean doses (D-mean) of the contralateral breast and esophagus, lung, and body-PTV V-5 (volume receiving 5 Gy) were reduced in FIF, whereas in the HT, Heart D-mean, LAD D-mean, D-max, healthy tissue (body-PTV) D-mean, heart and left lung V-20, and thyroid V-30 were significantly reduced (P < 0.0001). Conclusions: FIF and HT techniques were found to be significantly advantageous over 7F-IMRT and VMAT for OARs. Using those three multiple-beam techniques reduced high-dose volumes of healthy tissues and organs in mastectomized left breast cancer radiotherapy but also increased low-dose volumes and contralateral lung and breast doses. Complete and directional blocks applied in HT reduce heart, lung, and contralateral breast doses.