PMID- 33836910 OWN - NLM STAT- MEDLINE DCOM- 20211124 LR - 20211124 IS - 1873-4022 (Electronic) IS - 1873-4022 (Linking) VI - 46 IP - 3 DP - 2021 Autumn TI - Challenges in lung and heart avoidance for postmastectomy breast cancer radiotherapy: Is automated planning the answer? PG - 295-303 LID - S0958-3947(21)00021-2 [pii] LID - 10.1016/j.meddos.2021.03.002 [doi] AB - Postmastectomy radiotherapy (PMRT) has been shown to improve the overall survival for invasive breast cancer patients. However, it represents a challenging treatment geometry and individualized planning strategies with complex field arrangements are usually adopted to decrease radiotoxicity to heart and lungs. Automated treatment planning has the potential to improve plan quality consistency and planning efficiency. Herein, we describe the application of the Pinnacle(3) Autoplanning engine as a valuable technological resource able to allow the treatment of challenging patients theoretically unfit for radiotherapy for major cardiac and pulmonary comorbidities. Treatment was planned for three left-sided chest wall and regional lymph-nodes postmastectomy breast cancer patients. A deep inspiration breath-hold (DIBH) technique was used aiming to reduce the OARs irradiation. Three manually generated plans (hybrid-IMRT (HMRT), hybrid-VMAT (HVMAT) and full VMAT (MP-VMAT) and a fully automated plan created by the Autoplanning engine (AP-VMAT) were optimized in order to ensure a safe radiation therapy to the patients. The plans were evaluated based on planning target volumes (PTVs) coverage, dose homogeneity index (HI), conformity index (CN), dose to organs at risk (OARs) and normal tissue complication probabilities (NTCPs) of pericarditis, long term mortality and pneumonitis. Despite the use of deep moderated breath-hold, all human-driven plans failed to reach the stringent dose objectives for OARs. All plans provided an optimal coverage for chest wall and lymph-nodal area. AP-VMAT delivered the lowest mean dose to the heart (3.4 to 4.9 Gy) and ipsilateral lung (7.5 to 12.5 Gy) reporting the lowest NTCP for pneumonitis (<1%), confirming the only chance to comply the dose objectives. Moreover, AP-VMAT reported a decrease of the integral dose, which was lower by about 4-8% with respect to manual plans. AP-VMAT plan resulted in up to 58% increase of MUs with respect to manual plans, suggesting a more pronounced fluence modulation and plan complexity. A major difference was found for the planning time which was reduced to less than 30 minutes by using the Auto-Planning module. With improved planning quality and efficiency, Auto-planning is an effective tool to enable high-quality plans in challenging postmastectomy breast cancer radiotherapy. CI - Copyright (c) 2021 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved. FAU - Cilla, Savino AU - Cilla S AD - Medical Physics Unit, Gemelli Molise Hospital, Universita Cattolica del Sacro Cuore, Campobasso, Italy. Electronic address: savino.cilla@gemellimolise.it. FAU - Macchia, Gabriella AU - Macchia G AD - Radiation Oncology Unit, Gemelli Molise Hospital, Universita Cattolica del Sacro Cuore, Campobasso, Italy. FAU - Romano, Carmela AU - Romano C AD - Medical Physics Unit, Gemelli Molise Hospital, Universita Cattolica del Sacro Cuore, Campobasso, Italy. FAU - Morabito, Vittoria Emanuela AU - Morabito VE AD - Medical Physics Unit, Gemelli Molise Hospital, Universita Cattolica del Sacro Cuore, Campobasso, Italy. FAU - Boccardi, Mariangela AU - Boccardi M AD - Radiation Oncology Unit, Gemelli Molise Hospital, Universita Cattolica del Sacro Cuore, Campobasso, Italy. FAU - Picardi, Vincenzo AU - Picardi V AD - Radiation Oncology Unit, Gemelli Molise Hospital, Universita Cattolica del Sacro Cuore, Campobasso, Italy. FAU - Valentini, Vincenzo AU - Valentini V AD - Radiation Oncology Department, Fondazione Policlinico Universitario A. Gemelli, Universita Cattolica del Sacro Cuore, Rome, Italy; Istituto di Radiologia, Universita Cattolica del Sacro Cuore, Rome, Italy. FAU - Morganti, Alessio Giuseppe AU - Morganti AG AD - Radiation Oncology, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy; DIMES, Alma Mater Studiorum, Bologna University, Bologna, Italy. FAU - Deodato, Francesco AU - Deodato F AD - Radiation Oncology Unit, Gemelli Molise Hospital, Universita Cattolica del Sacro Cuore, Campobasso, Italy; Istituto di Radiologia, Universita Cattolica del Sacro Cuore, Rome, Italy. LA - eng PT - Journal Article DEP - 20210406 PL - United States TA - Med Dosim JT - Medical dosimetry : official journal of the American Association of Medical Dosimetrists JID - 8908862 SB - IM MH - *Breast Neoplasms/radiotherapy/surgery MH - Female MH - Humans MH - Lung MH - Mastectomy MH - Organs at Risk MH - Radiotherapy Dosage MH - Radiotherapy Planning, Computer-Assisted MH - *Radiotherapy, Intensity-Modulated OTO - NOTNLM OT - Autoplanning OT - Breast OT - Breath-hold OT - Chest wall OT - VMAT COIS- Declaration of Competing Interest There are no conflicts of interest to declare. EDAT- 2021/04/11 06:00 MHDA- 2021/11/25 06:00 CRDT- 2021/04/10 05:33 PHST- 2020/10/07 00:00 [received] PHST- 2021/02/24 00:00 [revised] PHST- 2021/03/02 00:00 [accepted] PHST- 2021/04/11 06:00 [pubmed] PHST- 2021/11/25 06:00 [medline] PHST- 2021/04/10 05:33 [entrez] AID - S0958-3947(21)00021-2 [pii] AID - 10.1016/j.meddos.2021.03.002 [doi] PST - ppublish SO - Med Dosim. 2021 Autumn;46(3):295-303. doi: 10.1016/j.meddos.2021.03.002. Epub 2021 Apr 6.