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  • br Practical Radiation Oncology May


    Practical Radiation Oncology: May-June 2019 Cardiac segment radiation doses breast cancer 161
    A Midline photon tangents B Wide photon tangents
    C Direct KRN 7000 IMC D Oblique electron chest wall
    Direct electron chest wall, lateral thorax photons
    Oblique cobalt IMC,
    oblique cobalt chest wall
    G Direct cobalt bilateral IMC H Direct cobalt IMC, oblique electron chest wall
    Table 1 Mean radiation therapy doses to myocardial structures from left-sided breast cancer radiation therapy regimens used in Sweden (1958-2001) or Denmark (1978-2000)
    Radiation therapy regimen*
    Mean cardiac doses (Gy)y
    Country Median Medial Field arrangementz,x Usual Dose
    Left ventricular myocardial segments
    Year Border r> Heart Left Right
    Apex Lateral Inferior Septal Anterior
    energy Gy
    Anterior electron or orthovoltage
    Anterior megavoltage
    Practical Radiation Oncology: May-June 2019
    Practical Radiation Oncology: May-June 2019
    supraclavicular fossa
    orthovoltage tangents
    60ZZZZZZZcobalt60;contracontralateral;IMCinternalmammarychain;kVkilovoltage;latlateral;MeVmegaelectron-volts;MVmegavoltage;SCF electronororthovoltageregimensareobliqueelectronelds,othersincludedirectelds.fifi
    Meancardiacdosesestimatedusingmanualplanning(ie,orthovoltageandcobaltchain)aregiventothenearestGy. RegimensathroughpareillustratedinFigures1andE1(availableonlineat Regimens1through7werereconstructedon10scanstostudytheeffectofpatientanatomyonsegmentdoses(Figs.3-5). except 23
    center of
    dose delivered
    regimens the
    , and for tangential
    Bold tangential regimens are wide tangents, others are midline tangents. Bold anterior
    Abbreviations:Co * For further details on the radiation therapy regimens, see Table E1.y z x where the total dose was the skin dose at the surface of the breast.k ** For a description of cobalt chain, see Taylor (2009).
    Cardiac segment radiation doses breast cancer 163
    because interpatient variability in cardiac dose is usually lower from right radiation therapy.22
    For each regimen, interpatient variability in mean doses was calculated as the difference between the highest and lowest mean doses recorded for each cardiac segment. Interpatient variability in hotspot doses was calculated as the difference between the highest and lowest hotspot doses recorded for each cardiac segment. The hotspot doses recorded included D2cc (minimum dose covering the hottest 2.0 cc) of the ventricular myocardium (right ventricle [RV] and LV combined) and D0.5cc (minimum dose covering the hottest 0.5 cc) of the main coronary arteries (left main coronary artery, left-anterior descending coronary artery [LADCA], right coronary artery [RCA], and circumflex coronary artery [Cx] combined).
    Correlation analyses between cardiac segment and whole heart doses, and between coronary artery segment and LV segment doses, were performed using STATA, version 13.2 (StataCorp, College Station, TX).
    A total of 41 regimens were identified from 470 ra-diation therapy charts, including 20 regimens for left breast cancer, 20 for right cancer, and 1 that was the same for left and right cancers (Fig. 1, Fig. E1, Table E1).
    Tangential regimens
    For left megavoltage tangential radiation therapy, cardiac doses were determined mainly by the position of the medial border and divergence of the posterior border (Tables 1, 2, E3, and E4 [available online https://doi. org/10.1016/j.prro.2019.01.004], Fig. 2). For left midline megavoltage tangents, the mean doses were 6.0 Gy to 7.6 Gy for LV and 3.0 Gy to 4.7 Gy for RV (Table 1, Fig. 2A). For left wide megavoltage tangents with a divergent posterior field border, both ventricles received 12.5 Gy, but for the partially wide tangents, both ventricles received <6.1 Gy (Table 1, Fig. 2B). For the left megavoltage tangents, the mean individual LV segment doses varied substantially (range, 0.6-38.8 Gy). The LV apex received the highest doses of 22.5 Gy. The anterior LV segment received 11.7 Gy from the wide divergent and partially wide megavoltage tangents but 9.2 Gy from the midline megavoltage tangents. The LV septal segment received 12.8 Gy from the wide divergent megavoltage tangents but 5.3 Gy from partially wide and midline megavoltage tangents. The lateral and inferior segments were further from the fields and received 6.4 Gy from all left megavoltage tangents.