Impact of deep inspiration breath-hold and fractionation on immune system exposure in breast radiotherapy

Abstract Objective The immune system has been recognized as an organ-at-risk in oesophageal and lung cancers. The potential impact of deep inspiration breath-hold (DIBH) and fractionation on immune system preservation in breast radiation therapy is presently unknown. The aim of this study was to assess the magnitude of the benefit of DIBH and hypofractionation on immune system exposure in adjuvant irradiation of right breast cancers. Methods Ten consecutive patients treated volumetric-modulated arc therapy (VMAT) with DIBH for adjuvant locoregional irradiation of the right breast where included. The effective dose to the immune system (EDIC) was calculated for each patient (the absolute contribution of the lungs, heart, liver and total integral dose to the EDIC was evaluated) based on normo-fractionated and hypofractionated regimens, with or without DIBH. Results EDIC was significantly lower in DIBH than in free breathing, both in standard fractionation (2.81 Gy [range: 2.44; 3.38] vs 3.1 Gy [2.63; 3.94], P < . 01) and hypofractionation (2.15 Gy [1.87; 2.58] vs 2.35 Gy [2.02; 2.96], P < .01), corresponding to a relative EDIC reduction of approximately 10% with DIBH. EDIC was lower with hypofractionation with free breathing than with conventional fractionation with DIBH (P < .01). Conclusion DIBH significantly reduces the dose to the immune system by 10% in cases of locoregional irradiation of right breast cancers, and moderate hypofractionation results in an EDIC gain compared with any standard fractionation treatment. Pending formal demonstration of a relationship between dose to the immune system and survival, as is the case in other localizations, we suggest as a precaution the use of DIBH combined with hypofractionated treatment in cases where immune sparing seems most important, such as breast cancers with a poor response after preoperative immunotherapy. Advances in knowledge DIBH significantly reduces the dose to the immune system by 10% in cases of locoregional irradiation of right breast cancers, and moderate hypofractionation results in an EDIC gain compared with any standard fractionation treatment. Pending formal demonstration of a relationship between dose to the immune system and survival, as is the case in other localizations, we suggest as a precaution the use of DIBH combined with hypofractionated treatment in cases where immune sparing seems most important, such as breast cancers with a poor response after preoperative immunotherapy.