Dosimetric impact of source-positioning uncertainty in high-dose-rate balloon brachytherapy of breast cancer

Purpose: To evaluate the dosimetric impact of source-positioning uncertainty in high-dose-rate (HDR) balloon brachytherapy of breast cancer.

Material and methods: For 49 HDR balloon patients, each dwell position of catheter(s) was manually shifted distally (+) and proximally (–) with a magnitude from 1 to 4 mm. Total 392 plans were retrospectively generated and compared to corresponding clinical plans using 7 dosimetric parameters: dose (D₉₅) to 95% of planning target volume for evaluation (PTV_EVAL), and volume covered by 100% and 90% of the prescribed dose (PD) (V₁₀₀ and V₉₀); skin and rib maximum point dose (D_max); normal breast tissue volume receiving 150% and 200% of PD (V₁₅₀ and V₂₀₀).

Results: PTV_EVAL dosimetry deteriorated with larger average/maximum reduction (from ± 1 mm to ± 4 mm) for larger source position uncertainty (p value < 0.0001): from 1.0%/2.5%, 3.3%/5.9%, 6.3%/10.0% to 9.8%/14.5% for D₉₅; from 1.0%/2.6%, 3.1%/5.7%, 5.8%/8.9% to 8.7%/12.3% for V₁₀₀; from 0.2%/1.5%, 1.0%/4.0%, 2.7%/6.8% to 5.1%/10.3% for V₉₀. ≥ ± 3 mm shift reduced average D₉₅ to < 95% and average V₁₀₀ to < 90%. While skin and rib D_max change was case-specific, its absolute change (|Δ(Value)|) showed that larger shift and high dose group had larger variation compared to smaller and lower dose group (p value < 0.0001), respectively. Normal breast tissue V₁₅₀ variation was case-specific and small. Average |Δ(V₁₅₀)| was 0.2 cc for the largest shift (± 4 mm) with maximum < 1.7 cc. V₂₀₀ was increased with higher elevation for larger shift: from 6.4 cc/9.8 cc, 7.0 cc/10.1 cc, 8.0 cc/11.3 cc to 9.2 cc/13.0 cc.

Conclusions: The tolerance of ± 2 mm recommended by AAPM TG 56 is clinically acceptable in most clinical cases. However, special attention should be paid to a case where both skin and rib are located proximally to balloon, and the orientation of balloon catheter(s) is vertical to these critical structures. In this case, sufficient dosimetric planning margins are required.