Evaluation of Hybrid VMAT Advantages and Robustness Considering Setup Errors Using Surface Guided Dose Accumulation for Internal Lymph Mammary Nodes Irradiation of Postmastectomy Radiotherapy

OBJECTIVES: Setup error is a key factor affecting postmastectomy radiotherapy (PMRT) and irradiation of the internal mammary lymph nodes is the most investigated aspect for PMRT patients. In this study, we evaluated the robustness, radiobiological, and dosimetric benefits of the hybrid volumetric modulated arc therapy (H-VMAT) planning technique based on the setup error in dose accumulation using a surface-guided system for radiation therapy. METHODS: We retrospectively selected 32 patients treated by a radiation oncologist and evaluated the clinical target volume (CTV), including internal lymph node irradiation (IMNIs), and considered the planning target volume (PTV) margin to be 5 mm. Three different planning techniques were evaluated: tangential-VMAT (T-VMAT), intensity-modulated radiation therapy (IMRT), and H-VMAT. The interfraction and intrafraction setup errors were analyzed in each field and the accumulated dose was evaluated as the patients underwent daily surface-guided monitoring. These parameters were included while evaluating CTV coverage, the dose required for the left anterior descending artery (LAD) and the left ventricle (LV), the normal tissue complication probability (NTCP) for the heart and lungs, and the second cancer complication probability (SCCP) for contralateral breast (CB). RESULTS: When the setup error was accounted for dose accumulation, T-VMAT (95.51%) and H-VMAT (95.48%) had a higher CTV coverage than IMRT (91.25%). In the NTCP for the heart, H-VMAT (0.04%) was higher than T-VMAT (0.01%) and lower than IMRT (0.2%). However, the SCCP (1.05%) of CB using H-VMAT was lower than that using T-VMAT (2%) as well as delivery efficiency. And T-VMAT (3.72) and IMRT (10.5).had higher plan complexity than H-VMAT (3.71). CONCLUSIONS: In this study, based on the dose accumulation of setup error for patients with left-sided PMRT with IMNI, we found that the H-VMAT technique was superior for achieving an optimum balance between target coverage, OAR dose, complication probability, plan robustness, and complexity.