Breast-Conserving Radiotherapy with Simultaneous Integrated Boost—A Dosimetric Comparison of 3DCRT, VMAT and IMRT: Do We Really have a Better Plan?

  • Bindhu JosephEmail author
  • Vedamanasa Ikkurthi
  • Nisma Farooq
  • K. Nithin
  • C. R. Vijay
  • C. Ramesh
  • V. Lokesh
Original Article


Background and Purpose

The availability of more advanced technology like hypo-fractionation has the potential of being the new standard of care in breast cancer. This study evaluates whether 3DCRT with a field-in-field technique (FIF) and a simultaneous integrated boost (SIB) could provide a dosimetrically comparable plan delivered to VMAT or IMRT.

Materials and Methods

3DCRT-FIF-SIB, VMAT and IMRT-SIB plans were generated for 20 patients. The plans were compared for planning target volume coverage (PTV 95), homogeneity and conformity, dose delivered to lungs, heart and C/L breast.


3DCRT FIF provided better sparing of C/L breast V1 and V5, whole lung V5, p = 0.000. The VMAT plans spared heart V30: (0.1 ± 0.46 vs. 11.5 ± 18.3) p = 0.000 and I/L lung V20: (19.3 ± 5 vs. 32.2 ± 11.1) p = 0.000. It provided a better coverage V95: (97 ± 0.8 vs. 95 ± 2.9) p = 0.002 and sparing of the heart V30: (0.1 ± 0.5 vs. 8.6 ± 11.5) p < 0.002 and lungs I/L V20: (19.3 ± 5.0 vs. 30.7 ± 6.1) p = 0.000. The treatment was faster with less exposure in terms of MU: (529 ± 57.8 vs. 1024 ± 298) p = 0.000.


3DCRT provides a dosimetrically acceptable alternative to more advanced technologies. VMAT and IMRT provide better sparing of heart and lungs. VMAT has a slight benefit of conformity, reduced exposure and shorter treatment time.




Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Human and Animal Rights Statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Shelley W, Brundage M, Hayter C, Paszat L, Zhou S, Mackillop W. A shorter fractionation schedule for post lumpectomy breast cancer patients. Int J Radiat Oncol Biol Phys. 2000;47(5):1219–28.CrossRefGoogle Scholar
  2. 2.
    Kim KS, Shin KH, Choi N, Lee SW. Hypofractionated whole breast irradiation: new standard in early breast cancer after breast-conserving surgery. Radiat Oncol J. 2016;34(2):81.CrossRefGoogle Scholar
  3. 3.
    Yarnold J, Ashton A, Bliss J, Homewood J, Harper C, Hanson J, et al. Fractionation sensitivity and dose response of late adverse effects in the breast after radiotherapy for early breast cancer: long- term results of a randomised trial. Radiother Oncol. 2005;75:9–17.CrossRefGoogle Scholar
  4. 4.
    Owen JR, Ashton A, Bliss JM, Homewood J, Harper C, Hanson J, et al. Effect of radiotherapy fraction size on tumour control in patients with early- stage breast cancer after local tumour excision: long- term results of a randomised trial. Lancet Oncol. 2006;7:467–71.CrossRefGoogle Scholar
  5. 5.
    START Trialists’ Group, Bentzen SM, Agrawal RK, Aird EG, Barrett JM, Barrett-Lee PJ, et al. The UK standardisation of breast radiotherapy (START) trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet Oncol. 2008;9:331–41.CrossRefGoogle Scholar
  6. 6.
    START Trialists’ Group, Bentzen SM, Agrawal RK, Aird EG, Barrett JM, Barrett-Lee PJ, et al. The UK standardisation of breast radiotherapy (START) trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet. 2008;371:1098–107.CrossRefGoogle Scholar
  7. 7.
    Joseph B, Farooq N, Kumar S, Vijay CR, Puthur KJ, Ramesh C, Lokesh V. Breast-conserving radiotherapy with simultaneous integrated boost; field-in-field three-dimensional conformal radiotherapy versus inverse intensity-modulated radiotherapy—a dosimetric comparison: Do we need intensity-modulated radiotherapy? South Asian J Cancer. 2018;7(3):163.CrossRefGoogle Scholar
  8. 8.
    Moorthy S, Sakr H, Hasan S, Samuel J, Al-Janahi S, Murthy N. Dosimetric study of SIB-IMRT versus SIB-3DCRT for breast cancer with breath-hold gated technique. Int J Cancer Ther Oncol. 2013;1(1):010110.Google Scholar
  9. 9.
    Kannan V, Bajpai R. Conforming modern radiation oncology facilities to the irregular contours of the vast and varied nation of India. Int J Radiat Oncol Biol Phys. 2016;94(4):645–51.CrossRefGoogle Scholar
  10. 10.
  11. 11.
    van der Laan HP, Dolsma WV, Maduro JH, Korevaar EW, Hollander M, Langendijk JA. Three-dimensional conformal simultaneously integrated Boost technique for breast-conserving radiotherapy. Int J Radiat Oncol Biol Phys. 2007;68(4):1018–23.CrossRefGoogle Scholar
  12. 12.
    Herbert C, Nichol A, Olivotto I, Weir L, Woods R, Speers C, Truong P, Tyldesley S. The impact of hypofractionated whole breast radiotherapy on local relapse in patients with grade 3 early breast cancer: a population-based cohort study. Int J Radiat Oncol Biol Phys. 2012;82(5):2086–92.CrossRefGoogle Scholar
  13. 13.
    Yarnold J, Haviland J. Pushing the limits of hypofractionation for adjuvant whole breast radiotherapy. Breast. 2010;19(3):176–9.CrossRefGoogle Scholar
  14. 14.
    Deantonio L, Gambaro G, Beldì D, Masini L, Tunesi S, Magnani C, Krengli M. Hypofractionated radiotherapy after conservative surgery for breast cancer: analysis of acute and late toxicity. Radiat Oncol. 2010;5(1):112.CrossRefGoogle Scholar
  15. 15.
    Jagsi R, Griffith KA, Boike TP, Walker E, Nurushev T, Grills IS, Moran JM, Feng M, Hayman J, Pierce LJ. Differences in the acute toxic effects of breast radiotherapy by fractionation schedule: comparative analysis of physician-assessed and patient-reported outcomes in a large multicenter cohort. JAMA Oncol. 2015;1(7):918–30.CrossRefGoogle Scholar
  16. 16.
    Sioshansi S, Rivard MJ, Hiatt JR, Hurley AA, Lee Y, Wazer DE. Dose modeling of noninvasive image-guided breast brachytherapy in comparison to electron beam boost and three-dimensional conformal accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys. 2011;80(2):410–6.CrossRefGoogle Scholar
  17. 17.
    Baycan D, Karacetin D, Balkanay AY, Barut Y. Field-in-field IMRT versus 3D-CRT of the breast. Cardiac vessels, ipsilateral lung, and contralateral breast absorbed doses in patients with left-sided lumpectomy: a dosimetric comparison. Jpn J Radiol. 2012;30(10):819–23.CrossRefGoogle Scholar
  18. 18.
    Singla R, King S, Albuquerque K, Creech S, Dogan N. Simultaneous-integrated boost intensity-modulated radiation therapy (SIB-IMRT) in the treatment of early-stage left-sided breast carcinoma. Med Dosim. 2006;31(3):190–6.CrossRefGoogle Scholar
  19. 19.
    Guerrero M, Li XA, Earl MA, Sarfaraz M, Kiggundu E. Simultaneous integrated boost for breast cancer using IMRT: a radiobiological and treatment planning study. Int J Radiat Oncol Biol Phys. 2004;59(5):1513–22.CrossRefGoogle Scholar
  20. 20.
    Michalski A, Atyeo J, Cox J, Rinks M, Morgia M, Lamoury G. A dosimetric comparison of 3D-CRT, IMRT, and static tomotherapy with an SIB for large and small breast volumes. Med Dosim. 2014;39(2):163–8.CrossRefGoogle Scholar
  21. 21.
    Bucci MK, Bevan A, Roach M. Advances in radiation therapy: conventional to 3D, to IMRT to 4D, and beyond. CA Cancer J Clin. 2005;55(2):117–34.CrossRefGoogle Scholar
  22. 22.
    van der Laan HP, Dolsma WV, Schilstra C, Korevaar EW, de Bock GH, Maduro JH, Langendijk JA. Limited benefit of inversely optimised intensity modulation in breast conserving radiotherapy with simultaneously integrated boost. Radiother Oncol. 2010;94(3):307–12.CrossRefGoogle Scholar
  23. 23.
    Hurkmans CW, Meijer GJ, van Vliet-Vroegindeweij C, van der Sangen MJ, Cassee J. High-dose simultaneously integrated breast boost using intensity-modulated radiotherapy and inverse optimization. Int J Radiat Oncol Biol Phys. 2006;66(3):923–30.CrossRefGoogle Scholar
  24. 24.
    Hijal T, Fournier-Bidoz N, Castro-Pena P, Kirova YM, Zefkili S, Bollet MA, Dendale R, Campana F, Fourquet A. Simultaneous integrated boost in breast conserving treatment of breast cancer: a dosimetric comparison of helical tomotherapy and three-dimensional conformal radiotherapy. Radiother Oncol. 2010;94(3):300–6.CrossRefGoogle Scholar

Copyright information

© Association of Gynecologic Oncologists of India 2019

Authors and Affiliations

  • Bindhu Joseph
    • 1
    • 4
    Email author
  • Vedamanasa Ikkurthi
    • 1
  • Nisma Farooq
    • 1
  • K. Nithin
    • 2
  • C. R. Vijay
    • 3
  • C. Ramesh
    • 3
  • V. Lokesh
    • 1
  1. 1.Department of Radiation OncologyKidwai Memorial Institute of OncologyBangaloreIndia
  2. 2.Department of Medical PhysicistKidwai Memorial Institute of OncologyBangaloreIndia
  3. 3.Department of Epidemiology and BiostatisticsKidwai Memorial Institute of OncologyBangaloreIndia
  4. 4.BangaloreIndia

Personalised recommendations