Radiation burden from modern radiation therapy techniques including proton therapy for breast cancer treatment - clinical implications

................................................................................................................... 1 SAMMANFATTNING ................................................................................................... 3 LIST OF PAPERS ........................................................................................................... 5 ABBREVIATIONS ......................................................................................................... 7 1. INTRODUCTION .................................................................................................... 9 1.1 Epidemiology of breast cancer ........................................................................... 9 1.2 Diagnosis of breast cancer ................................................................................ 10 1.3 Treatment of breast cancer ............................................................................... 11 1.3.1 Surgery in breast cancer ......................................................................... 11 1.3.2 Systemic therapy in breast cancer ........................................................... 11 1.3.3 Radiation therapy for breast cancer ....................................................... 12 2. MODERN RADIATION THERAPY FOR BREAST CANCER .......................... 15 2.1 Historical perspective ....................................................................................... 15 2.2. Radiotherapy techniques ................................................................................. 15 2.3. Definition of target volume for breast cancer radiotherapy ............................ 16 2.4. Side effects in breast cancer radiotherapy and relevant organs at risk ............ 17 2.5 Pathogenesis and histopathology of radiation-induced heart and coronary artery damage ......................................................................................................... 20 2.6 Monitoring cardiac side effects ........................................................................ 20 2.7 Tolerance levels and recommendations for the heart ....................................... 21 2.8 Pathogenesis and histopathology of radiation-induced damage to the lung .... 22 2.9 Monitoring lung damage .................................................................................. 22 2.10 Tolerance levels and recommendations for the lung ...................................... 23 3. AIMS ....................................................................................................................... 25 4. MATERIAL AND METHODS .............................................................................. 27 4.1 Patient cohorts .................................................................................................. 27 4.2 Calculation algorithms in photon therapy ........................................................ 28 4.3 Irregular surface compensator (ISC) ................................................................ 28