Heterogeneity-corrected vs -uncorrected critical structure maximum point doses in breast balloon brachytherapy

Recent studies have reported potentially clinically meaningful dose differences when heterogeneity correction is used in breast balloon brachytherapy. In this study, we report on the relationship between heterogeneity-corrected and -uncorrected doses for 2 commonly used plan evaluation metrics: maximum point dose to skin surface and maximum point dose to ribs. Maximum point doses to skin surface and ribs were calculated using TG-43 and Varian Acuros for 20 patients treated with breast balloon brachytherapy. The results were plotted against each other and fit with a zero-intercept line. Max skin dose (Acuros) = max skin dose (TG-43) * 0.930 (R(2) = 0.995). The average magnitude of difference from this relationship was 1.1% (max 2.8%). Max rib dose (Acuros) = max rib dose (TG-43) * 0.955 (R(2) = 0.9995). The average magnitude of difference from this relationship was 0.7% (max 1.6%). Heterogeneity-corrected maximum point doses to the skin surface and ribs were proportional to TG-43-calculated doses. The average deviation from proportionality was 1%. The proportional relationship suggests that a different metric other than maximum point dose may be needed to obtain a clinical advantage from heterogeneity correction. Alternatively, if maximum point dose continues to be used in recommended limits while incorporating heterogeneity correction, institutions without this capability may be able to accurately estimate these doses by use of a scaling factor.