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Oncol."],"abstract":"<jats:sec><jats:title>Purpose<\/jats:title><jats:p>This study aimed to evaluate the robustness with respect to the positional variations of five planning strategies in free-breathing breast hypofractionated radiotherapy (HFRT) for patients after breast-conserving surgery.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Twenty patients who received breast HFRT with 42.72 Gy in 16 fractions were retrospectively analyzed. Five treatment planning strategies were utilized for each patient, including 1) intensity-modulated radiation therapy (IMRT) planning (IMRT<jats:sub>pure<\/jats:sub>); 2) IMRT planning with skin flash tool extending and filling the fluence outside the skin by 2\u00a0cm (IMRT<jats:sub>flash<\/jats:sub>); 3) IMRT planning with planning target volume (PTV) extended outside the skin by 2\u00a0cm in the computed tomography dataset (IMRT<jats:sub>ePTV<\/jats:sub>); 4) hybrid planning, i.e., 2 Gy\/fraction three-dimensional conformal radiation therapy combined with 0.67 Gy\/fraction IMRT (IMRT<jats:sub>hybrid<\/jats:sub>); and 5) hybrid planning with skin flash (IMRT<jats:sub>hybrid-flash<\/jats:sub>). All plans were normalized to 95% PTV receiving 100% of the prescription dose. Six additional plans were created with different isocenter shifts for each plan, which were 1\u00a0mm, 2\u00a0mm, 3\u00a0mm, 5\u00a0mm, 7\u00a0mm, and 10\u00a0mm distally in the X (left-right) and Y (anterior-posterior) directions, namely, (X,Y), to assess their robustness, and the corresponding doses were recalculated. Variation of dosimetric parameters with increasing isocenter shift was evaluated.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>All plans were clinically acceptable. In terms of robustness to isocenter shifts, the five planning strategies followed the pattern IMRT<jats:sub>ePTV<\/jats:sub>, IMRT<jats:sub>hybrid-flash<\/jats:sub>, IMRT<jats:sub>flash<\/jats:sub>, IMRT<jats:sub>hybrid<\/jats:sub>, and IMRT<jats:sub>pure<\/jats:sub> in descending order. <jats:italic>V<\/jats:italic><jats:sub>95%<\/jats:sub> of IMRT<jats:sub>ePTV<\/jats:sub> maintained at 99.6% \u00b1 0.3% with a (5,5) shift, which further reduced to 98.2% \u00b1 2.0% with a (10,10) shift. IMRT<jats:sub>hybrid-flash<\/jats:sub> yielded the robustness second to IMRT<jats:sub>ePTV<\/jats:sub> with less risk from dose hotspots, and the corresponding <jats:italic>V<\/jats:italic><jats:sub>95%<\/jats:sub> maintained &amp;gt;95% up until (5,5).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Considering the dosimetric distribution and robustness in breast radiotherapy, IMRT<jats:sub>ePTV<\/jats:sub> performed best at maintaining high target coverage with increasing isocenter shift, while IMRT<jats:sub>hybrid-flash<\/jats:sub> would be adequate with positional uncertainty&amp;lt;5\u00a0mm.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fonc.2023.1259851","type":"journal-article","created":{"date-parts":[[2023,10,31]],"date-time":"2023-10-31T11:07:02Z","timestamp":1698750422000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Robustness of hypofractionated breast radiotherapy after 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