Dosimetric Characteristics of IMRT versus

3DCRT for Intact Breast Irradiation with

Simultaneous Integrated Boost
1Dr.

1Division

1Suresh Moorthy, M.Sc, M.Phil, 2Prof. P. Narayana Murthy, Ph.D,

Saroj Kumar Das Majumdar, MD, DNB, 1Dr. Hamdy El Hateer, MD,
3Dr. R. Mohan, Ph.D, 1V. Ramanathan, B.Sc.

of Radiation Oncology, Department of Oncology & Hematology, Salmaniya Medical Complex,

MOH, Manama, Kingdom of Bahrain.
2Acharya Nagarjuna University, Nagarjuna Nagar, Guntur, AP, India.
3American Hospital, Dubai, UAE.

Abstract
Background and Purpose: Whole breast irradiation is part
of breast conservative management for early breast cancer.
Simultaneous Integrated Boost methods are used for head
& Neck and Prostate cancers. Most recently SIB for intact
breast is gaining interest. In this study we attempt to compare
and analyze the dosimetric aspects of Simultaneous Integrated
Boost technique (SIB) of IMRT over 3DCRT.

Methods: We took the CT simulation data of 27 consecutive

patients for our retrospective study to compare the SIB-IMRT
and SIB-3DCRT. Dose prescribed was 45 Gy/25 fractions
to whole breast (1.8 Gy/Fraction) and 60 Gy/25fractions to
Lumpectomy cavity (2.4Gy/Fraction) .The prescribed dose
delivered in a 5 fraction per week schedule. Treatment Plans
were compared for Target Minimum, Maximum, Mean,
Conformity Index, Homogeneity Index and Organs at Risk
doses were compared and analysed.
Results: The Target coverage was achieved with 95% of
prescription to the 95% of the lumpectomy cavity as well
as whole breast for all the plans. Dose conformity to the
boost volume was significantly higher with IMRT technique;
3DCRT technique showed more dose spillage outside the
boost volume. SIB-IMRT better in sparing critical organs
parameters like Lung V20 &Mean, Heart V30&Mean, and
LAD maximum dose.

Keywords: Simultaneous Integrated Boost (SIB), Intensity

Modulated Radiotherapy (IMRT), Three Dimensional
Conformal Therapy (3DCRT), Left Anterior Descending
Artery (LAD)

Conclusion: We infer from our study that both methods

achieved adequate target coverage, IMRT reduces maximum
doses and improves Conformity and Homogeneity indices of
target volumes, also reduces dose to OAR.

Author's address for communication: Mr. Suresh Moorthy, Division of Radiation Oncology, Department of Oncology & Hematology, Salmaniya Medical
Complex, MOH, Manama, Kingdom of Bahrain.
221
E-mail: nmsureshm@yahoo.com

Suresh Moorthy

Introduction
Breast cancer is the most common cancer in female
worldwide. As per WHO estimate, in Bahrain the
incidence of breast cancer was 116.47 per 100,000in
2008. Radiotherapy is an integral part of breast cancer
management after Breast Conservative Surgery (BCS).
Survival rates are similar for BCS with adjuvant RT and
mastectomy for early stage breast cancer. Whole breast
irradiation is the commonest method of management
for early breast cancer treatment after BCS. There
are various methods to employ radiotherapy for breast
cancer in women. Conventionally tangential fields are
employed to treat the whole breast. With the recent
advances in treatment planning technology and Multi
Leaf Collimators (MLC), Three Dimensional Conformal
Radiotherapy (3DCRT) is widely used for treatment of
breast carcinoma. Conformal therapy reduces normal
tissue doses and increases conformity to target volume.
Introduction of Intensity Modulated Radiotherapy
(IMRT) to breast cancer treatment further improved
conformity and doses to normal tissue. Switch over from
3DCRT to IMRT for whole breast irradiation, may result
in improved PTV coverage and OAR spare but this
assumption needs more clinical assessment. Studies have
shown improved homogeneity of PTV coverage with the
use of IMRT over 3DCRT, the median volume of PTV
receiving >110% of prescribed dose was 0.1% with IMRT
compared to 10 % with conventional wedges.1
Several studies in breast cancer have indicated that
delivering a boost dose to the tumor bed plus margin,
typically with electrons, following conventional whole
breast radiotherapy results in improved in-breast control
rates.2 Local recurrence after boost radiation to the tumor
bed was 6.2 % compared to 10.2% without boost so it
became standard of care for early stage breast cancer.3
The conventional dose fractionation schedule for whole
breast irradiation is 50 Gy in 25 fraction over 5 week
duration, when boost is given it takes 2-3- more weeks
making over all treatment period 7-8 weeks, shortening
of over all treatment period would be more convenient
for patients (especially those coming from remote areas
to RT facilities) and for health care providers, as it would
increase the turnover in RT departments.
SIB method delivers 45 Gy to whole breast and 60
Gy to surgical cavity in 25 fractions simultaneously by
prescribing the dose per fraction 1.8 Gy to whole breast
and 2.4 Gy to boost volume. So the total treatment
duration reduces by 2 weeks. The radiobiology asserts

Austral - Asian Journal of Cancer ISSN-0972-2556, Vol. 11, No. 3, July 2012

that shorter the course of treatment better tumor control

probability. A study in early breast cancer patients by
Donovan E et al showed that IMRT had better cosmetic
results compared to conventional treatment.4 Recently
SIB for breast is gathering momentum. We were using the
SIB-IMRT for whole breast for the past two years. In the
present study we attempt to compare the SIB planning
and dosimetric criteria of 3DCRT and IMRT.

Materials and Methods

We took CT simulation data of 27 consecutive patients
(13 left sides and 14 right sides) for our retrospective
planning study. These patients were already treated by
SIB-IMRT. Radiation therapy was started within 3 weeks
after all surgery and chemotherapy. The same CT data sets,
target volumes and Organ at risk volumes were used for
SIB-3DCRT study. Breast size varied from 985.5 cm3 to
3692.1 cm3with a mean of 1602.3 cm3. Tumor bed volume
varied from 33.4 cm3 to 420.8 cm3 with a mean of 119 cm3.

Target Delineation
After Planning CT Scan is done, the DICOM images
were transferred to Eclipse version 10.0.34 (Varian
Medical Systems, USA) treatment planning system.
Then Planning Target Volume (PTV) and Organ at Risk
Volumes (OAR) were delineated. The RTOG Breast
cancer atlas was used as guideline for target delineation.
The Clinical Target Volume (CTV-1) is the whole breast
and supraclavicular and axillary lymph nodes were
included as per indication, CTV-2 is lumpectomy cavity
and the surgical clips. The PTV-1 was created using
three dimensional margin of 5mm around CTV-1 except
anteriorly towards the skin was decreased to zero and
posteriorly towards the lung was increased to 7 mm.
The PTV-2 is created with an outer margin of 5mm to
1 cm from CTV-2.The Organ at Risk (OAR) structures
are delineated according to clinical and radiological
data in the CT-Images taken on breath hold. The OAR
are contoured as Lungs, Contra lateral Breast, Heart,
LAD (Left Anterior Descending Artery), Spinal cord,
Esophagus, Trachea, humerus head and Liver.

Planning Details and dose prescription

6 MV X-ray from Clinac 600CD Linear Accelerator
(Varian Medical Systems, USA) which integrated with
120 leaves Millennium MLC was used for Dynamic

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Dosimetric Characteristics of IMRT versus 3DCRT for Intact Breast .....

IMRT treatment. The Dynamic MLC leaf width is from

the central 20cm of field has 5mm leaf width and outer
20cm of field has 10mm leaf width.
The treatment fields are almost evenly spaced within
an arc of 180 degree on the side of the tumour. Gantry
angles ranged from 330 to150 (clockwise) for left side
tumours and from 50 to 210 (counterclockwise) for right
side tumours. The dose prescribed to the Breast volume
(PTV-1) was 45 Gy in 25 fractions (1.8Gy/fraction) and
Boost volume (PTV-2) was 60 Gy in 25 fractions (2.4 Gy/
fraction) in 5 fractions per week schedule. The target dose
uniformity and conformity are calculated and evaluated.
The conformity index (CI) as defined in ICRU 83 is
CI (ref) = Volume of PTV covered by the reference dose
/ Volume of PTV
CI = 1.0 is ideal value
The Homogeneity Index (HI) as defined in ICRU is
HI = D 2% - D 98% / D 50%
HI = 0 (Zero) is ideal value
Where
D 2%, D 98%, D 50% is dose received by 2%, 98%, 50%
volume

3DCRT planning
Using Beams Eye View (BEV) fields were set up to
minimize the dose to heart and lung and maximize the

target coverage. Two plans were created for 3DCRT. In

plan 1, two to four coplanar beams were used to produce
adequate dose coverage for whole breast volume (PTV1) and two coplanar beams were used for tumor bed
volume (PTV-2). Critical organs were shielded using MLC
without compromising PTV coverage. Beam weights were
adjusted until the optimum coverage and acceptable hot
spots were achieved. In addition to that the field in fields
was created to reduce hotspot or better target coverage
and to improve homogenous dose distribution in PTV-1
and PTV-2. Whole breast set to receive at least 95% of the
prescribed breast dose. Similarly, 95 % of the boost volume
set to receive at least 95 % of the boost dose. Then
integrated treatment plan comprising Whole breast plan
and boost plan were generated with common isocenter.

IMRT Planning
New volume is created by the name Whole breast
excluding boost volume by subtracting boost volume with
5mm margin from whole breast volume. Seven coplanar
beams were used to achieve the minimum criteria of 95%
of the volume receives the 95% of the prescribed dose.
The dose constraints to the Target and Critical Organs
were mentioned in Table 1. Heterogeneity correction
was done using Modified Batho method in Eclipse.
Dose-Volume Histograms (DVH) was used to analyze
the Volume receiving 20Gy, 30Gy and 40Gy, Mean,
Maximum and Minimum doses. Also to illustrate the low

Table 1: Optimization objectives for Simultaneous Integrated Boost IMRT plans

Organ

Type

Target (Gy)

Volume (%)

PTV1-PTV2

max

47

(Whole breast excluding Tumor bed)

min

45

100

PTV2

max

62

(Tumor bed only)

mi n

60

100

Ipsilateral Lung

max

20

30

min

10

35

max

36

min

30

20

max

30

Heart

LAD

Austral - Asian Journal of Cancer ISSN-0972-2556, Vol. 11, No. 3, July 2012

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223

Suresh Moorthy

dose volume effect, V5Gy volume and Integral Dose (ID)

were calculated for normal healthy tissue.
Integral Dose (ID) = Mean Dose (Gy) X Volume (cm3)

Statistical Analysis
Statistical Analysis was performed using the Wilcoxon
Signed Rank test. This matched pair t test was applied
to determine the statistical difference between the dose
volume data for IMRT versus 3DCRT. The reported p
value is two tailed and p values of < 0.05 are considered
significant.

Results
The planning objectives are met in all cases with both
the techniques. 3DCRT plans frequently shown hotspots
near the skin surface but within the acceptable range.
The normalized target coverage of IMRT and 3DCRT and
their Breast PTV and Boost PTV are presented in Table
2a, 2b.The dose distribution in axial sections is shown
in Figures 1a, 1b.These axial sections clearly shows that
concave PTV coverage and exclusion of LAD during
optimization by IMRT.

There is a consistent improvement in CI for breast

volume from 0.233 for 3DCRT to 0.201 for IMRT
(p=0.04311) also for boost volume from 0.1061 for
3DCRT to 0.0834 for IMRT (p=0.0128).The HI is
improved with IMRT for the breast volume (p=0.0012)
and to lesser extent for the Boost volume (p= 0.1126).
To evaluate the better conformity, V50 Gy and V55 Gy
volumes were created in whole breast excluding boost
volume and significant dose spillage outside the boost
volume is recorded.
Ipsilateral lung V20 Gy is significantly reduced with
IMRT (p< 0.0001). Both lungs V20 Gy is significantly
improvement with IMRT (p<0.0001). The OAR results
are represented in the Table 3.
In our study the heart V30 Gy is 2.71% for IMRT than
3.94 % for 3DCRT. The V40 Gy is significantly lower
in IMRT than 3DCRT (p= 0.05), the LAD maximum
dose is 41.22 Gy for 3DCRT and 29.16 Gy for IMRT
(p=0.0046). To evaluate low dose volume effect V5 Gy
is calculated and dose paint shown in Figure 2. Dose
Volume Histograms (DVH) describing the dose volume
relationship of the Target as well as Normal tissues of the
both techniques is presented in Figure 3a-3g. DVH shows
better normal tissue sparing with IMRT than 3DCRT.

Table 2a: Comparison of Whole breast minus boost volume coverage parameter (Mean) for IMRT and 3DCRT
methods of whole breast cancer patients (Prescribed Dose 45 Gy)
Dosimteric Parameter

SIB-3DCRT

SIB-IMRT

P Value

Minimum Dose (Gy)

24.07

32.03

0.0016

Maximum Dose (Gy)

60.03

59.68

0.0002

Coverage (%)

96.8

98.22

0.0012

Conformity Index

0.233

0.201

0.04311

Homogeneity Index

1.033

1.018

0.0012

Mean Dose (Gy)

49.72

51.62

<0.0001

Modal Dose (Gy)

49.12

48.92

NS

Median Dose (Gy)

50.5

48.8

0.0071

Standard Deviation(Gy)

6.35

4.17

<0.0001

V 50 Gy (%)

48.69

29.83

<0.0001

V 55 Gy (%)

30.7

11.29

<0.0001

Austral - Asian Journal of Cancer ISSN-0972-2556, Vol. 11, No. 3, July 2012

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Dosimetric Characteristics of IMRT versus 3DCRT for Intact Breast .....

Table 2b: Comparison of boost volume coverage parameter (Mean) for IMRT and 3DCRT methods of whole
breast cancer patients (Prescribed Dose 60 Gy)
Dosimteric Parameter

SIB-3DCRT

SIB-IMRT

P Value

Minimum Dose (Gy)

53.96

55.25

0.0061

Maximum Dose (Gy)

65.79

64.18

0.0009

Coverage (%)

97.3

99.38

NS

Conformity Index

0.1061

0.0834

0.0128

Homogeneity Index

1.037

1.006

NS

Mean Dose (Gy)

61.24

61.65

NS

Modal Dose (Gy)

61.12

62.39

0.0027

Median Dose (Gy)

61.18

62.0

0.0089

1.7

1.31

0.0119

Standard Deviation(Gy)

Fig1a: Represents the axial section dose distribution of SIB3DCRT in which LAD receives high dose

Fig1b: Represents the axial section dose distribution of SIBIMRT in which capable to exclude LAD in order to cover the
concave target.

Table 3: Comparison of Mean values of Normal tissue dose volume parameters for IMRT and 3DCRT breast
cancer patients
Parameter

SIB-3DCRT

SIB-IMRT

P Value

V20 Gy (%)

39.355

26.827

<0.0001

V30 Gy (%)

32.244

16.081

<0.0001

Mean (Gy)

20.294

16.51

0.0006

Max (Gy)

60.48

53.68

<0.0001

Ipsilateral Lung

Austral - Asian Journal of Cancer ISSN-0972-2556, Vol. 11, No. 3, July 2012

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225

Suresh Moorthy

Heart
V30 Gy (%)

3.936

2.71

NS

V40 Gy (%)

2.08

0.753

0.05

Mean (Gy)

7.44

7.08

NS

V20 Gy (%)

19.997

13.615

<0.0001

Mean (Gy)

11.52

10.82

0.0001

6.12

5.65

NS

41.22

29.16

0.0046

Both Lung

Contralateral Breast
V5 Gy (%)
LAD
Maximum Dose (Gy)

Fig 2: Represents the 5Gy volume of dose color wash of 3DCRT and IMRT

Fig 3a: Represents a Cumulative Dose Volume Histogram

(DVH) of Breast PTV comparing SIB methods of 3DCRT
and IMRT plans.

Austral - Asian Journal of Cancer ISSN-0972-2556, Vol. 11, No. 3, July 2012

Fig 3 b: Represents a Cumulative Dose Volume Histogram

(DVH) of Boost PTV comparing SIB methods of 3DCRT and
IMRT plans.

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226

Dosimetric Characteristics of IMRT versus 3DCRT for Intact Breast .....

Fig 3 c: Represents a Cumulative Dose Volume Histogram

(DVH) of Ipsilateral Lung comparing SIB methods of 3DCRT
and IMRT plans

Fig 3 d: Represents a Cumulative Dose Volume Histogram

(DVH) of Both Lung comparing SIB methods of 3DCRT and
IMRT plans

Fig 3 e: Represents a Cumulative Dose Volume Histogram

(DVH) of contralateral Breast comparing SIB methods of
3DCRT and IMRT plans

Fig 3 f: Represents a Cumulative Dose Volume Histogram

(DVH) of Heart comparing SIB methods of 3DCRT and
IMRT plans

Discussions
In our institution, we are using 60 Gy in 25 fractions
for whole breast and tumor bed irradiation using SIB
technique based on the BED calculation as presented in
the Table 4. The Calculated BED values are comparable
to conventional fractionation schedules.

Fig 3 g: Represents a Cumulative Dose Volume Histogram

(DVH) of Normal Healthy Tissue comparing SIB methods of
3DCRT and IMRT plans

Austral - Asian Journal of Cancer ISSN-0972-2556, Vol. 11, No. 3, July 2012

In general, both IMRT and 3DCRT provided similar

results regarding PTV coverage. But in depth analysis of
dosimteric data revealed significant differences in quality
of target coverage and normal tissue doses. In this study we
used equally spaced beam angles for IMRT and tangential
fields for 3DCRT plans. The use of equally spaced gantry
angles improved homogeneity and conformity indices,

pp 221-230

227

Suresh Moorthy

Table 4: Comparison of BED for SIB versus conventional fractionation schedules

50 Gy/25 #+16Gy/8#
Sequential Boost

60Gy /25#
SIB

Late Responding Tissue

(3Gy)

110 Gy

104 Gy

Breast Cancer (4Gy)

99 Gy

96 Gy

Early Responding
Tissue(10 Gy)

79 Gy

74.4 Gy

also reduced the volume of OAR such as the heart and

ipsilateral lung receiving a high dose as shown by Hong
et al.5 Though the mean breast volume is 1602cc which
is relatively higher with respect to literature that showed
the mean breast volume of 483 cc, we were able to have
optimized coverage and reduced dose to OAR.6 BCT long
term complication is generally acceptable but using higher
dose per fraction for the SIB technique needs further
reduction of dose to critical structure.
IMRT for breast is explored for its ability to confirm
the dose to the concave target volume. With increasing
sophistication in radiation treatment plans, Homogeneity
indices showed improvement with inverse IMRT as
reported by Fisher.7 Compared to conventional tangential
field breast radiotherapy, conformal RT proved better
normal tissue sparing, IMRT proved further reduction of
skin toxicity and late effects so the quality of life improved
much. The potential advantages that IMRT technique
may have over conventional 3D and non-3D techniques
are (1) the ability to achieve dose uniformity throughout
the breast target and (2) the potential to reduce the dose
to underlying heart and lung. These abilities are expected
to translate into an improved cosmetic outcome and
reduced toxicity.
The inverse-planned IMRT further reduce hotspots,
because of beam modulation during optimization
compared to 3DCRT. Reports from Planning studies
with multiple fields show that PTV95% coverage values
ranging from 90% to 99 % whereas all our optimized plans
had PTV95% coverage values of >95% of prescription
dose.8, 9 The incidence of Radiation Pneumonitis (RP)
is related to the ipsilateral lung volume irradiated.10 In
our study the Ipsilateral Lung V20 for IMRT (26.83%)
is significantly less than (39.36%) 3DCRT (P<0.0001).
Both Lung V20 Gy and Mean dose is also significantly
lower in IMRT than 3DCRT (p<0.0001).Contra lateral

Austral - Asian Journal of Cancer ISSN-0972-2556, Vol. 11, No. 3, July 2012

lung V5 Gy and mean dose of both the methods show no

significant differences.
The ipsilateral MLD was 16.51 Gy for IMRT, compared
to 20.29 Gy in 3DCRT plan (p=0.0006). The mean lung
doses are higher compared to the report from Marks L
B et al as 6.4 to 11 Gy probably because of larger breast
volumes. There is no absolute safe Mean Lung Dose
(MLD) below which there is no pneumonitis.11 The
clinically acceptable risk of RP depends on the risk-benefit
ratio of the individual patient selection basis.
In patients with breast cancer, it is intended that the
irradiated heart volume be minimized to the greatest
possible degree without compromising the target
coverage. The risk of pericardial events is probably related
to both dose and volume of radiation. Stewart JR et al
concluded that the dose should be limited to 60 Gy for
less than 25% of cardiac volume and 45 Gy for more
than 65% of cardiac volume.12 Gagliardi et al reported
that CAD risk was much reduced at doses less than 30
Gy.13 In our study the mean values of V30 Gy were 2.7%
and 3.9% for IMRT and 3DCRT respectively compared
to studies reporting V30 Gy values in the range of 2% to
5%.14 Increased cardiac mortality risk associated with
Left side breast patients in the long term was reported
by multiple relatively old literatures.15, 16 The advances
in the treatment techniques including IMRT reduced
cardiac exposure so that steady decline of Radiation Risk
is being noticed.17 Boivin et al noted that the anteriorly
placed coronary arteries were more often affected by RT
(compared with the circumflex artery).18 In our study
LAD maximum dose (mean) is 41.22 Gy for 3DCRT
and 29.16 Gy for IMRT (p=0.0046) Mean heart doses
for Lt. breast patients were 4 Gy for IMRT and 6.5 Gy
for 3DCRT, this results are comparable to other studies.
The IMRT plans contributed a modestly higher dose

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228

Dosimetric Characteristics of IMRT versus 3DCRT for Intact Breast .....

Table 5: Comparison of MU, ID and V5 parameter (Mean) for IMRT and 3DCRT chest wall breast cancer patients
Parameter
Monitor Units
Integral Dose
V5 Gy (%)

(Gy-Cm3)105

SIB-3DCRT

SIB-IMRT

P Value

281

1530

<0.0001

1.34

1.9

0.01

18.898

30.612

0.0004

to adjacent healthy soft tissues. Especially the low dose

volume (V5 Gy) which represents the late effects was
higher in IMRT. The excess dose to normal tissue outside
the whole breast volume is created. In our study the mean
V5 Gy volume for conformal therapy is significantly lower
than IMRT. The main concern with healthy soft tissue
dose increases of this magnitude is an increased risk of
late second malignancy.19, 20
The monitor unit for IMRT is 6-8 times more than
3DCRT is a concern.21 This shows that the integral dose
would also be higher. Pirzkall et al studied that the Integral
dose for IMRT is higher than conventional treatment.22
The Integral Dose (ID) in our work for IMRT significantly
higher than 3DCRT. The ID is higher probably due to
multiple beams used in IMRT than tangential oriented 3D
conformal so that large volume of healthy tissue involved
during optimization, this in turn increases treatment time
during delivery. Also the leakage and scatter dose to non
target tissue is proportional to the number of monitor
units used. Some studies reported, increased low dose
volumes with increased number of beam angles.23 The
Integral dose data were represented in Table 5.
High integral dose attributed to second malignancy
which is likely to be of greatest concern in younger women
and in patients with a low risk for systemic relapse that are
likely to live for many years after the diagnosis of breast
cancer.24 There have been reports that adjuvant RT for
breast cancer may increase the risk of lung cancer and
angiosarcoma.25 The risk of sarcoma in the treated volume
is likely to be similar with IMRT or standard techniques,
but it is possible that second primary lung cancers might be
increased by IMRT, especially in smokers. 24 Balancing the
short to medium-term benefits of reducing the volume of
heart and left lung receiving a high dose of RT against the
risk of late malignancy requires an individual assessment
of the treatment volume goals and the patients longevity
prospects with and without RT. Evaluation of 121 patients
treated with IMRT compensation found a 3% rate of
secondary malignancy after 7 years 26 which was not

Austral - Asian Journal of Cancer ISSN-0972-2556, Vol. 11, No. 3, July 2012

significantly differ from 4% rate observed by conventional

radiation.27 Limited studies are available for breast with
SIB IMRT. The dosimteric study investigated by various
authors with advanced techniques in selected cases,
IMRT is definitely beneficial compared to conformal
therapy.28, 29 Many authors quoted that SIB with IMRT is
feasible and proved better compared to sequential method
of treatment.30-32

Conclusion
We infer from our study that both methods proved better
in target coverage but IMRT reduces maximum doses
and improves Conformity and Homogeneity indices of
target volumes. Also dose to OAR like ipsilateral lung,
Heart, LAD is higher with conformal RT. Simultaneous
Integrated Boost method with 3DCRT and IMRT for
breast cancer treatment is feasible.

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