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Dustin Melancon June Case Study June 28, 2012 3D CRT for Invasive Ductal Carcinoma of the Left Breast History of Present Illness: Patient TM is a 48-year-old female who palpated a mass in her left breast about 2 months ago. She noticed discomfort in her left axilla which had been ongoing for several months prior to that. She had a mammogram on September 26, 2012 that showed a 3.7 centimeter (cm) mass in the upper, outer quadrant of the left breast. There were also 2 lymph nodes with abnormal appearance in the left axilla, one measured 2.2 cm and the other was 1.4 cm. The patient underwent a biopsy of this region on September 27, 2012. It was positive for invasive ductal carcinoma. The tumor was estrogen receptor (ER) negative, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) negative. She also had the left axillary lymph nodes biopsied which were also positive for metastatic adenocarcinoma. The patient was diagnosed with poorly differentiated, grade 3 invasive ductal carcinoma of the upper-outer quadrant. She was presented to radiation oncology with T2N1M0 left breast cancer status post mastectomy with tissue expander reconstruction. Past Medical History: TM has a history of hypertension, diabetes, coronary artery disease, and asthma. Social History: The patient is married with 6 children. She currently works at the YMCA. She denies any alcohol or illicit drug use. The patient is a one pack per day smoker for the past 35 years. Her family history includes her mother with uterine cancer and a maternal aunt with ovarian cancer. Medications: TM uses the following medications: Norvasc, Hydrochlorothiazide, Lovastatin, Lisinopril, Metformin, and Singulair. Diagnostic Imaging: Posterior-anterior (PA) and lateral chest radiographs were taken in March 2012 after chest pain complaints. No active cardiopulmonary disease was found. In August 2012, she felt a palpable mass in her left breast. She had diagnostic breast mammograms performed in September 2012. Mammography is an important modality in the detection of 90% breast cancers.1 The palpable area of concern was marked with a radiopaque marker in the upper

outer quadrant. This area contained a high density irregular mass with spiculated margins measuring up to 3.7 x 2.3 x 3.2 cm in width by length by height. A bilateral breast ultrasound on September 26, 2012 found an irregular, heterogeneous, hypoechoic mass with microlobulated and spiculated margins in the left breast. Maximum ultrasound dimensions were 2.7 x 2.4 x 3 cm. There were two lymph nodes in the left axilla with abnormal sonographic appearance with abnormal thickened cortices. The imaging suggested breast cancer and ultrasound-guided core needle biopsy was recommended. Fine needle aspiration cytology was also recommended because of the left axillary lymph node involvement. In October 2012, ultrasound guided core biopsy and ultrasound guided fine needle aspiration provided pathology results that the specimen was malignant. After the positive biopsy, the patient also had a computed tomography (CT) scan of the chest, abdomen, and pelvis with no evidence of distant metastasis. Radiation Oncologist Recommendations: The patient had a mobile primary mass about 3 cm in greatest dimension. There was a macular, thick, striated, and inflammatory like reaction in the tail of the breast that extended into the axilla that was suspicious. The radiation oncologist discussed the treatment options, risks, benefits, and role of radiation therapy in the treatment of her breast cancer. The patient was scheduled to have a port placed and then started neoadjuvant chemotherapy the following week. They scheduled her to come back for a follow-up visit in about 4 months after surgical removal of her breast. The Plan (Prescription): The radiation oncologist planned post-mastectomy radiation therapy using a 3-field monoisocentric technique with beam splitting techniques for matching fields. This would involve multileaf collimation (MLC) for complex blocking. The monoisocentric technique was planned to minimize any dosimetric overlap between abutting fields. The patient would receive a total dose of 50.4 gray (Gy) in 28 fractions using a combination of 6 and 18 megavoltage (MV) photons to this region encompassing the chest wall and regional lymph nodes of the supraclavicular fossa and axilla. Patient Setup / Immobilization: In April 2013, TM underwent a CT simulation scan. The patient was placed head first in the supine position on the CT simulation couch on a tilt board immobilization device (Figure 1). The patients head was turned to the right and supported with a tilt board headrest. The left upper arm was extended and positioned above the patients head while her right arm was positioned akimbo. The patient had a sponge under her knees for

support. The radiation oncologist marked the superior, inferior, medial, and lateral regions of the left chest wall. Anatomical Contouring: After completion of the CT simulation scan, the CT data set was transferred into the Varian Eclipse 10.0 radiation treatment planning system (TPS). The medical dosimetrist contoured artifacts and the patients tissue expander. The medical dosimetrist also contoured the organs at risk (OR) which included the right and left lungs, a total lung volume, spinal cord, and the heart. The radiation oncologist reviewed the OR and made final adjustments to the left breast contour in order to begin radiation treatment planning. Beam Isocenter / Arrangement: The radiation oncologist placed the isocenter in the left chest wall volume on the TPS, which was located in the superior portion of the patients left breast tissue. The medial and lateral conventional tangential photon beams of the chest wall plan utilized gantry angles of 309 degrees and 129 degrees respectively. For the supraclavicular field, a slight right anterior oblique (RAO) field was angled away from the spinal cord at 345 degrees. The lower left and bottom borders met at the isocenter for the tangential field. The half beam split technique was used for both areas. Treatment Planning: The radiation oncologist outlined the dose prescription and objectives for the chest wall treatment (Figure 2). The medical dosimetrist created two plans within the TPS; a plan with tangential fields and a plan with one supraclavicular field. The objective was to reduce radiation toxicity to the heart and left lung while maintaining the prescription dose evenly throughout the chest wall. The prescription dose for the conventional tangential fields was prescribed to a calculation point placed by the medical dosimetrist at a depth of 11.4 cm within the medial tangent field and 14.9 cm within the lateral tangent field. The medical dosimetrist placed the calculation point near the mid-plane depth of the medial and lateral tangential beams, in the center of the superior and inferior extents of the left chest wall volume, and approximately 3 cm from the left chest wall (Figure 3). The medical dosimetrist used custom blocking to match the tangential and supraclavicular fields with non-divergent beams. In order to do this, the beam was split along the central-axis. The MLCs were used to block dose to critical structures, such as the heart and lung (Figures 3 and 4). Both unequally weighted tangential beams were assigned to the calculation point and computed to deliver the prescription dose. Mixed beam energies of 6 MV and 18 MV, MLCs, and the field-in-field technique were used to improve dose homogeneity

in the target (Figures 5-9). The hot spot was 109.6%. The supraclavicular field included a calculation point placed at a depth of 3 cm. The medical dosimetrist placed this point within tissue and made sure it was not located near the field edge. The MLCs were used to reduce dose to the spinal cord and humeral head. In addition, a 10 degree enhanced dynamic wedge was added to push dose away from the field junction of the tangent and supraclavicular fields. The supraclavicular field had a hot spot of 107.8% (Figures 12-15). Once adequate prescription dose coverage was achieved to the left chest wall volume within each plan, the medical dosimetrist reviewed the OR doses, the isodose lines, and the dose volume histograms (DVH) (Figures 10, 16-17). The OR on the composite plans DVH (Figure 17) reflected doses of 4460.9 centigray (cGy) in the heart, 177.5 cGy in the spinal cord, 4986.4 cGy in the left lung, and 831.6 cGy in the right lung. Mean doses include 317.9 cGy in the heart, 64.3 cGy in the spinal cord, 1280.9 cGy in the left lung and 33.5 cGy in the right lung. The plan of the left chest wall utilized conventional tangent and supraclavicular fields to achieve adequate prescription coverage and a homogeneous dose distribution throughout the left chest wall tissue. Quality Assurance/Physics Check: The monitor units (MU) were reviewed and a second check was completed with MUCheck, a quality assurance (QA) computer program (Figures 18-19). The MUs were within 5% tolerance and passed. The treatment plan was reviewed by a medical physicist for a final check before treatment began. Diodes and weekly physics chart checks were employed for QA. Conclusion: The chest wall and regional nodes are traditionally treated by matching a supraclavicular field to tangents.2 The medical dosimetrist determined an ideal match between the caudal edge of an anterior supraclavicular field and the cephalad edge of two opposed tangential fields. The planning technique presented the medical dosimetrist with several challenges. One challenge was determining the desirable gantry angles to provide adequate coverage, while sparing critical structures without compromising the target. The medical dosimetrist used conformal blocking to protect the heart and lung from the primary beams. Blocking was also used in the supraclavicular field to block the spinal cord and humeral head. In addition, the hot spot areas presented another problem for the medical dosimetrist. Mixed energy beams helped provide homogeneous dose in the chest wall plan. The supraclavicular plan featured a 10 degree enhanced dynamic wedge to push dose away from the field junction of the

tangent and supraclavicular fields. This case was the first time the student noticed the enhanced dynamic wedge and its effect on the supraclavicular fields dose distribution. This case study proved to be a great learning experience.

Figures

Figure 1. CT simulation setup demonstrating the patients placement. The patient was head first in

the supine position on the CT simulation couch on a tilt board immobilization device. The patients head was turned to the right and supported with a tilt board headrest (A). The left upper arm was extended and positioned above the patients head while her right arm was positioned akimbo. The patient had a sponge under her knees for support. The radiation oncologist marked the superior, inferior, medial (B), and lateral regions (C) of the left chest wall.
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Figure 2. Left chest wall plan summary.

Figure 3. Left chest wall plan in the beams eye view for the left medial tangent field.

Figure 4. Left chest wall plan in the beams eye view for the left lateral tangent field.

Figure 5. Left chest wall plan in the beams eye view for the left medial tangent field with the field in field technique.

Figure 6. Left chest wall plan in the beams eye view for the left lateral tangent field with the field in field technique.

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Figure 7. Left chest wall plan in the transverse view.

Figure 8. Left chest wall plan in the frontal view.

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Figure 9. Left chest wall plan in the sagittal view.

Figure 10. Left chest wall plan DVH.

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Figure 11. Supraclavicular plan summary.

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Figure 12. Supraclavicular field in the beams eye view.

Figure 13. Supraclavicular plan in the transverse view.

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Figure 14. Supraclavicular plan in the frontal view.

Figure 15. Supraclavicular plan in the sagittal view.

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Figure 16. Supraclavicular plan DVH.

Figure 17. Composite plan DVH.

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Figure 18. QA for the chest wall plan.

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Figure 19. QA for the supraclavicular plan.

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References 1. Chao K, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011. 2. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.