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Teri Burrier

Brittany Butler
Nancy Gustafson
DOS 711 – Research Methods I
April 24, 2018
Research Proposal
Title: Correlation of hot spot to breast separation in patients treated with tangent 3D-CRT.
Abstract: Intact breasts following lumpectomy of breast cancer are most commonly treated with
3D-CRT medial and lateral opposing tangent beams to the whole breast followed by electron
boosts. Field-in-field control points are often used to decrease the hot spots. This study aims to
identify a correlation between hot spot and separation, quantify the correlation, and identify
associations with photon energy and chest wall coverage. This information may be useful as a
guideline to decide on an appropriate coverage versus hot spot compromise. It may be possible to
identify a solution.
Intro and Literature Review: Previous studies have assessed the inhomogeneity of the breast
and patterns of dose. For example, Buchholz et al1 reported that studies have quantified dose
inhomogeneity of intact breast irradiation and found a significant volume of breast receives
greater than 110% of dose and is greater in larger breast sizes. Another study assessed
inhomogeneity in phantoms with small and large breasts.2 These studies focused on
inhomogeneity and location in the breast tissue. Other studies have assessed collimator angle,3
irregular surface compensation,4 multiple-segment tangent fields to decrease hot spots,5 PTV
margin reduction to reduce dose to OAR,6 identified the lack of dose specification,7 and when
hypo-fractionation is employed.8 However, only two studies, one by Das et al9 and one by Neal
et al10 have compared breast separation with resulting hot spot. The study by Das et al9 found a
variation of 2-27% in maximum dose depending on chest wall separation and the study by Neal
et al10 found that 0.2 – 23.8% of the breast received an absorbed dose outside the desired 95-
105% of the prescribed dose. These studies are 21 and 23 years old respectively and compared
patients with various prescriptions. Additionally, the study by Neal et al10 studied patients whose
plans were created using compensators, wedges, and only 6 megavoltage (MV) photons. This
study will determine if the findings from these studies are still valid, or if these numbers can be
improved upon by utilizing tools available to medical dosimetrists currently in the field, such as
field-in-field techniques, mixed beam energy, etc. to decrease hot spots and improve dose
homogeneity within the breast.
Hypothesis: Hot spot dose will be greater in patients with larger separations. Secondary
hypothesis: Larger separations require higher energies. Tertiary hypothesis: Larger separations
result in less chest wall coverage.
Materials and Methods: Treatment plans from 90 patients, 30 patients from three radiation
facilities, will be examined. These patients will be divided into three size categories as defined
in the study by Das et al. Patients will be limited to those with an intact breast following
lumpectomy being treated with opposing medial and lateral 3D-CRT tangent beams. The
prescription of patients included in the study will be limited to 180 cGy per fraction in 28
fractions to a total initial dose of 5040 cGy. Any boost delivered after the initial 5040 cGy will
not be included in the study. Data obtained from the plans will include measurement of
separation in cm, 3D-CRT planning technique (e.g. field-in-field), photon energy, number of
beams, normalization, target volume, and hot spot measurement in absolute dose.
Conclusion: Protocols exist to guide beam design, fractionation, and maximum dose.
Dosimetrists spend much of their planning time trying to optimize a plan. Correlating and
quantifying hot spot to separation may shorten planning times by providing a guideline as to
what maximum doses are achievable for given separations. This study may also be able to
provide solutions for achieving optimal plans.
References
1. Buchholz TA, Gurgoze E, Bice WS, Prestidge BR. Dosimetric analysis of intact breast
irradiation in off-axis planes. Int J Radiat Oncol Biol Phys. 1997;39(1):261-7.
http://dx.doi.org/10.1016/S0360-3016(97)00292-7
2. Delaney G, Beckham W, Veness M, et al. Three-dimensional dose distribution of
tangential breast irradiation: results of a multicentre phantom dosimetry study. Radiother Oncol.
2000;57(1):61-8. http://dx.doi.org/10.1016/S0167-8140(00)00262-0
3. Buchholz TA, Bilton S, Gurgoze E, et al. Isoseparation curves: a mechanism for optimizing
off-axis dose homogeneity of intact breast irradiation. Radiat Oncol Investig. 1998;6(4):191-8.
http://dx.doi.org/10.1002/(SICI)1520-6823(1998)6:4%3C191::AID-ROI7%3E3.0.CO;2-T
4. Emmens DJ, James HV. Irregular surface compensation for radiotherapy of the breast:
correlating depth of the compensation surface with breast size and resultant dose distribution. Br
J Radiol. 2010;83(986):159-65. http://dx.doi.org/10.1259/bjr/65264916
5. Mayo C, Lo YC, Fitzgerald TJ, Urie M. Forward-planned, multiple-segment, tangential fields
with concomitant boost in the treatment of breast cancer. Med Dosim. 2004;29(4):265-70.
http://dx.doi.org/10.1016/j.meddos.2003.12.003
6. Basaula D, Quinn A, Walker A, et al. Risks and benefits of reducing target volume margins
in breast tangent radiotherapy. Australas Phys Eng Sci Med. 2017;40(2):305-315.
http://dx.doi.org/10.1007/s13246-017-0529-3
7. Kantorowitz DA. The impact of dose-specification policies upon nominal
radiation dose received by breast tissue in the conservation treatment of breast cancer. Int J
Radiat Oncol Biol Phys. 2000;47(3):841-8. http://dx.doi.org/10.1016/S0360-3016(00)00453-3
8. Jagsi R, Griffith KA, Heimburger D, et al. Choosing wisely? Patterns and correlates of the use
of hypofractionated whole-breast radiation therapy in the state of Michigan. Radiation Oncology
Quality Consortium. Int J Radiat Oncol Biol Phys. 2014;90(5):1010-6.
http://dx.doi.org/10.1016/j.ijrobp.2014.09.027
9. Das IJ, Cheng CW, Fein DA, Fowble B. Patterns of dose variability in radiation prescription
of breast cancer. Radiother Oncol. 1997;44:83-89. http://dx.doi.org/10.1016/S0167-
8140(97)00054-6
10. Neal AJ, Torr M, Helyer S, Yarnold JR. Correlation of breast dose heterogeneity with breast
size using 3D CT planning and dose-volume histograms. Radiother Oncol. 1995;34(3):210-218.
http://dx.doi.org/10.1016/0167-8140(95)01521-H

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