Research Proposal

Kyle Garafolo
Stephanie Hufnal
Keenan Fuller

Title: Radiation therapy treatment of the prone breast using EZFluence: A case study
Problem Statement: The problem is there are no current studies indicating the efficacy of
EZFluence software with the planning of prone breasts. This study aims to identify the effective-
ness of EZFluence software by evaluating several core metrics.
Purpose: The purpose of this study will be to provide information which may help to improve
prone breast planning time, organ at risk (OAR) sparing, and overall dose uniformity to the tar-
get. If the study demonstrates the validity of EZFluence software within the scope of a prone
breast plan, it could potentially pave the way for the use and development of future treatment
methods and the advance of similar types of software.
Literature Review: Since its inception, multiple studies have recognized the benefits of whole
breast irradiation in the prone position as compared to the supine position. These benefits include
improved dose coverage, better homogeneity, less hotspots within treatment volume, lower ipsi-
lateral lung and heart dose, lower contralateral breast dose, and reduced skin reactions.1-3As
awareness for cardiac toxicity effects caused by left sided breast irradiation have become more
known, utilization of the deep inspiration breath hold (DIBH) technique as well as the prone pa-
tient positioning have drastically increased.3 Additionally, studies have demonstrated that prone
setups can be reproducible in greatly minimizing intrafractional respiratory motion to the chest
wall.4,5 While setup position is one factor that affects dose to the target and surrounding OARs,
the ability to reduce hot spots is another vital aspect to minimizing patient toxicities.
Based on their research, Keenan et al6 found that a V105% of more than 30cc and conventional
fractionation have a strong indicator for acute skin toxicity in general breast planning.6 For this
reason, V105 will be one of the criteria evaluated in this study. As a means to help achieve these
aforementioned benefits of the prone position, multiple planning techniques have been utilized
over the years, such as physical wedges, enhanced dynamic wedges, manual FiF, electronic com-
pensators, and IMRT. One new software has been developed, known as EZFluence, which cre-
ates an optimal fluence pattern to generate a homogenous dose distribution for breast radiation
treatments.7 To date, only one peer reviewed source has examined the benefits of EZFluence as
compared to manual FiF techniques for supine breast patients. The results of this study found
that EZFluence was able to greatly improve treatment planning time, reduce the volume of PTV
receiving 105% hotspot, and achieved similar dose constraints to the OAR. The purpose of this
purposed case study will be to evaluate EZFluence as it relates to the planning of prone breast
patients.
Hypothesis: The use of EZFluence software script for prone breast radiotherapy planning will
improve planning times and reduce the PTV volume receiving 105% of prescribed dose
(V105%). Secondary hypothesis: EZFluence will produce similar dose sparing to OAR as com-
pared to manual FiF planning techniques.
Materials and Methods: Treatment plans from 10-20 patients from two separate facilities will
be evaluated. Patients will be limited to those with intact, pendulous breasts (following lumpec-
tomy) without nodal involvement, and set up in the prone position as selected by the attending
radiation oncologist. Patients included in this study will be receive hypofractionated whole breast
irradiation with a prescription dose of 266 cGy in 16 fractions to a total dose of 4256 cGy. Plan-
ning techniques will include non-divergent medial and lateral 3D-CRT tangential beams pro-
duced by manual FiF techniques and EZFluence software. Dose from any boost after the initial
4256 cGy will not be included in this study. Data collected from the plans will include the total
planning time, maximum, mean, and relevant dose to critical structures, target volume dose, and
the overall hotspot will be accounted for with both types.

References
1. Mulliez T, Veldeman L, Van Greveling A, Speleers B, Sadeghi S, Berwouts D, et al.
Hypofractionated whole breast irradiation for patients with large breasts: a randomized trial
 comparing prone and supine positions. Radiother Oncol. 2013;108(2):203–8. doi:
10.1016/j.radonc.2013.08.040.
2. Haffty, BG. Supine or prone breast radiation: Upsides and downsides. Int J Radiat Oncol
Biol Phys. 2018;101(3):510-512. doi: https://doi.org/10.1016/j.ijrobp.2018.03.023.
3. Huppert N, Jozsef G, Dewyngaert K, Formenti SC. The role of a prone setup in breast radia-
tion therapy. Front Oncol. 2011;1:31. doi:10.3389/fonc.2011.00031.
4. Morrow NV, Stepaniak C, White J, et al. Intra- and interfractional variations for prone breast
irradiation: an indication for image-guided radiotherapy. Int J Radiat Oncol Biol Phys. 2007;
69(3):910–917. doi: 10.1016/j.ijrobp.2007.06.056.
5. Mitchell J, Formenti SC, DeWyngaert JK. Interfraction and intrafraction setup variability for
prone breast radiation therapy. Int J Radiat Oncol Biol Phys. 2010;76(5):1571–1577. doi:
10.1016/j.ijrobp.2009.07.1683.
6. Keenan LG, Lavan N, Dunne M, McArdle O. Modifiable risk factors for acute skin toxicity
in adjuvant breast radiotherapy: Dosimetric analysis and review of the literature. Med
Dosim.2019; 44(1):51-55. doi: 10.1016/j.meddos.2018.01.004.
7. Yoder T, Hsia AT, Xu Z, Stessin A, Ryu S. Usefulness of EZFluence software for radiother-
apy planning of breast cancer treatment. Med Dosim. 2019. doi:
https://doi.org/10.1016/j.meddos.2018.12.001.