1

A Dosimetric Comparison of 3DCRT, TomoDirect and Helical Tomotherapy for Large

Separation of Left Sided Intact Breast Cancer: A Case Study
Authors: Tera Christianson, B.S., R.T.(T), Stephanie Olson, B.S., R.T.(T), Amy Heath, M.S.,
R.T.(T), Zacariah Labby, Ph.D., Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD, Ashley
Pyfferoen, B.A., M.S., CMD
Abstract:
Introduction: The purpose of this study is to compare and contrast planning target volume
(PTV) coverage and organs at risk (OR) limits for left-sided, intact breast cancer patients with
large tangential separation using dosimetric comparison of three-dimensional conformal
radiation therapy (3DCRT), TomoDirect (TD) and Helical Tomotherapy (HT) treatment planning
techniques.
Case description: In the treatment of left-sided, intact breast cancer in patients with large
tangential separation, achieving acceptable target coverage and normal tissue constraints can be
challenging. The large anatomical separation can cause the need for higher beam energies or
intensity-modulated radiation therapy (IMRT) treatment techniques to be used and is
demonstrated in the following 4 patient cases: Patient 1 represents stage IIA invasive ductal
carcinoma of the left breast with a tangential separation of 27.2 cm; Patient 2 represents stage IA
infiltrating lobular carcinoma of the left breast with a tangential separation of 25.9 cm; Patient 3
represents stage IIA infiltrating ductal carcinoma of the left breast with a tangential separation of
24.5 cm; and Patient 4 represents stage IA invasive ductal carcinoma of the left breast with a
tangential separation of 28.8 cm. Three plans were created for each patient using 3DCRT fieldin-field tangents, TD and HT treatment planning techniques.
Conclusion:
Key Words: TomoTherapy, TomoDirect, breast cancer treatment, epidemiology
Introduction
Incidence of breast cancer cases has steadily increased over the past 3 decades with an
estimated 1.4 million new diagnoses each year.1 This rise in incidence can be correlated to an
increased use of mammographic screening which began in the 1980s.1,2 Until the use of
mammography, breast tumors were found in the advanced stages through palpable masses and

were often associated with poor prognosis.2 In this day and age, mammographic screening has
led to earlier diagnoses, which combined with surgery, chemotherapy and radiotherapy, has
provided better prognostic outcomes.
Treatment options for women diagnosed with breast cancer have seen dramatic changes
through the years. From the Halstead mastectomy used in the 1880s to breast conserving surgery
combined with external beam radiotherapy (EBRT) in the late 1900s, advances in therapy have
contributed to the declining mortality rate for breast cancer.3 Standard EBRT treatment regimens
consist of adjuvant whole breast radiation therapy (AWBRT) of 50 Gy given in 25 fractions with
an additional lumpectomy boost of 10 Gy in 5 fractions.3 More recently, trials studying hypo
fractionated treatment regimens of 40 Gy in 15 fractions have been published and found to have
similar results to standard treatment regimens.3,4 Fewer fractions makes the course of treatment
more convenient and tolerable for the patient while producing equivalent side effects when
compared to standard fractionation.4
Adverse side effects associated with AWBRT include those to the contralateral breast,
lung and heart. Dose to the contralateral breast can be associated with increased long-term risk of
developing a secondary breast cancer in the opposing breast.5 Radiation induced lung
complications are correlated with both the volume of lung irradiated and the mean ipsilateral
lung dose.5 Coronary artery disease (CAD) can be a late side effect, in particular with left sided
breast cancers, usually occurring 10 or more years after completion of AWBRT.4 Through
advancements made in radiotherapy treatment techniques and understanding of the relationship
between accurate dose calculations and normal tissue complication probability, these adverse
side effects have been minimized.
Improved imaging and computer technology has made the treatment delivery modalities
such as 3DCRT, IMRT and tomotherapy ideal techniques to treat target volumes precisely and to
higher doses while minimizing dose to nearby critical structures.3 Daily to weekly image
guidance is performed to ensure treatment position is replicated from the treatment planning
session thus confirming the target volume and critical structure alignment.3 Image guidance is
particularly important when using IMRT because escalated treatment doses are often prescribed
and margins added to PTV are minimized. In addition, IMRT has the ability to place high dose
gradients next to the treated volume, necessitating accurate alignment.

In some cases, such as patients with large, pendulous breast anatomy, 3DCRT dose
objectives may be difficult to achieve.5 Static and rotational IMRT can be used in difficult cases
to help improve the dosimetric distribution and homogeneity within a treatment plan.5 Typically,
IMRT techniques are able to increase PTV coverage while reducing the dose to normal critical
structures.5 In women with large breasts, IMRT has shown many benefits including a decreased
risk of moist desquamation and less severe skin reactions and reduced acute toxicities of
telangiectasia and fibrosis.6
Large tangential separation of the breast is the factor most correlated with increased hot
spots and dose inhomogeneity and can lead to poor cosmetic outcomes.6,7 Tangential separation
is the distance between the midline of the anterior chest and the point 2 cm below the breast
tissue measured along the central axis of the beam (Figure 1).7 Depending on the patients size
and shape, hot spots could be as high as 20% of the prescription dose and typically appear in the
most superior and inferior portions of the breast tissue.6 Das et al7 concluded that tangential
separations of 22 cm or greater resulted in the need for higher beam energies to be used to obtain
better dose homogeneity. However, with higher beam energy, breast PTV coverage is reduced
because of the increase distance required for dose buildup. To overcome the reduced breast PTV
surface coverage, bolus or Lucite beam spoilers can be used as well as more advanced treatment
techniques such as IMRT and field-in-field treatment planning.7 Determination of the treatment
technique which is best suited for an individual needs to be made on a case-by-case basis. This
decision is dependent on the treatment techniques available, the physicians experience with the
technique, specific patient characteristics and risk factors associated with the chosen treatment
technique.5
To investigate which treatment planning technique is able to achieve the most favorable
PTV coverage and OR objectives, 4 patients were selected for this study who were previously
treated with AWBRT to the left breast. All patients had a tangential separation greater than 22
cm. For each of these 4 patients, a 3DCRT, TD and HT plan were created. Dosimetric
comparisons included PTV coverage and OR sparing. The analyses of OR objectives included
the heart, ipsilateral lung, contralateral lung and contralateral breast. The purpose of this study is
to compare and contrast PTV coverage and OR limits for left-sided, intact breast cancer patients
with large tangential separation using dosimetric comparison of 3DCRT, TD and HT treatment
planning techniques.

Case Description
Patient Selection
Four patients were selected for this study based on numerous factors. Each patient was
diagnosed with left-sided breast cancer and had previously undergone breast conserving surgery.
Inclusion criteria included a tangential separation of 22 cm or greater, absence of lymph node
involvement and an intact breast post-surgery. Patients selected were being treated with curative
intent.
Patients were simulated using a General Electric (GE) CT scanner. Patients were placed
in the supine position using a CIVCO wing board with a standard clear head support. The
patients had both arms up holding on to handles of the wing board. Head position was rotated
away from the affected side of treatment. A sponge was placed under their knees for support.
Planning CT images were acquired using 2.5 mm slices. The scanning parameters included the
level of the chin and extended through the entire thoracic cavity. The patients were marked using
one set of 3-point reference markings on their chest. Radiopaque wires were placed on the
patients scars at both the lumpectomy and nodal biopsy sites for CT visualization. After
completion of the CT scan, permanent tattoos were placed on each patients skin in the chest
region at the points of fiducial placement.
Target Delineation
Computed tomography (CT) data sets were transferred into the Philips Pinnacle3
treatment planning system (TPS) for contouring. The radiation oncologist contoured the
lumpectomy tumor bed volume which was expanded by 1.5 cm to create a lumpectomy PTV.
The location and size of the involved disease was verified from the mammography reports or by
the location of the clips placed during the breast conserving surgery. The left breast tissue and
lumpectomy tumor bed volume were contoured by the radiation oncologist. The left breast
contour was retracted 5 mm off of the skin surface to create the PTVeval which was used for the
dose volume histogram (DVH) constraints and analysis (Figure 2). Posteriorly, the breast
PTVeval was limited to no deeper than the anterior surface of the ribs to exclude the bony thorax
and lung.
The medical dosimetrist contoured the OR which included the heart, spinal cord,
ipsilateral lung, contralateral lung, and contralateral breast. The contralateral breast and heart
structures were contoured as defined in the Radiation Therapy Oncology Group (RTOG) 1005

protocol. The ipsilateral lung, contralateral lung, and spinal cord were contoured using the autosegmentation tools in the Pinnacle3 TPS. In addition to the OR listed, other planning structures
were created to assist in the treatment planning process. Planning structures included a spinal
cord planning at risk volume (PRV), which consisted of a 5 mm expansion of the spinal cord
contour; an external contour, which was used as a normal structure to keep hot spots out of
unspecified tissue; a contralateral breast expansion of 5 to 7 mm to help minimize the
contralateral breast maximum dose beyond what would typically be achieved using a complete
block; and a posterior block which was placed behind the lungs to limit dose through the lungs
and mediastinum (Figure 3). The radiation oncologist completed a treatment planning order
identifying the prescription, dose constraints and other pertinent treatment planning information.
The dose prescription and planning objectives identified by the radiation oncologist are listed in
Table 1.
Treatment Planning
To compare and contrast PTV coverage and OR limits for left-sided, intact breast cancer
patients with large tangential separation, three plans were generated for each of the four patients
selected. Adjuvant whole breast radiation therapy plans were created using 3DCRT field-in-field
tangents, TD and HT treatment planning techniques. Conventional 3DCRT treatment plans were
created using the Philips Pinnacle3 TPS. Two opposed tangential beams were utilized to treat the
left breast PTVeval using beams of 6 or 10 MV photons or a combination of the 2. Optimal beam
energy was chosen based on dose homogeneity, hot spots, and lumpectomy location. Field
borders were set to include the entire left breast PTVeval with a margin extending 1.0 cm in the
superior and inferior directions. Posteriorly a margin was given to the left breast PTVeval while
minimizing the lung volume to less than 2 cm. Anteriorly, adequate flash was given to the left
breast to account for respiratory motion during treatment. Multi-leaf collimators (MLC) were
used to add blocking along the chest wall to further shield the lung and heart (Figure 4). Beams
were weighted accordingly and a field-in-field treatment plan was created to allow for a more
uniform dose distribution while reducing the hot spots in the most superior and inferior regions
of the breast tissue.
To generate the field-in-field treatment plan, beams were calculated using open field
tangents (Figure 4). Beam energies and weightings were manipulated until an optimal dose
distribution was established. Dose clouds were then visualized on the beams eye view (BEV) for

each beam and a sub-field was created (Figure 5). Sub-fields were weighted 3% to 8% per field
to achieve a desirable dose distribution. A maximum of 5 sub-fields were used per tangential
beam.
For the TD treatment planning, the patients data sets and contoured structures were
transferred from the Pinnacle3 treatment planning system to the TomoTherapy Hi-Art version 5.0
planning system. Four tangential beams with jaw field widths of 2.5 cm were used. When TD
beams are used, the pitch value is automatically set to 1/10 of the field width. The pitch value
determines the amount of couch travel in cm per gantry rotation. Medial tangential beam angles
were 315 and 325 and lateral tangential beam angles were 135 and 145 for Patient 1 (Figures
6-7). The coordinate system used by TomoTherapy is in accordance with IEC 61217. Beam
angles were selected on an individual patient basis depending on patient anatomy. Optimal
angles were chosen to avoid dose to OR and lessen dose to the contralateral breast. Beam angles
chosen for each patient are included in Table 2. To help ensure proper target coverage from intrafractional motion, 3 leaves of the MLC were opened on the anterior aspects of the tangential
beams. Each leaf is 0.625 cm thus adding 1.875 cm of flash. By opening the MLC leaves
anteriorly, the risk of missing the target due to breathing motion is reduced. TomoTherapy is a
mono-energetic treatment modality; therefore the plan was computed using 6 MV treatment
beams. TomoDirect uses static gantry angles, similar to those of conventional 3DCRT, along with
couch translations and MLC modulation to deliver lower doses to the OR.5,8
Treatment planning for HT is done similarly to TD planning. Dose objectives were set
according to desired constraints instructed by the radiation oncologist. For HT treatment
planning, there are no set gantry angles as the treatment delivery for HT consists of a continuous
rotating fan beam along with couch translation and MLC modulation.8 Prior to beam
computation, parameters including pitch, modulation factor, and field width were determined. An
initial pitch value of 0.300, modulation factor of 2.4 and field width of 5 cm were set for all
patient plans. Table 3 lists the final pitch, modulation factor and field width used for each patient.
For all patients, dose limitations to the ipsilateral lung and heart were of high importance
when optimizing individual plans. Left breast PTVeval coverage of 95% of the volume receiving
95% of the dose was the desired goal for all patients. Minimizing dose to the contralateral lung
and breast were additional constraints used when optimizing treatment plans therefore a
complete block was placed on the contralateral breast, contralateral lung and posterior block

structures. A complete block is used in TomoTherapy treatment planning to instruct the machine
to not allow for any beam entrance or exit through those structures. Simultaneous optimization of
the left breast PTVeval, ipsilateral lung, contralateral lung, heart and contralateral breast
structures were essential to ensure all dose limiting constraints were met.
Plan Analysis & Evaluation
Dosimetric comparisons of prescription doses and desired planning objectives for the 3
different planning techniques are shown in Tables 4 through 7. The treatment plans were
evaluated using MIM software version 6.4.7. Figures 8 through 11 demonstrate isodose
distributions and DVHs for the 3DCRT, TD, and HT treatment plans for Patients 1 through 4
respectively.
As seen in the isodose distributions and DVHs in Figure 8, along with the analysis in
Table 4, adequate left breast PTVeval coverage was accomplished in all treatment plans for
Patient 1. The TD plan demonstrated the best target coverage at 99.8% while also producing the
lowest hot spot of 105.4% of the prescription dose. Planning objectives for the heart were met in
all treatment plans with the HT plan showing the lowest values for all objectives. The mean
heart doses were 2.1 Gy for the 3DCRT and 1.7 Gy for both the TD and HT treatment plans.
Ipsilateral lung objectives were also met for all constraints for Patient 1. The V16 objective was
lowest in the HT plan while the TD treatment plan demonstrated to be lowest for the V8 and V4
constraints. Contralateral lung objectives were seen with the V4 being 0% in all plans.
Contralateral breast doses were less than the desired 2.4 Gy constraint measuring at 0.8 Gy for
3DCRT, 0.67 Gy for TD, and 1.2 Gy for HT.
As was seen for Patient 1, the contralateral breast dose for Patient 2 measured highest for
the HT plan and lowest for TD. Similarity between Patient 1 and Patient 2 was also seen in the
contralateral lung, ipsilateral lung and heart constraints. The HT treatment plan resulted in the
lowest doses for all constraints. Mean heart doses measured the same for both TomoTherapy
treatment planning techniques. The ipsilateral lung V16 objective was lowest in the HT plan while
the V8 and V4 constraints were lowest in TD treatment plan. The plan with the greatest PTV
coverage was demonstrated in the HT plan at 98% while the TD plan had the lowest maximum
dose of 105.8%.
All plans for Patient 3 were shown (Table 6) to have adequate left breast PTVeval
coverage and can be seen in the DVHs in Figure 10. Contralateral breast maximum dose was met

in all treatment plans with values of 2.8 Gy, 1.3 Gy, and 2.9 Gy for the 3DCRT, TD, and HT
plans respectively. As with Patient 1, contralateral lung V5 was 0% in all plans. Ipsilateral lung
constraints for all plans were met, with the TD plan showing moderately lower doses compared
to 3DCRT and HT. The heart V20 was lowest in the HT while the 3DCRT plan had the lowest
heart V10 and mean doses of 2.4% and 2.1 Gy correspondingly.
The heart V25 was lowest in the HT plan followed by TD and 3DCRT in the DVH
analysis for Patient 4 (Table 7). Mean heart dose was lowest in the TD plan. Dose volume
histograms in Figure 11 show acceptable PTV coverage for the left breast target objectives.
Maximum dose was below the desired 115% of the prescription dose for all treatment plans with
the highest hot spot being 113% in the HT plan. Ipsilateral lung V20 was 12.7%, 9%, and 6.7%
for the 3DCRT, TD, and HT treatment plans respectively. As with all patients, contralateral lung
V5 was 0% in all plans.
The plan comparison results indicate similarities among all 3 treatment planning
techniques. Target coverage was greater than the desired 95% in all Patients and all treatment
modalities. The maximum PTV dose objective was met for all patients and was found to be
highest in the 3DCRT for Patient 1 while for Patients 2, 3, and 4 were greatest in the HT plans.
According to Fields et al9, the monoenergetic 6 MV beam used by TomoTherapy may be the
contributing factor as to why these hot spots occur especially in patients with larger breasts given
the higher attenuation of the lower energy beam. Heart, ipsilateral lung, contralateral lung and
contralateral breast values were all within desired constraints.
Conclusion
Results from this case study demonstrate adequate target coverage and OR sparing for all
treatment planning techniques. Das et al7, concluded that patients with a tangential separation
greater than 22 cm can result in treatment plans with increased hot spots, poorer dose
homogeneity, and reduced coverage resulting in the need for higher energy beams. These
conclusions can be seen in the patients presented in this case study. Coverage of the left breast
PTV was worst for 3DCRT plans when compared to TD and HT plans due to the need for 10 MV
beams to be used in the field-in-field 3DCRT treatment plans.
Along with better PTV coverage, TD and HT treatment plans demonstrated greater
reduction in heart dose in the high dose regions when compared to 3DCRT. Minimizing heart
dose is beneficial in reducing the risk of developing CAD after irradiation.4 Nevertheless, heart

dose constraints were met for all treatment plans and not likely to be of clinical significance in
this study. TomoDirect and HT also demonstrated better sparing of the ipsilateral lung dose in the
V16 doses for Patients 1 and 2 and V20 for Patients 4. However due to the rotational delivery of
HT, higher integral doses were observed in these plans.
Rotational delivery using HT also demonstrated an increase in the maximum dose to the
contralateral breast. The maximum dose to the contralateral breast should be kept to a minimum
to reduce the risk of secondary malignancy in the contralateral breast. Depending on the patients
age and other health conditions, the radiation oncologist will need to decide if administering a
higher dose to the contralateral breast with rotational delivery is worth the risk to spare the dose
delivered to the ipsilateral lung and heart.
This case study demonstrated that 3DCRT, TD, and HT treatment planning techniques are
all adequate in the PTV coverage and OR sparing thus making them all possible choices for the
treatment of left-sided, intact breast cancer. Disadvantages to using HT include higher integral
doses and increased time required for both treatment planning and delivery. TomoDirect results
showed equivalent or superior target coverage and OR sparing when compared to 3DCRT
treatment plans. All treatment planning techniques demonstrated to be acceptable, therefore,
radiation oncologists treatment delivery decision should remain a patient-by-patient basis.

10

References
1. Eisemann N, Waldmann A, Katalinic A. Epidemiology of breast cancer-current figures and
trends. Geburtsh Frauenheilk. 2013;73(2):130-135. http://dx.doi.org/10.1055/s-00321328075
2.

Buyske J, Mackarem G, Ulmer B, et al. Breast cancer in the nineties. AORN J.

1996;64(1):64-72. http://dx.doi.org/10.1016/s0001-2092(06)63371-1

3.

Zurrida S, Veronesi U. Milestones in breast cancer treatment. Breast J. 2014;21(1):3-12.

http://dx.doi.org/10.1111/tbj.12361

4. Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation
therapy for breast cancer. N Engl J Med. 2010;362(6):513-520.
http://dx.doi.org/10.1056/NEJMoa0906260
5. Qi XS, Liu TX, Liu AK, et al. Left-sided breast cancer irradiation using rotational and fixedfield radiotherapy. Med Dosim. 2014;39:227-234.
http://dx.doi.org/10.1016/j.meddos.2014.02.005
6. McCormick B, Hunt M. Intensity-modulated radiation therapy for breast: Is it for everyone?
Semin Radiat Oncol. 2011;21(1):51-54. http://dx.doi.org/10.1016/j.semradonc.2010.08.009
7. Das IJ, Shikama N, Cheng CW, Solin LJ. Choice of beam energy and dosimetric
implications for radiation treatment in a subpopulation of women with large breasts in the
United States and Japan. Med Dosim. 2006;31(3):216-223.
http://dx.doi.org/10.1016/j.meddos.2006.02.002
8. Franco P, Catuzzo P, Cante D, et al. TomoDirect: an efficient means to deliver radiation at
static angles with tomotherapy. Tumori. 2011;97:498-502.
http://dx.doi.org/10.1700/950.10404
9. Fields E, Rabinovitch R, Ryan N, Miften M, Westerly D. A detailed evaluations of
TomoDirect planning for whole-breast radiation. Med Dosim. 2013;38(4):401-406.
http://dx.doi.org/10.1016/j.meddos.2013.04.008

11

Figures

Figure 1. The red line denotes the tangential separation for this patient.

12

Figure 2. The breast planning contours demonstrating breast PTVeval (red), lumpectomy
PTVeval (orange), and lumpectomy tumor bed volume (yellow).

13

Figure 3. Posterior block structure (teal) placed posteriorly to the lungs to limit dose through the
lungs and mediastinum for TD and HT treatment planning. Other structures include the
contralateral breast (orange), contralateral lung (green), heart (purple), ipsilateral lung (blue),
spinal cord (forest green), cord PRV (lavender), left breast PTVeval (pink) and lumpectomy PTV
(red).

14

Figure 4. Beams eye view (BEV) of the 3DCRT medial tangent field for Patient 1. The left
breast PTVeval is shown in pink, ipsilateral lung in blue, and heart in purple.

15

Figure 5. Medial and lateral tangential sub-fields of the first control point in field-in-field
treatment plan. The medial sub-field dose cloud is the 122% dose cloud and the lateral sub-field
dose cloud is the 118% dose cloud.

16

Figure 6. Medial tangent beam angles for the TD treatment plan for Patient 1.

17

Figure 7. Lateral tangent beam angles for the TD treatment plan for Patient 1.

18

(3DCRT + 3DCRT boost)

(TD + 3DCRT boost)

(HT + 3DCRT boost)

Figure 8. Dose distributions and DVHs of the 3DCRT, TD, and HT treatment plans in the axial
views for Patient 1. The isodose lines shown include: 110% (light pink), 105% (magenta), 100%
(red), 95% (orange), 90% (yellow), 80% (green), 50% (teal) and 20% (blue). Dose volume
histogram lines include: left breast PTVeval (pink), contralateral breast (orange), contralateral
lung (green), heart (purple), and ipsilateral lung (blue).

19

(3DCRT + 3DCRT boost)

(TD + 3DCRT boost)

(HT + 3DCRT boost)

Figure 9. Dose distributions and DVHs of the 3DCRT, TD, and HT treatment in the axial views
for Patient 2. The IDL shown include: 110% (light pink), 105% (magenta), 100% (red), 95%
(orange), 90% (yellow), 80% (green), 50% (teal) and 20% (blue). Dose volume histogram lines
include: left breast PTVeval (pink), contralateral breast (orange), contralateral lung (green), heart
(purple), and ipsilateral lung (blue).

20

(3DCRT + 3DCRT boost)

(TD + 3DCRT boost)

(HT + 3DCRT boost)

Figure 10. Dose distributions and DVHs of the 3DCRT, TD, and HT treatment plans in the axial
views for Patient 3. The IDL shown include: 110% (light pink), 105% (magenta), 100% (red),
95% (orange), 90% (yellow), 80% (green), 50% (teal) and 20% (blue). Dose volume histogram
lines include: left breast PTVeval (pink), contralateral breast (orange), contralateral lung (green),
heart (purple), and ipsilateral lung (blue).

21

(3DCRT + 3DCRT boost)

(TD + 3DCRT boost)

(HT + 3DCRT boost)

Figure 11. Dose distributions and DVHs of the 3DCRT, TD, and HT treatment plans in the axial
views for Patient 4. The IDL shown include: 110% (light pink), 105% (magenta), 100% (red),
95% (orange), 90% (yellow), 80% (green), 50% (teal) and 20% (blue). Dose volume histogram
lines include: left breast PTVeval (pink), contralateral breast (orange), contralateral lung (green),
heart (purple), and ipsilateral lung (blue).

22

Tables
Table 1. Prescription doses and planning objectives for Patients 1 through 4.

Left breast
Breast PTVeval

Heart
Ipsilateral Lung
Contralateral Lung
Contralateral Breast

Prescription Dose:
Patient 1
Patient 2
42.56 Gy/16 fx 40.05 Gy/15 fx

Patient 3
50 Gy/25 fx

Desired Planning Objectives:

D95% 95%
D95% 95%
D95% 95%
Max dose
Max dose
Max dose
110%
110%
110%
V16 5%
V16 5%
V20 5%
V8 10%
V8 10%
V10 30%
Mean 3.2 Gy Mean 3.2 Gy Mean 4 Gy
V16 15%
V16 15%
V20 15%
V8 35%
V8 35%
V10 35%
V4 50%
V4 50%
V5 50%
V4 10%
V4 10%
V5 50%
Dmax 2.4 Gy Dmax 2.4 Gy Dmax 8 Gy

Patient 4
50 Gy/25 fx
D95% 95%
Max dose
115%
V25 5%
Mean 4 Gy
V20 30%
V5 10%

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Table 2. TD medial and lateral tangential beam angles (in degrees) chosen to best minimize
dose to OR and avoid dose to the contralateral breast.
Medial tangent 1
Medial tangent 2

Patient 1
315
325

Patient 2
315
325

Patient 3
315
325

Patient 4
315
325

Lateral tangent 1
Lateral tangent 2

135
145

130
140

130
140

135
145

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Table 3. Pitch, modulation factor and field width parameters used for HT treatment planning.
Pitch
Modulation factor
Field width (cm)

Patient 1
0.287
2.4
5.0

Patient 2
0.287
2.4
5.0

Patient 3
0.430
2.0
2.5

Patient 4
0.215
2.8
2.5

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Table 4. Planning objective analysis of treatment plans for Patient 1.

Breast PTVeval

Heart
Ipsilateral Lung
Contralateral Lung
Contralateral Breast

Prescription Dose:
Desired
Planning
3DCRT
TD
HT
Objectives
D95% 95% D95% = 96.8% D95% = 99.8% D95% = 99.2%
Max dose
Max dose =
Max dose =
Max dose =
110%
108.8%
105.4%
107.1%
V16 5%
V16 = 2.8%
V16 = 1.8%
V16 = 1.1%
V8 10%
V8 = 5.0%
V8 = 3.6%
V8 = 2.5%
Mean 3.2 Gy Mean = 2.1 Gy Mean = 1.7 Gy Mean = 1.7 Gy
V16 15%
V16 = 10.7%
V16 = 6.6%
V16 = 6.1%
V8 35%
V8 = 15.5%
V8 = 9.6%
V8 = 10.6%
V4 50%
V4 = 22.3%
V4 = 14.4%
V4 = 18.2%
V4 10%
V4 = 0.0%
V4 = 0.0%
V4 = 0.0%
Dmax 2.4 Gy Dmax = 0.8 Gy Dmax =0.6 Gy Dmax = 1.2 Gy

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Table 5. Planning objective analysis of treatment plans for Patient 2.

Breast PTVeval

Heart
Ipsilateral Lung
Contralateral Lung
Contralateral Breast

Prescription Dose:
Desired
Planning
3DCRT
TD
HT
Objectives
D95% 95% D95% = 96.7% D95% = 95.5% D95% = 98%
Max dose
Max dose =
Max dose =
Max dose =
110%
106.4%
105.8%
108%
V16 5%
V16 = 5.0%
V16 = 1.8%
V16 = 0.5%
V8 10%
V8 = 7.6%
V8 = 3.3%
V8 = 2.3%
Mean 3.2 Gy Mean = 3.0 Gy Mean = 1.5 Gy Mean = 1.5 Gy
V16 15%
V16 = 13.8%
V16 = 8.1%
V16 = 6.5%
V8 35%
V8 = 17.1%
V8 = 10.6%
V8 = 11.4%
V4 50%
V4 = 22.3%
V4 = 14.6%
V4 = 19.4%
V4 10%
V4 = 0%
V4 = 0%
V4 = 0%
Dmax 2.4 Gy Dmax = 0.9 Gy Dmax =0.5 Gy Dmax = 1.8 Gy

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Table 6. Planning objective analysis of treatment plans for Patient 3.

Breast PTVeval

Heart
Ipsilateral Lung
Contralateral Lung
Contralateral Breast

Prescription Dose:
Desired
Planning
3DCRT
TD
HT
Objectives
D95% 95%
D95% = 97% D95% = 100% D95% = 99%
Max dose
Max dose =
Max dose =
Max dose =
110%
108%
105%
109%
V20 5%
V20 = 1.0%
V20 = 1.5%
V20 = 0.89%
V10 30%
V10 = 2.4%
V10 = 4.2%
V10 = 4.1%
Mean 4 Gy Mean = 2.1 Gy Mean = 2.2 Gy Mean = 2.7 Gy
V20 15%
V20 = 10.6%
V20 = 6.0%
V20 = 10.9%
V10 35%
V10 = 16.2%
V10 = 11%
V10 = 23.3%
V5 50%
V5 = 24.2%
V5 = 16.1%
V5 = 42.1%
V5 50%
V5 = 0.0%
V5 = 0.0%
V5 = 0.0%
Dmax 8 Gy Dmax = 2.8 Gy Dmax = 1.3 Gy Dmax = 2.9 Gy

28

Table 7. Planning objective analysis of treatment plans for Patient 4.

Breast PTVeval

Heart

Prescription Dose:
Desired
Planning
3DCRT
TD
HT
Objectives
D95% 95% D95% = 97.5% D95% = 99.7% D95% = 98.3%
Max dose
Max dose =
Max dose =
Max dose =
115%
106.7%
112%
113%
V25 5%
V25 = 3.0%
V25 = 2.2%
V25 = 0.9%
Mean 4 Gy Mean = 3.0 Gy Mean = 2.5 Gy Mean = 3.1 Gy

Ipsilateral Lung

V20 30%

V20 = 12.7%

V20 = 9.0%

V20 = 6.7%

Contralateral Lung
Contralateral Breast

V5 10%

V5 = 0.0%

V5 = 0.0%

V5 = 0.0%