Amanda

Lisher
DOS 773: Clinical III
Final Planning Project

Patient Selection
This patient is a 64-year-old female diagnosed with clinical stage T3N1M0 Grade III
infiltrating ductal carcinoma of the right breast, ER/PR 50% +, Her-2/Neu 2+ in March.
Ultrasound confirmed a poorly differentiated mass, approximately 6cm x 2cm x 2cm in size.
At the time of consultation, the physician explained that the patient was not a candidate for
breast conservation, due to her tumor being larger than 5cm in size. Current
recommendations for locally advanced breast cancer are neoadjuvant chemotherapy
followed by surgical resection and radiation therapy.1 Patients who demonstrate a
favorable response to chemotherapy may become eligible for breast conserving surgical
management.

The patient completed her final cycle of multi-agent chemotherapy in July. In August, she
was determined eligible for breast conserving surgery, and a right breast lumpectomy and
sentinel lymph node biopsy were performed. There was significant lymphovascular
invasion throughout the tumor, surgical margins were negative for invasive disease, and
one of two sampled lymph nodes was positive for metastatic carcinoma.

In September, the patient returned to the clinic for evaluation and discussion regarding the
specifics of radiation therapy. Given the aggressive nature of her disease at diagnosis, and
the presence of residual disease in the nodal regions, the physician recommended a course
of radiation to the whole breast as well as the supraclavicular and axillary lymph nodes.
Following current practice1, the physician prescribed 5040 cGy to the breast and regional
lymph nodes, 180 cGy per day for 28 fractions. The lumpectomy site was prescribed an
additional 1000cGy boost to be given in 5 fractions.

Simulation & Treatment Set Up
In mid-September, a CT-simulation was performed in preparation for external beam
radiation therapy. The patient was positioned supine on the table, on an extended
wingboard with a Silverman B headrest. Both arms were placed above the head, with
hands holding the wingboard pegs at position B4. An angle sponge was placed under the
knees for comfort. CT images were obtained in 5mm increments from the level of C1
through the costophrenic angles. The data set was imported into the Philips Pinnacle3
workstation, version 9.8. I contoured the dose-limiting organs at risk (OR) including the
heart, right lung, right humeral head, spinal cord and esophagus. I also contoured set-up
structures, including the external body, and simulation markers placed on the treatment
borders and surgical scar. The physician contoured the CTV-right tumor bed, the PTV-right
breast, and the CTV-right supraclavicular (SCV) and axillary lymph nodes.

Patient ID:
Plan Name:
Lock Status:

L2808
R BREAST
Not Locked

Comment:
mandy node contours
Physician/Physicist:
AT/

Planner:
Institution:

Figure 2. Anatomical contours for right breast and regional lymph nodes. (Red=CTV-RT
tumor bed, Yellow=PTV-RT breast, Aqua=CTV-RT SCV and axillary nodes, Blue=RT lung,
Purple=Heart, Orange=Esophagus, Cream=Spinal cord, Green=RT humeral head. External
contours include Forest=Body, Orange=Treatment borders, Magenta=Scar.)

SMB
9.8 LCCOTTAWA

Patient Name:
Patient ID:
Plan Name:
Lock Status:

FLAGER, VIRGINIA,
L2808
R BREAST
Not Locked

Date/Time:
20151029 18:08:37
Comment:
mandy breast contours
Physician/Physicist:
AT/

Revision:
Planner:
Institution:

Figure 3. Anatomical contours for right breast and regional lymph nodes. (Red=CTV-RT
tumor bed, Yellow=PTV-RT breast, Aqua=CTV-RT SCV and axillary nodes, Blue=RT lung,
Purple=Heart, Orange=Esophagus, Cream=Spinal cord, Green=RT humeral head. External
contours include Forest=Body, Orange=Treatment borders, Magenta=Scar.)


As indicated in the images above, our physicians contour one node volume for the SCV and
axillary lymph nodes, and do not delineate between levels. Nodal volumes are based on the
RTOG Breast Cancer Atlas2, shown below. Recently, studies3,4 have suggested an update to
the current atlas based on CT evidence that SCV nodal volumes often extend superior,
posterolateral and lateral to the current RTOG recommendations. I have discussed these
findings with our physicians, I will be interested to see if and how their node contours
change based on the new data.

R01.P01.D03
SMB
9.8 LCCOTTA





Treatment Planning
At my clinical site, the majority of our breast/chest wall and regional node plans have two
isocenters. Due to field size limitations for both dynamic and physical wedges (a product of
our machine commissioning) it is often difficult to fit the entire tangent fields in a mono-
isocentric set-up, and still be able to use wedges. Once the contours were completed, I
selected an isocenter for my tangents and a separate isocenter for my SCV. Our goal is to
minimize the amount of shifting the therapists have to do each day during treatment. So,
when we can, we keep the isocenters in the same lateral plane, so there is only a
longitudinal shift from the SCV isocenter to the tangent isocenter. In this case, the tangent
isocenter is 8 cm inferior to the SCV isocenter. The tangent isocenter is determined by
creating a medial tangent that intersects medial and lateral markers placed during
simulation. The isocenter is placed about halfway between the two BBs, along the central
axis of the beam. Typically, we like to have less than 2 cm of lung in the field. However, this
particular patient had a rather rectangular chest anatomy, which resulted in a deeper
isocenter than usual.

Plan Name:
Lock Status:

R BREAST
Not Locked

Physician/Physicist:

AT/

Institution:

9.8 LCCOTTAWA

Figure 5. Isocenter placement. (Green=SCV isocenter, Aqua=Tangent isocenter.)

Figure 6. Transverse view of tangent isocenter (aqua) and medial beam (red lines).

After the isocenters were determined, I set the SCV gantry angle at 10o, to avoid dose to the
spinal cord and esophagus. The PA SCV field was set at 180o. The medial gantry angle was
Patient Name:
FLAGER, VIRGINIA,
Date/Time:
20151029 17:56:04
determined as mentioned above. Next, I set the
sizes
LC blocks
to
Patientfield
ID:
L2808 and created M
Comment:
mandy 3D
Plan Name:
R BREAST
Physician/Physicist:
AT/
protect the ORs, including the humeral head, Lock
spinal
esophagus, and lung. I copied
and
Not Locked
Status: cord,
opposed the medial field to create the lateral tangent. In order to avoid overlap at the
Patient Name:
FLAGER, VIRGINIA,
Date/Time:
18:00:24
Revision:
R01.P01.D03
1 of 1
match
line,
for the medial
and 20151029
lateral
fields the
collimator
was Page:
rotated
to 357o and the
Patient ID:
L2808
Comment:
mandy blocks
Planner:
SMB
Scaling:
Fill Page
Plan Name:
R BREAST
Physician/Physicist:
AT/
Institution:
9.8 LCCOTTAWA
o
couch
was
turned 5 away from the gantry.
Not Locked
Lock Status:
RTP System 9.8

Figure 7. Block arrangement, clockwise from top leftLAO SCV, PA SCV, Lateral, Medial.
Figure 8. Skin rendering of LAO SCV and medial tangent field showing match line. The
superior medial border of the medial tangent crosses toward the contralateral side in order
to capture the deep axillary lymph nodes.

Revision:
Planner:
Institution:

R01
SMB
9.8 L

The final beam arrangement is listed in the table below. I selected the 15 MV beam for the
LAO and PA SCV, to reduce the hot spot near the AP surface, and to push the dose from the
PA past midline toward the CTV. I avoided using a 15 MV beam or a wedge on the medial
tangent, to avoid unnecessary scatter to the contralateral breast. I used forward planning
control points on the medial and lateral 6 MV tangents to reduce the hot spots in the breast
PTV. I utilized a 10o inferior dynamic wedge on the 15 MV lateral beam, to help push the
remaining hot spot up into the breast tissue, and to minimize skin irritation at the inferior
breast fold. I normalized the tangent fields to the 97% isodose line, to increase coverage to
the PTV. Typically, we dont normalize lower than 97% on our 3D plans.


Field
Energy
Gantry Collimator
Couch
Beam
Weighting
Name
Angle
Angle
Angle
Modifiers
LAO SCV
15 MV
10
0
0
n/a
68%
PA SCV
15 MV
180
0
0
n/a
32%
Med Tang 6 MV
54
357
5
Control
46%
points
Lat Tang
6 MV
234
357
355
Control
31.5%
points
Lat2 Tang 15 MV
234
357
355
EDW 10o
22.5%
BV
12 MeV
300
0
330
n/a
100%




Ultimately, I was satisfied with the isodose coverage for this plan. During treatment
planning, we subtract out a 0.4 mm skin rind just inside the body contour, and pull the PTV
contour back the same distance. The skin rind acts as an allowance for the dose build up
region, and it also helps us measure the dose to the skin, which should receive a mean dose
> 70% of the prescribed dose. There was some dose lost at the corners of the breast PTV,
near the skin surface anteriorly and laterally. This is due to blocking from my control
points and the 15 MV beam on the lateral.

At my clinic, we aim to keep the maximum dose at or below 110% for breast plans, and the
actual hot spot less than 108% whenever possible. In my final plan, the maximum dose for
the total volume was 5482 cGy (109%). The actual hot spot was 5443 cGy (108%), shown
in the images below. The maximum dose point was in the GTV, which is ideal. In the
composite plan, with the en face electron boost added, the maximum hot spot was 6617
cGy (110%), again in the GTV.

Patient Name:
Patient ID:
Plan Name:
Lock Status:

FLAGER, VIRGINIA,
L2808
R BREAST
Not Locked

Date/Time:
20151029 18:39:21
Comment:
mandy breast isodose
Physician/Physicist:
AT/

Revision:
Planner:
Institution:

Figure 9. Isodose distribution for total volume breast PTV and node CTV. (Royal=108%,
Green=100%, Purple=95%, Red=90%, Aqua=50%.)

R01.P0
SMB
9.8 LCC

Patient ID:
Plan Name:
Lock Status:

L2808
R BREAST
Not Locked

Comment:
mandy composite isodose
Physician/Physicist:
AT/

Planner:
Institution:

Figure 10. Isodose distribution for composite plan with en face electron boost.
(Royal=108%, Green=100%, Purple=95%, Aqua=95% of prescribed tangent dose.)

SMB
9.8 LCCOTTAWA

For the SCV nodes, the calculation point was placed just posterior to the deepest contoured
volume, about 6.6 cm deep. Prior to CT simulation, SCV nodes were prescribed to 3-4 cm
depth. Studies have shown, however, that the SCV fossa is deeper than 3 cm in > 80% of
patients.3 During planning, it became difficult to meet the prescribed 5040 cGy to the node
CTV and still meet the lung constraints. Dose to the nodes was also lost due to part of the
Patientlying
Name:under
FLAGER,
VIRGINIA,
20151029
18:36:24
volume
the humeral
head block. TDate/Time:
he physician
advised
me that he would Revision:
Patient
ID:
L2808
Comment:
mandy
scv
isodose
accept a dose of 4500 cGy to the nodal volumes, which is a more common prescribed dPlanner:
ose
Name:
BREAST
AT/
Institution:
for bPlan
reast/chest
wRall
nodes at our center. Physician/Physicist:
Not Locked
Lock Status:

Figure 11. Isodose distribution for the SCV and axillary lymph nodes. Lines are relative to
prescribed 5040 cGy, modified planning goal was 4500 cGy (red) to the nodes.
(Green=100%, Purple=95%, Red=90%, Aqua=50%.)

R01.P01.D03
SMB
9.8 LCCOT

All treatment objectives and OR constraints were met with this plan, as shown below.
Site
Objective
Objective Met?
CTV-RT Tumor Bed
v100 > 95%
Yes
PTV-RT Breast
v95 > 95%
Yes
Patient Name:
FLAGER, VIRGINIA,
Patient
ID:
L2808
CTV-RT SCV + Axillary
v95 > 95%
Yesat variation acceptable
Plan Name:
R BREAST
Nodes
dose of 4Lock
500cGy
Not Locked
Status:
OR
Constraint
Constraint Achieved?
RT Lung
v20 < 30
Yes
Heart
Max dose 2000 cGy
Yes
Heart
Mean dose < 400 cGy
Yes
Spinal Cord
Max dose 4500 cGy
Yes
Esophagus
Mean dose < 3500 cGy
Yes

Patient Name:
FLAGER, VIRGINIA,
Date/Time:
20151029 18:47:09
Revision:
R01.P01.D03
Page:
1 of 1
L2808
Comment:
mandy composite dvh
Planner:
SMB
Scaling:
Fill Page
Patient ID:
Plan Name:
R BREAST
Physician/Physicist:
AT/
Institution:
9.8 LCCOTTAWA
Lock Status: Not Locked
RTP System 9.8

Figure 12. Final composite DVH.

One thing I have struggled with when planning 4-field breast patients is knowing where to
place the match line between the SCV and tangent fields. There is always a break in the
isodose coverage at the match line, and I typically move the match line 3 or 4 times during
planning, to determine which arrangement will afford me the best PTV coverage. Also, I try
not to place the match line too inferior, to limit unnecessary dose to the lung apex.
Depending on which physician is contouring (and maybe perhaps what day of the week it
is!) The breast PTV and the SCV PTV overlap to a different degree. What has been working
for me recently is to place the match line where the slope of the patient changes. The
superior node volumes are usually fairly horizontal in the patient, while the axillary nodes
start to follow the curve of the lateral chest wall. A lot of the time I can capture the inferior

Date/T
Comm
Physic

axillary nodes with my tangent fields. For this plan, my match line landed superior to the
entire breast PTV. Depending on the patients anatomy, sometimes the superior breast PTV
lies more horizontal, overlapping the SCV nodes. In that case, my match line would
probably fall below the most superior portion of the breast PTV. As demonstrated in this
treatment plan, 100% coverage to the deep axillary nodes is difficult to achieve when
prescribed to a dose of 5040 cGy. A dose of 4500 cGy is usually easier to achieve. Above all,
what I have learned from planning 4-field breasts is that it all comes down to anatomy.
Each patient is different, and what works for one will not always work for another. The key
is knowing what tools I have, and how to utilize them to design a treatment plan that meets
dose objectives while sparing the ORs and limiting skin toxicity during treatment.



1. Chao KSC, Perez CA, Brady LW. Breast: locally advanced (T3 and T4), inflammatory, and
recurrent tumors. In: Radiation Oncology Management Decisions. 3rd ed. Philadelphia,
PA: Wolters Kluwer; 2011.
2. White J, Tai A, Arthur D, et al. Breast cancer atlas for radiation therapy planning:
Consensus definitions. Radiation Therapy Oncology Group (RTOG).
https://www.rtog.org/LinkClick.aspx?fileticket=vzJFhPaBipE%3d&tabid=236.
Accessed October 7, 2015.
3. Jing H, Wang S-L, Li J, et al. Mapping patterns of ipsilateral supraclavicular nodal
metastases in breast cancer: Rethinking the clinical target volume for high-risk patients.
Int J Radiat Oncol Biol Phys. 2015;93(2):268-276.
http://dx.doi.org/10.1016/j.ijrobp.2015.08.022
4. Brown L, Diehn FE, Boughey JC, et al. Delineation of supraclavicular target volumes in
breast cancer radiation therapy. Int J Radiat Oncol Biol Phys. 2015;92(3):642-649.
http://dx.doi.org/10.1016/j.ijrobp.2015.02.022