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1 Nick Piotrowski Clinical Practicum 1 April 24, 2013 Left Prone Breast History of Present Illness: JM is a 46 year old female

that has been recently diagnosed with a non-infiltrating intraductal carcinoma in situ of the left breast. The suspicious breast led to a biopsy which resulted in the above pathology. The size and biopsy resulted in the possibility of surgery, or radiotherapy for the patient. Past Medical History: JM has an extensive past medical history, especially in the form of surgeries. Fortunately none of these previous issues have been cancer related until recently. Starting in 1972 JM had a tonsillectomy, followed by an elbow surgery, cervical disc removal, cesarean section, colonoscopy, and most recently her left breast lumpectomy. JM has also had infections such as bronchitis, anemia, and a few broken bones. All of this comes in addition to chronic diseases such as high cholesterol, hypertension, migraines, heartburn, and hypothyroidism. Social History: JM has relatively no social history issues. She has no known family medical history with cancer, and has never been a smoker or drinker. She has one child and is married to her husband who she currently lives with. While she is in good mental health, she does struggle allowing her husband to take care of her in this situation. Medications: She is currently taking a daily dose of 81 milligrams (mg) of aspirin, 40mg of Atorvastatin, two tablets of Citrucel, 65mg of ferrous sulfa, 2,0000mg of fish oil, 0.2mg of Levothyroxine, 50mg of Losartan, 40mg of Omeprazole, and 2,000 units of Vitamin-D3. Fortunately, JM has no known allergies to any drugs at this point. Diagnostic Imaging: All of the diagnostic imaging that JM has had completed has been due to her most recent diagnosis. She has received her annual mammogram at this facility since 2008. Her mammogram in March of 2013 brought suspicion and follow-up testing. She had an ultrasound-guided biopsy which continued into a needle localized excisional biopsy in 3 separate areas. She then proceeded to have a left breast x-ray to verify the biopsy, and eventually a treatment planning computed tomography (CT) scan for her radiation treatments. Radiation Oncologist Recommendations: With JM’s disease being a relatively early stage cancer, the physician suggested that there would be no need for concurrent chemotherapy. It was

Beam Isocenter/Arrangement: Using a Varian Trilogy linear accelerator. The physician also felt as though the patient would be better off being resimulated before her boost portion as she may be treated supine. but were slightly edited during planning. The plan was created using the field in field technique with a variation of energies. A custom VacLok mold was formed to help immobilize the upper body of the patient. and wires. With the isocenter being set in the simulator. It also became necessary to copy these fields and add a field in field technique to improve on coverage. the lumpectomy scar. The two tangential beams were also set by the physician. The fields were perfect squares measuring 8 centimeters (cm) in each direction. a boost plan is being created that will include another four fractions at 2. lungs. JM is receiving 42. carina.5Gy each. JM is receiving her 20 fractions of external beam radiation therapy. Treatment Planning: Using Eclipse 10. Also during the simulation. The two fields were slightly off from being directly parallel opposed and had rotated collimators in order to match the divergence of the inner field border. but not directly opposed as the required border needed to have a matched divergence. JM first had the superior. Although there . With some of the contralateral breast showing in the field the physician allowed the addition of multileaf collimators (MLC) to block unnecessary tissue. nipple. and breast were pinpointed with markers. This addition will bring the total dose of the plan to 52. left. In addition. seen in Figure 1.66Gy/fraction for 16 fractions.56Gy over 20 fractions.0 JM’s plan was created with the intentions of giving 52. heart. there was no need to set it or change it during treatment planning. There were two opposing tangents. inferior. the physician went ahead and set isocenter using the lasers. The contouring on JM’s CT was relatively simple as all that needed to be done was the body.2 suggested that to remove gross disease she receive a lumpectomy. with her arms above her head. spinal cord.56Gy while minimizing some of the dose to critical surrounding structures. Following the initial plan. Patient Setup/Immobilization: During her treatment planning CT. The Plan (prescription): Following the trial RTOG 1005. She was placed in the prone position on a prone breast board.56 Gray (Gy) at 2. Anatomical Contouring: With the isocenter being set during the simulation there was no need to set the user origin. The patient would be administered to Radiation Therapy Oncology Group (RTOG) 1005 study and receive doses based on that trial. and then radiation therapy for residual disease. and right clinical borders marked with radiopaque markers.

I had not yet used it on a breast plan. the already lightly weighted beams were split between four beams. as well as the attending physician. reading these charts often bring the case to life. I couldn’t help but notice the youth of this patient. the monitor units that were calculated by Eclipse were double checked using RadCalc. This field arrangement helped improve my coverage. It has provided me with an opportunity to get to know some of these people and pushed me to become a better dosimetrist. it still didn’t reach the necessary coverage. encompassing the tumor with the 98% isodose line and keeping the hot spot to 6%. The concept was the same. By using the 18MV beams for the field in field. Quality Assurance/Physics Check: Before printing. Without electronic compensation. and 5. the plan was checked and signed off by both the medical physicist. there was a large amount of dose coverage missing from the middle of the breast. we did go ahead and take a look at the left and right lung as well as the cord and the heart dose.3 were no real threats of surpassing any dose tolerances. When the 6 megavoltage (MV) beams were first placed on the plan.08Gy. Figure 2 shows how we were able to use MLCs to protect these tissues.40Gy. . this was a great plan to help out with.66Gy respectively. Once the numbers were found to be within tolerance. These maximum doses reached 3. While there weren’t any complications with this plan. but getting the MLC’s to fit the dose shape wasn’t quite as easy as other plans. In order to eliminate unnecessary dose. 0. it definitely required a different train of thought. For this reason we attempted to add 18MV beams of the same field dimensions and give them a lighter weighting. Although we are more removed from the patient than a therapist or oncologist. Conclusion: This plan gave me an opportunity to break into some new areas that I had not yet explored. While the contouring and treatment philosophies were identical. While this definitely improved the plan. the next method to try was field in field.08Gy. As they do not find a benefit for this in a prone set up I was forced to think outside the box. While I have treated with the field in field technique before. This mixing of energies and field in field technique took some creativity but kept the plan relatively simple. I also did my best to minimize dose to the contralateral breast as sometimes it does enter the treatment field. With most of our supine breast patients I have used electronic compensation to remove hot spots and help improve my coverage. 0. Since I had not yet seen a prone breast.

4 Figures Figure 1: Prone breast board. .1 Figure 2: Placement of MLCs.

. 2013.5 References 1. 2013. CDR Systems.ca/prone-breast-positioning. Available at: http://www. Accessed April 24. Prone breast patient positioning.cdrsys.php.