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Ali Fitzpatrick
April Case Study
April 29, 2014
Right Breast Invasive Ductal Carcinoma
History of Present Illness: Patient CS is a 68 year old female with a history of abnormal
mammograms since January of 2011. Initially, the patient had screening mammograms that
showed areas of calcifications in the right breast for which short term follow up diagnostic
imaging was done. However, no indication for biopsy was present until December of 2014,
when the patient had a diagnostic right breast mammogram with slight interval increases in the
number of calcifications that were present in the breast. In December of 2014, a biopsy of the
area was performed of the most anterior and most posterior aspects of the calcifications in the
upper outer quadrant of the right breast. The biopsy from the anterior aspect showed invasive
ductal carcinoma (IDC) measuring 0.4cm with multifocal ductal carcinoma in situ (DCIS) and
several calcifications. The biopsy from the posterior aspect showed multifocal DCIS with
associated calcifications. The biopsies also revealed that the disease was positive for estrogen
receptors (ER) and progesterone receptors (PR), but human epidermal growth factor receptor 2
(HER2) negative. ER/PR assays are typically performed on patients with invasive and
noninvasive breast cancer in the United States because the results can correlate with the
prognosis and tumor response to chemotherapeutic and hormonal agents.
1
The HER2 oncogene
amplification is also a potential prognostic marker in breast cancer, and its relationship with
pathological and clinical parameters can be useful in the treatment decision process.
2
HER2
amplification is associated with various items such as nodal involvement, histological grade, or
even survival. Most always, a poor prognosis is indicated with HER2 amplification. Agreement
about the definitive prognostic and predictive analysis has yet to be reached regarding
immunohistochemistry (IHC), but significant progress continues to be made in the search to
identify successful treatment plans using biological markers.
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CS underwent a lumpectomy, performed in February of 2014, and was referred to
radiation oncology for a consultation in March of 2014 with a diagnosis of T1aN0M0 invasive
ductal carcinoma with multifocal ductal carcinoma in situ solid and cribiform types. There are
many variants of DCIS which include comedo, clinging, papillary and neuroendocrine in
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addition to the solid and cribiform variants that CS was identified as having.
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It is common that
DCIS lesions can exhibit more than one morphological variant, and all should be noted in the
pathology report. The radiation oncologist reviewed the pathology along with the patients
history and performance status, and ultimately recommended whole breast radiation to CS. The
physician discussed the rationale for radiation therapy, its potential risks, benefits, short and
long-term side effects, and complications, as well as alternatives to radiation therapy in detail.
At the end of consultation, CS signed the consent to proceed with radiation therapy treatment.
Past Medical History: CS has a past medical history of gastroesophageal reflux disease,
(GERD) asthma, hypercholesteremia, osteoporosis, and hypertension. She also had a total
abdominal hysterectomy in November of 2007 for a prolapsed uterus.
Social History: CS works full time as an office manager at an accounting firm. She is married,
with two children and two grandchildren, whom she watches often. The patient is a non-smoker
and has never used tobacco or drugs. CS also stated that she does not drink alcohol. The patient
reported a history of lung cancer in her family, both her mother and sister had the disease with
brain metastases.
Medications: CS uses the following medications: albuterol, famotidine, fluticasone propionate,
omeprazole, simvastin, and triamterene with hydrochlorothiazide. She also takes calcium, krill
oil and vitamin D supplements.
Diagnostic Imaging: CS has had annual screening mammograms until January of 2011, when
she began having diagnostic mammograms on her right breast every six months in addition to the
annual screening imaging. In December of 2013, CS had a diagnostic mammogram that
indicated an increase in the number of calcifications in the right breast, and underwent a biopsy
of the area. A bilateral MR scan was performed in January, 2014 which indicated suspicion for
additional disease behind a biopsy clip. Wide surgical margins were recommended for the
lumpectomy, and no evidence for left breast malignancy was present. A lumpectomy was
performed in February, 2014 in which the sentinel and axillary lymph nodes were not dissected
or reported. The lumpectomy confirmed a diagnosis of IDC with multifocal DCIS.
Radiation Oncologist Recommendations: After reviewing the surgical history and pathology
for CS, the radiation oncologist recommended that the patient undergo post-operative radiation
therapy to the right breast with traditional tangential fields. A boost to the tumor bed would be
added after whole breast irradiation.
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The Plan (prescription): The recommendation of the radiation oncologist was to utilize
conventional medial and lateral tangential beams to treat the right breast tissue. The prescription
plan was 50.4 Gy at 1.8 Gy per fraction for 28 fractions. The boost prescription dose to the
tumor bed region was 10 Gy at 2.0 Gy per fraction for 5 fractions. The composite dose to the
right breast tumor bed region was 60.4 Gy. For the evaluation of this case study, only the
primary right breast plan utilizing conventional tangent beams will be discussed.
Patient Setup/Immobilization: In April of 2014, CS had a CT scan performed for the purpose
of radiation therapy planning. The patient was lying on the table in the supine position with her
arms positioned above her head with the assistance of a breast board (Figure 1). The patients
head was turned slightly to the left and supported with a headrest. The right arm was positioned
in a way to provide as much comfort to the patient as possible while removing it from the
treatment area. The arm was slightly bent at the elbow and positioned outward to avoid as many
skin folds as possible in the axilla area to reduce a skin reaction throughout treatment. The
breast board that the patient was laying on was slightly angled at 15 so the breast tissue laid at a
position that was more desirable for treatment, which was determined by the physician at the
time of simulation. Wires were placed for simulation that outlined both the breast tissue and
boarders of the breast (Figure 2). Additional wires were placed over the left nipple and scar from
the lumpectomy.
Anatomical Contouring: After completion of the CT simulation scan, the CT data set was
transferred into the Varian Eclipse radiation treatment planning system (TPS). The radiation
oncologist contoured the left breast volume on the TPS, as well as the tumor bed. The medical
dosimetrist contoured organs at risk (OR) that included the right and left lungs, spinal cord, heart
and liver. The carina was also contoured for set-up purposes on the machine. The radiation
oncologist reviewed the contours and placed a prescription note in Mosiac, the record and verify
system that Loyola University utilizes.
Beam Isocenter/Arrangement: The medical dosimetrist placed the isocenter approximately
halfway between the widest distance of the breast boarder wires, and 1 cm away from the chest
wall (Figures 3 and 4). The medial and lateral tangential photon beams utilized angles of 55
and 231.7 to provide adequate coverage of the breast tissue and lumpectomy site. In total, six
treatment fields were utilized to complete the plan, with one LAO tangent beam with two field-
in-field beams, and one RPO tangent beam with two field-in-field beams. All fields used an
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energy of 6 Megavoltage (MV) due to the location of the breast tissue in relation to skin surface,
and because patient seperation was not large enough to warrant a higher energy. All three RPO
beams utilized a 30 hard wedge with the heel lateral to pull dose closer to the chest wall. An
enhanced dynamic wedge (EDW) was not able to be used because rotation of the collimator
would not have allowed the multileaf collimator blocking to create the desired field shapes. The
field sizes for the two initial tangent fields were determined with help from the breast border
wires placed on the simulation. The superior and inferior jaws were extended to cover these
wires, and 3 cm of flash was allowed to extend beyone the breast tissue laterally. The medial
portion of the fields utilized MLC blocking that was determined by the radiation oncologist to
allow adequate margin on the breast tissue while still blocking out as much of the right lung as
possible (figures 5 and 6).
The remaining fields were determined using a forward planning, field-in-field technique.
Once dose was calculated for the initial tangent LPO and RPO beams, additional, smaller fields
were placed to remove areas of high dose, while still providing adequate coverage to the breast
tissue and tumor bed. These field sizes were determined by turning the isodose lines on for
various doses, and using the MLCs to block out areas of high dose. The field sizes can be
observed in figures 7-10. A Varian EX linear accelerator was to be used to deliver the radiation
therapy treatment.
Treatment Planning: The radiation oncologist stated the dose prescription and objectives,
which were to cover 95% of the contoured breast tissue with 95% of the dose, and 100% of the
contoured tumor bed with 100% of the dose. The volume of the left lung recieving 20 Gy or
more could not exceed 20%. A calculation point was placed slightly closer to the chestwall than
the isocenter. The calculation point was placed in a different position from the isocenter because
there was some difficulty delivering dose so close to the lung, so moving the reference point will
extend the isodose lines toward that area. The initial LAO tangent field delivered 43.3% of the
prescription. The two field-in-fields delivered 4.5% and 3.0% respectively. The initial RPO
tangent field delivered 41.7% of the prescription, with the two field-in-fields delivering 4.5% and
3.0%. The goal of the field-in-field technique is for the majoirty of the dose to come from the
two initial tangent beams, with the field-in-fields only being wieghted very slightly to reduce the
areas of higer dose. The patient will receive a total dose of 50.4 Gy in 28 fractions with a
separate boost plan to follow. Once adequate coverage was established for the breast tissue and
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tumor bed, the medical dosimetrist reviewed the dose volume histogram (DVH), isodose lines
and OR. The DVH (figure 15) reflects that 100% of the tumor bed receives 99.6% of the dose,
and 95% of the breast tissue receives 100% of the dose. The spinal cord receives a maximum
dose of 117.3 cGy, the heart receives a maximum dose of 631 cGy, and the liver receives a
maximum dose of 506.3 cGy. Nine percent of the right lung received 20 Gy or more. This
forward planning breast plan utilized six fields in total to provide adequate prescription coverage
and homogenous dose distribution throughout the breast tissue and tumor bed. The radiation
oncologist reviewed the plan and approved it for treatment on the machine.
Quality Assurance/Physics Check: The monitor units (MUs) for the plan were double checked
using the RadCalc program. The tolerance for the department between the TPS monitor units
(MUs) and the RadCalc MUs is plus or minus 3% for each field, and this plan met these quality
assurance constraints. The plan created was considered a conventional treatment, and therefore,
a quality assurance (QA) test on the linear accelerator was not necessary.
Conclusion: Creating a plan that provided adequate dose coverage while not overdosing breast
tissue was achieved using a forward planning technique with a total of 6 treatment fields. Once
dose coverage was established with two initial tangential beams, four additional, smaller fields
were added and weighted slightly to eliminate regions of high dose. Dose was successfully
blocked from the liver and other organs at risk due to the field shapes that were utilized.













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References
1. Chao K, Perez C, Brady L. Radiation Oncology Management Decisions. 3
rd
ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2011:373-404.
2. Pavy J, Descotes F, Adessi G. HER-2/neu oncogene: what does amplification mean? Br J
Cancer. 1993;68:214-215. doi: http://dx.doi.org/10.1038/bjc.1993.317
3. Onitilo A, Engel J, Greenlee R, Mukesh B. Breast cancer subtypes based on ER/PR and Her2
Expression: Comparison of Clinicopathologic Features and Survival. Clin Med Res. 2009;
7(1-2): 413. doi: http://dx.doi.org/10.3121/cmr.2008.825
4. Bane A. Ductal carcinoma in situ: what the pathologist needs to know and why. Int J Breast
Cancer. 2013; 2013 doi: http://dx.doi.org/10.1155/2013/914053























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Figures

Figure 1. Patient position on breast board for CT simulation.


Figure 2. Wire placement showing breast tissue and boarders.




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Figure 3. Isocenter placement on AP and right lateral view, with carina in green.


Figure 4. Isocenter placement shown by yellow circle, and reference point shown by blue x on
axial, coronal, sagittal and multi-planar views.
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Figure 5. Field shape for LAO beam.


Figure 6. First field-in-field shape for LAO beam.

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Figure 7. Second field-in-field shape for LAO beam.


Figure 8. Field shape for RPO beam.

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Figure 9. First field-in-field shape for RPO beam.


Figure 10. Second field-in-field shape for RPO beam.

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Figure 11. Enlarged isodose line key for Figures 12-14.


Figure 12. Dose distribution on axial view, tumor bed shown in magenta.

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Figure 13: dose distribution in coronal view, tumor bed shown in magenta.


Figure 14: Dose distribution in sagittal view, tumor bed shown in magenta.



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Figure 15. Dose Volume Histogram (DVH).



Lt lung
Breast tissue
Heart
Spinal cord
Liver
Tumor bed