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Improved reproducibility and dosimetry of prone breast irradiation using styrofoam


blocks: a case study
Author: Derek Smith, B.S., Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD, Renee ONeal
CMD
Abstract
Introduction: Styrofoam blocks are often used with prone breast irradiation for the purposes of
improved reproducibility and dose homogeneity. The purpose of this case study was to evaluate
the reproducibility and dose homogeneity of female breast patients with and without the use of
styrofoam blocks during prone breast irradiation.
Case Description: When treating a malignant neoplasm of the female breast, the prone setup
technique is often used for large pendulous breasts which in turn spares dose to the ipsilateral
lung and heart. Typically, the problem with this technique is reproducibility, dose homogeneity
and conformity. This case study demonstrated two patient cases: patient 1 was simulated with
and without a styrofoam block but planned and treated only with the styrofoam block technique
due to improved dose homogeneity; patient 2 was simulated and treated with the same prone
styrofoam block technique. Patient 2 represented a smaller breast tissue volume to evaluate if the
styrofoam block helped improve dose homogeneity and conformity when used in comparison to
a large breast tissue volume (patient 1).
Conclusion: Each plan was evaluated based on dose constraints, homogeneity, and whole breast
dose coverage. While the homogeneity index and quality of coverage did not vary with the block,
the conformity index improved with the styrofoam setup technique. Although planning and setup
included a few more steps, the overall reproducibility and dose uniformity seemed to improve
when utilizing the styrofoam block setup technique.
Keywords: Prone, styrofoam block, homogeneity, reproducibility
Introduction
Radiotherapy after breast-conserving surgery reduces the risk of locoregional recurrences
and improves overall survival when appropriate prone and supine techniques are utilized.1 Prone
breast setup has become a popular treatment technique for patients with large pendulous breasts.
The primary advantage of the prone breast irradiation setup is the chance for better dose
homogeneity and a lower dose to the heart and ipsilateral lung.2 Research by Mak et al3 indicated
that the supine technique with large breast volumes yielded acute and late-effect skin toxicities.

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This is attributed to the dose inhomogeneity and increased separation distance that was often
associated with large breasted women in the supine position.4 The prone breast setup has been
proven superior to decrease toxicity of post-lumpectomy whole-breast irradiation.2 There are
current articles available to assist in the improvement concerning a more comfortable, efficient,
and reproducible immobilization for prone setup. According to Lymberis et al,4 the prone setup is
not only a helpful setup for large breasted women, but it has also reduced the mean ipsilateral
lung dose in all the patients as well as reducing the mean heart dose to 87% of left breast patients
in their study.
Although the prone setup is beneficial, there has been substantial reproducibility
problems.5 The most common difficulties with prone breast setups include inadequate target
coverage, incorrect positioning of the patient, potential issues with excessive sinking and rolling
toward the opening of the breast board, and respiratory motion.5 An important component of
ensuring treatment accuracy to avoid these common problems is verifying the patient position
before treatment delivery. The technique discussed in this case study involves the use of
styrofoam blocks to improve prone breast setup reproducibility and dose homogeneity.
Dose homogeneity is an important aspect to improve the comfort of the patient after
radiotherapy. Breast pain after breast-conserving radiotherapy is not unusual. The risks for this
pain after treatment includes younger age, preoperative breast pain, boost irradiation, and
dosimetric inhomogeneity. Mak et al 3 reported that long term breast pain was evident in patients
who received post lumpectomy whole breast irradiation 105% of the prescribed dose. From this
observation it was concluded that minimization of dosimetric inhomogeneity should be
prioritized. The styrofoam block could be a helpful tool in the planning and treatment process to
reduce dose inhomogeneity and increase planning target volume (PTV) conformity.
Case Description
Patient Selection & Set up
The patients in this case study were female and diagnosed with left sided breast cancer.
Each patient required a course of post lumpectomy radiation therapy to the left breast making
them suitable candidates for prone-setup whole breast irradiation.
Each patient was placed in the prone position on a Civco New Horizon prone breast
board for simulation. A flat horizontal rather than rolled patient position ensures reproducibility
as well as aids in the avoidance of the ipsilateral lung and heart within the treatment volume. To

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avoid the contralateral right breast, the patient and radiation therapist worked to pull the breast
laterally out of the treatment field. Once the patient is lying comfortably, arms above head, and
head turned to the contralateral breast, the patient is computed tomography (CT) scanned with
the affected left breast relaxed in air or touching the treatment table. For this case study the
patients were also simulated with a styrofoam block or blocks resting below the breast to achieve
greater reproducibility and dose homogeneity (Figure 1). Once in position, the breast is marked
with setup reference marks and the patients breast tissue is bordered with inferior, superior,
medial and lateral markers (Figure 2).
Once the patient is in the optimal treatment position, tattoos are marked on a plane
posterior to the rib cage to avoid discrepancies that result from breathing or breast organ motion
(Figure 3). Tattoos are also marked in reference to the inferior to superior lasers to ensure the
patient is not rotated to the left or right (Figure 4). The styrofoam blocks become very useful in
the process of reproducibility. The resting breast circumference, and lateral laser projections are
marked as a setup reference on the styrofoam blocks (Figure 5). A ruler is also placed on the
table to mark the inferior and superior borders of the breast board opening that has an index on
both the ruler and styrofoam block (Figure 6). For example, if the patients lateral tattoos and
laser alignments lie at 6 inches on the index ruler then this ensures that the breast is centered
correctly in all directions. The utilization of the styrofoam blocks are a helpful tool in
reproducibility and give the large pendulous breasts a more cylindrical shape for improved dose
homogeneity.
Target Delineation
The Varian Eclipse v.11 treatment planning system was used along with the Philips
Brilliance Big Bore CT scanner for the delineation of the lumpectomy and left breast tissue
excluding the chest wall. Organs at risk (OR) for each case included the ipsilateral lung, heart,
spinal cord, esophagus and contralateral breast. For evaluation purposes, the radiation oncologist
contoured the entire left breast excluding the chest wall and a PTV structure was created by
cropping the left breast contour 0.5 cm within the external contour surface.
Treatment Planning
For both patient 1 and 2, the data was transferred to the Varian Eclipse v.11 treatment
planning system (TPS). The medical dosimetrist imported the CT images. The medical
dosimetrist set up 6 MV lateral and medial fields with coordinates set to the medial, lateral,

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inferior, and superior wires (Figure 2). The radiation oncologist contoured the lumpectomy site
in reference to the scar wire and the seroma seen in the CT dataset. The medical dosimetrist
contoured OR which included the spinal cord, esophagus, heart, right lung, and left lung. The
radiation oncologist reviewed and approved the OR contours.
Two-field left breast tangential planning can become somewhat of an art for medical
dosimetrists. There has been much research on different techniques, but patient anatomy varies
leading to different gantry angles, field in field techniques, beam weighting, and wedges being
used.5 Patient 1 had a prescribed dose of 50.4 Gy for 28 fractions to the whole breast with a boost
to the lumpectomy site of 12.0 Gy for 6 fractions. A 3D breast tangential technique was used to
obtain an optimal plan (Figure 8). Patient 1 was treated with a styrofoam block setup technique,
but simulated with and without the styrofoam block. The radiation oncologist recommended that
the heart receive no more than a mean dose of 5 Gy andV25 <5%. The contralateral breast was
given a constraint of V3.08 <5%. The ipsilateral lung was also given a constraint of V5 <25% and
V20<10%. These constraints are standard goals for whole breast irradiation with a boost. For
Patient 1, the gantry angle for the medial field was set at 75.6 and the collimator remained at
180. The lateral field gantry angle was set at 245.2 and the collimator also remained at 180.
The photon beam energy used for both fields was 6MV with a dose rate of 400 MU/min (Figure
9).
Patient 2 was also treated with styrofoam blocks below the breast to a prescribed dose of
50.4 Gy for 28 fractions to the whole breast with a boost to the lumpectomy site of 10.0 Gy for 5
fractions. Traditional 3D breast tangentials were used to treat the entire left breast with the same
OR constraints for patient 1. The gantry angle for the medial field was set at 75.5 and the
collimator was turned to 182. The lateral field gantry angle was set at 249.9 and the collimator
was rotated to 178.0. The photon beam energy used for both fields was 6MV with a dose rate of
400 MU/min.
Patient 1 had CT datasets available that represented the breast with and without
styrofoam. The approved and prescribed patient plan included the styrofoam blocks. The medical
dosimetrist struggled to lower the maximum dose near the inner quadrant of the left breast. To
mitigate this problem, a 15 right wedge was added on the lateral beam. Two field-in-field beams
were created from the initial lateral beam and one field-in-field created from the medial beam. In
total there were three static 6MV beams and three 6MV field-in-field beams used to obtain an

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acceptable coverage and global dose max. The beam weight was adjusted slightly higher in
percentage to the medial beam for a minimum dose of 100.2% and a global dose max of 109.8%
of the prescribed dose.
Patient 2 had CT datasets available that represented the breast with and without
styrofoam. The medical dosimetrist worked to lower the maximum dose near the outer quadrant
of the left breast. A 15 left wedge was added on the lateral beam. There was a total of two static
6MV beams. The beam weighting was adjusted to obtain an acceptable minimum coverage and
maximum dose respectively of 109.8% and 98.5% of the prescribed dose.
Plan Analysis and Evaluation
In both cases, the medical dosimetrist was planning with the greatest dose homogeneity
in mind. For patient 1, the medical dosimetrist had difficulty lowering the global dose maximum.
The use of three static 6MV beams and three 6 MV field-in-field beams as well as a 15 right
wedge and a 30 right wedge placed on both lateral beams lowered the global dose maximum to
109.8%. The medical dosimetris had less difficulties when planning patient 2. Simply planning
with a 15 left wedge on the lateral beam lowered the global dose maximum to 109.8%. For the
purpose of this case study, there were two separate plans created on each patient dataset. The two
plans had the same gantry angles, collimator angles, and field sizes described previously. These
evaluation plans had dose distributions related only to the tangential fields with no dose
modifying techniques to obtain a more consistent dose homogeneity and conformity index
comparison between a setup with and without the styrofoam block. The only significant
controlled variable from patient 1 to patient 2 was that patient 1 had a larger overall left breast
tissue volume. This variable was helpful in identifying if the use of a styrofoam block would be
useful in the treatment of both smaller and larger breasts (Figure 7).
To determine if the use of the styrofoam block improved homogeneity, coverage, and
conformity three factors were evaluated. Dose homogeneity was evaluated using the RTOG
homogeneity index calculated via the ratio of the maximum isodose (IMAX) in the target and
reference isodose (RI). Dose conformity was measured with the RTOG conformity index defined
as the ratio of the reference isodose volume (VRI), or the tissue volume that receives 100% of the
prescribed dose, and the PTV. Dose coverage was calculated using the RTOG quality of coverage
equation which is a ratio of the minimum isodose surrounding the target (IMIN) and the reference
isodose values (RI). A homogeneity index less than or equal to 2 is complying with RTOG

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protocol. A conformity index of 1 is considered ideal dose conformation while anything below
indicates that the target volume is only partially irradiated and a conformity index greater than 1
indicates that the irradiated volume is greater than the target volume. RTOG quality of coverage
is considered to comply with protocol if the 90% isodose covers all of the PTV thus anything
between 90% and 100% covering all of the PTV is considered a higher quality of coverage
(Table 1).
Patient 1, with a larger PTV volume, had a high 3D maximum dose of 60.38 Gy with the
styrofoam block as compared to without the block at 56.17 Gy. From this higher 3D maximum,
the setup with the styrofoam block had a slight decrease in dose homogeneity at 1.19 rather than
1.11 for the plan without the styrofoam block. However, it was apparent that the conformity
index increased from 0.25 to 0.918 when using the styrofoam block. This increase in conformity
was most likely related to the more cylindrical shape of the breast with the block resting below it
(Figure 7).
Patient 2 did not have a comparable drastic change in shape as patient 1, but Table 2
demonstrates the use of the styrofoam block increased homogeneity and conformity, while the
quality of coverage remained the same with the conformity index increasing from 0.688 to 0.746.
A noticeable difference between patient 1 and patient 2 was the variation of hotspots when using
the styrofoam block. Patient 1 had a higher hotspot when using the block and a lower hotspot
without the block at 60.38 Gy and 56.12 Gy respectively. Patient 2 had a lower hotspot with the
block and a higher hotspot without the block at 56.55 Gy and 60.03 Gy respectively. This can be
attributed to the larger breast tissue volume for patient 1.3 The most drastic improvement was the
conformity index for both patients when using the styrofoam block. Due to a greater
reproducibility with the styrofoam blocks and an improved dose conformity, both patients were
planned and treated with the styrofoam block below the treated breast tissue. Although patient 2
initially had a higher hotspot, the physician determined treating patient 2 with the block would
likely result in a better reproducibility and further planning would lower the hotspot to an
acceptable dose.
Conclusion
The styrofoam block was used for both patient treatment plans for the sake of improved
reproducibility and an improved dose conformity. According to Kalpana et al,7 adding a breast
tissue index and circumference indicator helps improve reproducibility. The prone breast setup

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with a styrofoam block below the treated breast adds an index for the breast circumference. An
anterior reference to the setup isocenter can improve reproducibility overall. For the purposes of
this case study, the role of the styrofoam block in dose homogeneity, conformity, and quality of
coverage was evaluated in further detail with the equations in table 2.
Patient 1 and 2 were evaluated by comparing simple 3D breast tangential techniques
without the use of wedges, field-in-field technique, or beam weight adjustments to compare dose
differentiations simply with or without the use of a styrofoam block. However the plans used for
treatment were discussed to demonstrate the planning techniques that are typically used when
planning with a styrofoam block to further increase dose homogeneity, conformity, and quality of
coverage.
Patient 1 showed no change in quality of coverage, and a slight decrease in homogeneity.
Patient 2 also had no change in quality of coverage and a slight increase in homogeneity. The
most evident change when using the styrofoam block was the improved conformity index.
Patient 1 increased from 0.250 to 0.918 and patient 2 from 0.688 to 0.746 with the styrofoam
block. Research shows an increased dose conformity can help reduce long term breast pain.3
The prone technique has already concluded an improvement in dose toxicity to the heart
and ipsilateral lung but Huppert et al5 also mentioned that the prone technique can produce
reproducibility difficulties. Any contact with the breast to the treatment couch can compromise
the prone treatment technique reproducibility. Utilizing a styrofoam block can help in reducing
these issues by providing a breast tissue index while possibly providing improvements in whole
breast irradiation treatment planning.7 This technique proved beneficial to the dose conformity
for both patients in this case study. Due to a limitation of two patients in this case study, it cannot
be concluded that the use of a styrofoam block is more beneficial than not using a styrofoam
block for all patients. Further research is needed to evaluate dose homogeneity and
reproducibility with the use of styrofoam blocks and prone breast technique with a larger
population of patients.

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References
1. Shafiq J, Delaney G, Barton M. An evidence-based estimation of local control and survival
benefit of radiotherapy for breast cancer. Rad.Onc. 2007;84(1):11-17.
http://dx.doi.org/10.1016/j.radonc.2007.03.006
2. Stegman LD, Beal KP, Hunt MA, Fornier MN, McCormick B. Long-term clinical outcomes
of whole breast irradiation delivered in the prone position. Int J Radiat Oncol Biol Phys.
2007;69(1):73-81. http://dx.doi.org/10.1016/j.ijrobp.2006.11.054
3. Mak KS, Chen Y, Catalano PJ, et al. Dosimetric inhomogeneity predicts for long-term breast
pain after breast-conserving therapy. Int J Radiat Oncol Biol Phys. 2014;89(1):1-9.
http://dx.doi.org/10.1016/j.ijrobp.2014.05.021
4.

Lymberis SC, deWyngaert JK, Parahar P, et al. Prospective assessment of optimal individual
position (prone versus supine) for breast radiotherapy: volumetric and dosimetric correlation
in 100 patients. Int J Radiat Oncol Biol Phys. 2012;84(4):902-909.
http://dx.doi.org/10.1016/j.ijrobp.2012.01.040

5. Huppert N, Jozsef G, DeWyngaert K, Formenti S. The role of a prone setup in breast


radiation therapy. Front Oncol. 2011;31(1):1-8. http://dx.doi.org/10.3389/fonc.2011.00031
6. Kirby AM, Evans PM, Helyer SJ, et al. A randomized trial of supine versus prone set-up
errors and respiratory motion. Rad Onc. 2011;100(2):221-226.
http://dx.doi.org/10.1016/j.radonc.2010.11.005
7. Barrett-Lennard MJ, Thurston SM. Comparing immobilization methods for the tangential
treatment of large pendulous breasts. The Radiographer. 2008;55(2):7-13.
http://www.minnisjournals.com.au/articles/Radiographer%20Aug
%2008%20BarrettLennard.pdf. Published December 2008. Accessed July 1, 2014.

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Figures

Figure 1. Patient 1 (left) and patient 2 (right) setup with styrofoam block

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Figure 2. Breast tissue border markers for patient 2 (Red: medial, Dark Green: lateral, Light
green: superior, yellow: inferior)

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Figure 3. Patient 2 demonstrating lateral rib cage tattoos (arrow).

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Figure 4. Patient 2 demonstrating posterior setup tattoo and leveling/straightening tegaderm


marks.

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Figure 5. Patient 1 breast tissue resting on styrofoam block with breast tissue outlines (arrow).

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Figure 6. Patient 1 setup alignment marks on styrofoam blocks and ruler index (arrows).

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Figure 7. Difference in breast tissue shape with and without the styrofoam block respectively
from left to right and breast tissue size variation from patient 1 (upper images) to patient 2 (lower
images).

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Figure 8. Patient 1 treatment plan beam configuration and dose distribution (Green = 95%
isodose line and yellow = 100% isodose line).

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Figure 9. Patient 2 treatment plan beam configuration and dose distribution. (green= 95%
isodose line and yellow =100% isodose line).

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Tables
Table 1: Evaluation ratios/equations and parameters
Dose Improvement
Evaluated
Homogeneity index

Ratio/equation

RTOG parameters

IMAX/RI

2 complies
= 1 is ideal coverage;
If < 1 the irradiated volume is
greater than the PTV
90% isodose covers of PTV

Conformity index

VRI/PTV

Quality of coverage

IMIN/RI

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Table 2: Evaluation details and results.
Patient 1
HI

CI

Quality
of
coverage

IMAX
(Gy)

RI
(Gy)

VRI (cc)

PTV
(cc)

IMIN
(Gy)

With block

1.19

0.918

0.96

60.377

50.4

1380

1502.3

48.8

Without block

1.11

0.25

0.96

56.167

50.4

375.7

1502.3

48.8

Patient 2
With block

1.122

0.746

0.98

56.548

50.4

470.6

630.8

49.6

Without block

1.191

0.688

0.98

60.024

50.4

434.5

630.8

49.6