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Comparison of Volumetric Modulated Arc Therapy vs. a 4-Field Technique for Post
Mastectomy Irradiation of Barrel Shaped Right Chest Walls: A Case Study
Authors: Tayisiya Polishchuk, R.T.(T), Karen Krueger, R.T.(T), Michelle Rocque, R.T.(T),
Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD, Ruth Ann M. Good, RT (R)(T), CMD, Alex
Whittington, CMD
Medical Dosimetry Program at the University of Wisconsin – La Crosse, WI
Abstract:
Introduction: This study aims to evaluate the dose variations of planning treatment volumes
(PTVs) and organs at risk (ORs) between two treatment techniques for barrel shaped right chest
wall post mastectomy patients.
Case Description: In the treatment of the post mastectomy chest walls, some patients present
with chests that are thick anterior to posterior and somewhat resemble the shape of a barrel.
Barrel shaped right chest wall patients require involvement of additional volumes of the
ipsilateral lung in order to achieve adequate coverage of the chest wall and lymph node area.
Increasing the target volume increases the volume of the ipsilateral lung in the treatment fields,
and therefore increases the potential of higher toxicity to the ipsilateral lung volume and other
ORs.1 Patients were selected based on the barrel chest wall criteria of 3.5 to 4.5 cm ipsilateral
lung depth involvement, when evaluating tangent fields covering total nodal chest wall volumes.
Two techniques were performed to evaluate the ipsilateral lung dose. A four-field plan utilizing
extended tangents with the supraclavicular field and a posterior axilla boost was used as one of
the chest wall treatment techniques. A 3 mm bolus was applied every other day to the chest wall
area. The volumetric modulated arc therapy (VMAT) plan consisting of two coplanar arcs with
opposite rotation (clockwise and counter-clockwise) was utilized as the second treatment
technique. A total of 3 patients (collecting more data, 6 patients for the second draft) were
selected to evaluate doses to the ipsilateral lung and other ORs for both treatment techniques.
Conclusion:
Key Words: Barrel shaped chest wall irradiation, 3DCRT, VMAT, radiation pneumonitis
Introduction:
Radiation pneumonitis is the radiation-induced inflammation of the lungs caused when
delivering radiotherapy to the intrathoracic malignancies.2 Despite the fact that most risks of
radiation pneumonitis is caused while delivering lung cancer treatments, the literature suggests
that up to 5% of breast cancer patients will experience radiation induced symptoms when
receiving breast cancer treatments.3 There are guidelines provided by the National

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Comprehensive Cancer Network (NCCN) highlighting the importance of including total nodal
regions in the treatment fields when planning for the chest wall irradiation.4 Due to the higher
possibility of nodal recurrence, it is strongly recommended to consider treating the internal
mammary nodes when delivering chest wall radiation therapy, especially if any of the following
criteria was found during the mastectomy surgery: positive margins, negative axillary nodes and
tumor >5 cm, or the presence of positive axillary nodes. Extended tangents technique is required
when performing total nodal irradiation in order to encompass all of the lymph nodes involved,
in addition to including the chest wall treatment volume. Increasing the fields in order to include
all of the disease volumes can increase the lung volume in the extended tangent fields. Increasing
the lung volume in the treatment fields of total nodal post-mastectomy barrel shaped chest walls
can potentially increase the risks of radiation pneumonitis.
Two treatment techniques were utilized when planning for each of the 3 patients with the
total nodal barrel shaped right chest wall volume. A four field three-dimensional conformal
radiation therapy (3DCRT) with partially wide tangential fields and parallel opposed
supraclavicular portals treatment plan was used as one of the treatment techniques. A Volumetric
Modulated Arc Therapy (VMAT) was the second treatment planning method. Evaluating doses to
the chest wall, supraclavicular, axillary, and internal mammary lymph nodes, as well as heart,
contralateral lung, and contralateral breast were closely evaluated. In addition, dose to the
ipsilateral lung was analyzed for each patient in both 3DCRT and VMAT plans. Same treatment
prescription of 50 Gy in 25 fractions was applied to the selected 3 patient cases. The plans were
evaluated and compared for acceptability against criteria contained in the National Surgical
Adjuvant Breast and Bowel Project (NSABP) B-51 protocol (also known as the Radiation
Therapy Oncology Group RTOG-1304 protocol).5
Case Description
Patient Selection
Patient selection was determined based on a variety of factors. Two of the patients were
diagnosed with invasive ductal carcinoma, and the third patient was diagnosed with infiltrating
ductal carcinoma. Each patient underwent right-sided mastectomy and sentinel lymph node
evaluation. A curative dose of 50 Gy in 25 fractions was prescribed by the physician to the barrel
chest wall and the lymph nodes, and definitive radiation treatment following NSABP B-51
protocol was suggested.
Based upon RTOG protocol, each patient was placed in the supine position, head first
into the Computed Tomography (CT) scanner, and simulated via free breathing. Two of the

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patients were simulated on the Phillips CT scanner and the third patient was simulated on the
General Electric CT scanner. Patient #1 and patient #2 were simulated utilizing a breast board
with the right arm up, the left arm by patient’s left side, and the head slightly turned to the left.
Patient #3 was simulated utilizing an inclined wingboard/breastboard with both arms raised
above the head, and the head slightly turned to the left. In order to facilitate contouring
segmentation of the CT data-set, radio-opaque markers were placed on the patient’s skin in the
treatment position as external landmarks at the acquisition of the CT scan.4 These markers
identified the mastectomy scar, as well as the clinical outline of the physician’s clinical
assessment of the “at risk” chest wall which included postoperative changes and where the
ipsilateral breast previously was located. Weekly megavoltage (MV) imaging was used to aid in
reproducibility.
Target Delineation
Target delineation was specified using the Philips Pinnacle 9.6 treatment planning system
(TPS) or the Varian Eclipse Version 11.0 TPS. The chest wall Clinical Target Volume (CTV) was
delineated by the physician utilizing radiopaque markers placed at CT simulation identifying the
clinical extent of the chest wall, surgical changes visualized by CT, and consensus definitions of
anatomical borders of chest wall from the RTOG Breast Cancer Atlas.6 The chest wall CTV was
limited by the skin anteriorly and did not extend deeper that the ribs to exclude the lung and
heart. In addition, the chest wall CTV did not cross midline (Figure 1). The CTV was expanded 7
mm (excluding the heart and not crossing midline) to form the chest wall Planning Target
Volume (PTV) (Figure 2). The chest wall PTV evaluation (PTV Eval) structure was created
based on the chest wall PTV with some limitations. The chest wall PTV Eval was limited
anteriorly to exclude the part outside the patient and the first 3 mm of tissue under the skin in
order to remove some of the buildup region for the DVH analysis. In addition, the chest wall
PTV Eval was limited posteriorly to no deeper than the posterior rib surface and to exclude the
lung and the heart (Figure 3). The chest wall PTV Eval was the structure utilized for DVH
constraints and analysis and not for beam aperture generation. In addition, the supraclavicular
CTV was outlined by the physician following the RTOG breast cancer atlas. The CTV was
expanded 5 mm in all directions to create the supraclavicular PTV (Figure 4). The axillary CTV
was created to include all three levels of the axillary nodes. The CTV was then expanded 5 mm
to create the axillary PTV (Figure 5). Internal mammary nodes (IMN) CTV included the internal
mammary/thoracic vessels in the first three intercostal spaces, and then expanded 5mm medially,

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laterally, superiorly, and inferiorly to create the internal mammary node (IMN) PTV (image will
be provided utilizing patient #4 once we obtain the new data). Structures at risk were the
ipsilateral lung, contralateral lung, heart, spinal cord, and contralateral breast. Patient 1 was
treatment planned using Philips Pinnacle 9.6 TPS and patients 2 and 3 were planned utilizing
Varian Eclipse Version 11.0 TPS.
Treatment Planning
Each chest wall treatment was planned utilizing two techniques and plan comparison was
performed to evaluate the ipsilateral lung dose in both instances. In both planning techniques on
patient 1 and 3, the calculations were performed with a 3.0 cubic-millimeter dose grid resolution.
For treatment planning techniques on patient 2, the calculations were performed with a 2.5 cubicmillimeter dose grid resolution. A four-field plan utilizing extended tangents with the
supraclavicular field and a posterior axilla boost was used as one of the chest wall treatment
techniques. A 3 mm bolus was applied every other day to the chest wall area. A volumetric
modulated arc therapy (VMAT) plan consisting of two coplanar arcs with opposite rotation
(clockwise and counter-clockwise) was utilized as the second treatment technique. According to
the NSABP B-51 protocol no bolus was necessary for the VMAT plan. The path length of each
arc for patient 1 was 135 degrees (75 - 210 degrees) with the collimator rotated 5 degrees in the
clockwise arc and 355 degrees in the counter-clockwise arc. The path length of each arc for
patient 2 was 180 degrees (180 - 360 degrees) with the collimator rotated 90 degrees in the
clockwise arc and 180 degrees in the counter-clockwise arc. The path length of each arc for
patient 3 was 210 degrees (330 - 120 degrees) with the collimator rotated 30 degrees to 150 in
the clockwise arc and 30 degrees to 210 in the counter-clockwise arc. Both treatment plans
followed the prescription of 2 Gy for 25 fractions to a total dose of 50 Gy without any boost to
the post-mastectomy chest wall. In addition, both plans encompassed the chest wall PTV, as well
as the supraclavicular, axillary and internal mammary node targets. Although these plans were
designed for dosimetric comparison only, field arrangements for 3D conformal radiation therapy
and VMAT were at the discretion of the treating physician in order to produce optimal plans to
meet the dose-volume constraints provided by the NSABP B-51 protocol. The PTV goal for each
plan was to deliver 95% of the prescription dose to cover 95% of the PTV volume per NSABP
protocol. The maximum point dose of ≤ 115% of the chest wall prescription was established
as per NSABP protocol. Both supraclavicular (SCL) PTV and axillary PTV were given a

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constraint of ≥ 95% to receive 95% of the prescribed dose of 50 Gy, and the maximum point
dose of ≤ 55 Gy which is ≤ 110% of the prescribed dose of 50 Gy was established for both
structures. Internal mammary nodal (IMN) volumes were allowed ≥ 90% of the IMN PTV to
receive ≥ 90% of the prescribed dose of 50 Gy. The maximum point dose of 110% of the IMN
prescribed dose of 50 Gy was permissible per NSABP protocol. There were three dose constrains
for the heart: 0% of the heart should receive no more than 25 Gy, ≤ 10% of the heart should
receive no more than 15 Gy, and the mean heart dose should be ≤ 4 Gy. Ipsilateral lung were
given three dose constraints as well, which were ≤ 30% of the ipsilateral lung should receive
no more than 20 Gy, ≤ 50% of the ipsilateral lung should receive no more than 10 Gy, and
≤ 65% of the ipsilateral lung should receive no more than 5 Gy. The contralateral lung
constraint was to keep the dose of 5 Gy to the ≤ 10% of the contralateral lung. The
contralateral breast constraint was to keep the dose of 3 Gy to less than 5% of the contralateral
breast. The NSABP B-51 provided acceptable variations for all of the structures in both the
written and tabular formats.
Plan Comparison, Analysis and Evaluation
When evaluating three-dimensional conformal radiation therapy (3DCRT) treatment plan
for patient #1, 2 of the dose constraints were acceptable by the protocol variations, 2 of the dose
constraints did not meet the acceptable criteria, and the rest of 14 dose constraints were met as
per protocol (Figure 6). The acceptable variation for the chest wall PTV and the supraclavicular
PTV was to deliver 90% of the prescription dose to cover 90% of the PTV volume per NSABP
protocol. The criteria was met by the 3DCRT plan delivering 90% of the prescription (45 Gy) to
the 94.3% of the chest wall PTV volume, and 90% of the prescription (45 Gy) to the 91.9% of
the supraclavicular PTV volume. The acceptable variation for the ipsilateral lung was ≤ 35%
of the ipsilateral lung to receive no more than 20 Gy, and ≤ 60% of the ipsilateral lung to

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receive no more than 10 Gy. The 3DCRT treatment plan was not able to achieve the above
constraints for the ipsilateral lung, and instead 51.9% of ipsilateral lung received more than 20
Gy while 58.2% of the ipsilateral lung received over 10 Gy. When evaluating volumetric
modulated arc therapy (VMAT) treatment plan for patient #1, 3 of the dose constraints were
acceptable by the protocol variations, and the rest of 13 dose constraints were met as per protocol
(Figure 7). The acceptable variation for the ipsilateral lung was ≤ 35% of the lung to receive
no more than 20 Gy, and ≤ 70% of the lung to receive no more than 5 Gy. Both of the
constraints criteria were met, with 35% of ipsilateral lung receiving no more than 20 Gy and
65.3% of lung receiving no more than 5 Gy. The acceptable variation for the contralateral breast
was ≤ 5% of breast to receive no more than 4.1 Gy, which was achieved via arc treatment
plan.
When evaluating three-dimensional conformal radiation therapy (3DCRT) treatment plan
for patient #2, 3 of the dose constraints were acceptable by the protocol variations, 1 of the dose
constraints did not meet the acceptable criteria, and the rest of 12 dose constraints were met as
per protocol (Figure 8). The criteria for the chest wall PTV and the supraclavicular PTV was met
by the 3DCRT plan delivering 90% of the prescription (45 Gy) to the 99.4% of the chest wall
PTV volume, and 90% of the prescription (45 Gy) to the 95.9% of the supraclavicular PTV
volume. In addition, all of the axillary PTV volume (100%) received 95% of the dose. The
3DCRT treatment plan was not able to achieve the above constraints for the ipsilateral lung and
instead 48.7% of ipsilateral lung received more than 20 Gy. Acceptable criteria was met by the
2nd and 3rd ipsilateral lung constraints with 55.7% receiving less than 10 Gy and 69% receiving
less than 5 Gy. Evaluating volumetric modulated arc therapy (VMAT) treatment plan for patient
#2, 2 dose constraints were acceptable by the protocol variations, 9 dose constraints did not meet
acceptable criteria, and 5 dose constraints were met per protocol (Figure 9). Acceptable criteria (
≤ 57.5 Gy) was met by the axillary and internal mammary PTV with respect to maximal point

dose. The maximal point dose shown by the DVH of the axillary PTV was 55.13 Gy and the
maximal point dose of the internal mammary PTV was 55.17 Gy. The VMAT plan was unable to
meet per protocol or variation acceptable compliance criteria for the following target volumes:

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chest wall PTV maximum dose, supraclavicular maximal point dose, 2 of the 3 heart dose
constraints, 3 ipsilateral lung constraints, contralateral lung, and contralateral breast constraints.
When evaluating the three-dimensional conformal radiation therapy (3DCRT) treatment
plan for patient #3, 5 of the dose constraints were acceptable by the protocol variations, none of
the dose constraints were unacceptable criteria, and 11 dose constraints were met as per protocol
(Figure 10). The criteria for the chest wall PTV and the supraclavicular PTV was met by the
3DCRT plan delivering 90% of the prescription (45 Gy) to the 95% of the chest wall PTV
volume, and 90% of the prescription (45 Gy) to the 99.2% of the supraclavicular PTV volume.
The conformal treatment plan was able to achieve the constraints for the ipsilateral lung, with
31.3% of ipsilateral lung receiving 20 Gy and 41.3% of the ipsilateral lung receiving 10 Gy.
When evaluating the volumetric modulated arc therapy (VMAT) treatment plan for patient #3, 8
of the dose constraints were met as per protocol, 5 of the dose constraints were acceptable by the
protocol variations, and 3 of the dose constraints were unacceptable variations of the dose
criteria (Figure 11). The VMAT plan was unable to meet per protocol or variation acceptable
compliance criteria for the following target volumes: one of the ipsilateral lung constraints,
contralateral lung, and contralateral breast constraints.
In order to compare the deliverability of the 3DCRT treatment plans versus the
volumetric modulated arc therapy (VMAT) plans, a scoring system for the compliance criteria
ranging from number 1 through 3 was utilized to evaluate a total of 16 dose constraints for each
plan and each patient. The score of 1 was assigned to the plan meeting protocol criteria, the score
of 2 was assigned to the plan meeting the acceptable per protocol variation, and the score of 3
was assigned to the unacceptable deviation. In the event the plan could not meet the dose
constraints and scored 3 for any unacceptable deviations, it will not be able to participate in the
protocol. For patient #1, none of the dose constraints received a score of 3 in VMAT plan, and
therefore this plan passed as a deliverable treatment plan per NSABP protocol. The 3DCRT plan
for patient #1 was undeliverable treatment plan due to 2 dose constraints receiving a score of 3.
Both, VMAT and 3DCRT plans for patient #2 contained unacceptable deviations and neither of
the plans were deliverable per NSABP protocol. For patient #3, 3 dose constraints were assigned
a score of 3 in VMAT plan, which made it undeliverable treatment plan. As to 3DCRT plan for
patient #3 all of the constraints were met and the treatment plan passed as a deliverable treatment
plan per NSABP protocol. Evaluating 6 plans for 3 patients, we can see that one VMAT plan and
one 3DCRT plan were deliverable per NSABP protocol. Despite the fact that most of the plans

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did not meet protocol’s criteria, there is a high importance to evaluate ipsilateral lung dose.
Analyses of the ipsilateral lung dose are demonstrated in figure 12, where the dose of 20 Gy gets
evaluated by displaying the amount of ipsilateral lung volume (in percent value) receiving 20 Gy.
Comparison of lung doses in both treatment plans, 3DCRT and VMAT, are displayed for each
patient, and the values are evaluated based on the NSABP protocol guidelines. According to the
protocol, the acceptable variation for the ipsilateral lung is ≤ 35% of the ipsilateral lung to
receive no more than 20 Gy. Evaluating the ipsilateral lung dose data, 3 out of 6 plans met the
acceptable lung dose variation guideline of the NSABP B-51 protocol. Two of the plans were
performed utilizing VMAT technique, and one was performed utilizing 3DCRT technique.

References

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1. Moran MS, Haffty BG. Radiation techniques and toxicities for locally advanced breast
cancer. Semin Radiat Oncol. 2009;19(4):244-255.
http://dx.doi.org/10.1016/j.semradonc.2009.05.007
2. Muzio BD, Gaillard DF, et al. Radiopaedia. Radiation pneumonitis. Radiopaedia Website.
http://radiopaedia.org/articles/radiation-pneumonitis. Accessed June 21, 2015.
3. Marks L, Bentzen S, Deasy J, et al. Radiation dose-volume effects in the lung. Int J Radiat
Oncol Biol Phys. 2010;76(3):570-576. http://dx.doi.org/10.1016/j.ijrobp.2009.06.091
4. Fernando SA, Edge SB. Evidence and controversies in the use of post-mastectomy radiation.
J Natl Compr Canc Netw. 2007;5(3):331-338. PMID: 17439761. Accessed June 10, 2015.
5. A Randomized Phase III Clinical Trial Evaluating Post-Mastectomy Chestwall and Regional
Nodal XRT and Post-Lumpectomy Regional Nodal XRT in Patients with Positive Axillary
Nodes Before Neoadjuvant Chemotherapy Who Convert to Pathologically Negative Axillary
Nodes After Neoadjuvant Chemotherapy. NSABP B-51.
https://clinicaltrials.gov/show/NCT01872975
6. White J, Tai A, Arthur D, et al. Breast cancer atlas for radiation therapy planning: consensus
definitions. Radiation Therapy Oncology Group (RTOG).
http://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx. Accessed June 21,
2015.

Figures

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Figure 1. The chest wall CTV (orange) is delineated according to the definitions of anatomical
borders of chest wall from the NSABP breast cancer atlas (patient 1).

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Figure 2. The chest wall PTV (blue) was expanded 7mm in all directions from the chest wall
CTV, excluded the heart, and did not cross the midline (patient 1).

Figure 3. The chest wall PTV Eval (red) was limited anteriorly to exclude the part outside the
patient and the first 3 mm of tissue under the skin, and posteriorly was limited to no deeper than
the posterior rib surface excluding the lung and the heart (patient 1).

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Figure 4. Supraclavicular CTV (blue) delineated according to the definitions of anatomical
borders of Supraclavicular CTV from the NSABP breast cancer atlas. The Supraclavicular CTV
was expanded 5mm in all directions to create the Supraclavicular PTV (yellow), excluding the
ispsilateral thyroid, trachea, esophagus, vertebral body, and ipsilateral lung (patient 3).

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Figure 5. The Axillary Lymph Node PTV (red) expanded 5 mm from the Axillary Lymph Node
CTV (blue) outlined according to definitions contained in the NSABP breast cancer atlas (patient
2).

Figure 6. Dose constraint structures with the protocol doses and the collected data for the
3DCRT treatment plan for patient#1.

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Figure 7. Dose constraint structures with the protocol doses and the collected data for the VMAT
treatment plan for patient#1.

Figure 8. Dose constraint structures with the protocol doses and the collected data for the
3DCRT treatment plan for patient#2.

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Figure 9. Dose constraint structures with the protocol doses and the collected data for the VMAT
treatment plan for patient#2.

Figure 10. Dose constraint structures with the protocol doses and the collected data for the
3DCRT treatment plan for patient#3.

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Figure 11. Dose constraint structures with the protocol doses and the collected data for the
VMAT treatment plan for patient#3.

Ipsilateral Lung dose comparison
3DCRT

Patient 3

VMAT

28.6
31.3

57.8

Patient 2

Patient 1

48.7

35
51.9

Figure 12. Comparison of lung doses in 3DCRT versus VMAT displayed to evaluate the amount
of ipsilateral lung volume (in percent value) receiving 20 Gy.

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