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Simulation, Planning, and Delivery of

Breast/Chest Wall Treatment Using Uniform

Scanning Proton Beam Therapy

Stacey Schmidt, B.S., RT(T), CMD

Manager, Medical Dosimetry
CDH Proton Center
CDH Cancer Center
Delnor Cancer Center
Warrenville & Geneva, IL

Course Objectives
After participating in this session, you will be able to:
Explain the benefit of using protons to treat stage III disease or
previously treated patients.
Identify patient selection criteria.
Discuss the simulation process and immobilization device
Describe techniques used in treatment planning.
Demonstrate the dosimetric advantages of Uniform Scanning
(US) proton therapy over photon therapy.
Illustrate the daily imaging and treatment delivery processes
specific to US protons

What cancer types are typically

treated with protons?

Common indications for proton therapy

Pediatric tumors of the CNS or elsewhere

Brain tumors
Spinal cord tumors
Base of skull chordomas or chondrosarcomas
Prostate cancer
Ocular melanomas

Less common, yet emerging indications for treatment

with proton therapy

Lung cancer
GI cancers
Head and Neck cancers
and now, Breast cancer

Protons for Breast Cancer? Preposterous!

Past roadblocks include:

Concerns over target movement/reproducibility
Lack of skin sparing with Protons
Photons have been getting the job done very well for
These are valid concerns even with improved
techniques. However, it was worth looking into for a
select subgroup of these patients.

Why use protons?

Red Journal article from PSI in 2010

Stage III Breast Cancer patients

The most difficult breast cancer sub-type to treat with traditional xray/photon radiation therapy, due to the inclusion of axillary,
supraclavicular, and internal mammary lymph nodes.

These photon plans

are generally not very
homogeneous, and include
significant dose to the
Ipsilateral lung and heart
(particularly left
sided patients).

Retreat Breast Cancer patients

These patients have

typically already
received significant
dose to the
ipsilateral lung
and/or heart, and
therefore it is even
more important to
spare excess dose
to these structures.


Selection Criteria

ProCure specific selection criteria required for use of

protons in breast cancer patients
Stage III disease either post mastectomy or
lumpectomy AND require treatment to ipsilateral
supraclavicular, axillary, and internal mammary lymph
Or, must have had RT to the same side previously
Must not have a pendulous breast or metal expanders
in reconstructed implants
Must be able to lie with arms up or down for
approximately 45 mins


Patients can be treated off or on protocol

All patients treated so far have been on our Registry
protocol. PCG Reg 001
Patients have the option to enroll in the PCG cardiac
sparing BRE008 and be treated on protocol. These
patients are required to start txmt 9 weeks after
surgery or 8 weeks after the initiation of
chemotherapy. They must also have a CT
Angiography study, which is used to help contour
specific cardiac vessels for dose reporting.


Patients can be treated off or on protocol


The Simulation Process

Gantry or Inclined Beam treatment room?

Before selecting the appropriate immobilization
device, the determination must be made whether or
not the patient will be treated on the gantry or in one
of the inclined beam treatment rooms.

Gantry room has most flexibility with treatment angles
Inclined beam room has fixed gantry angles of 30 or 90
degrees, but our technique for this room allows for most
enface setup.




Incline Beam Line


Gantry setup
Patient must be positioned
with both arms up in a
particle-friendly long vacloc or alpha cradle device.

Chin is up, with head rotated

away from the treated side.
Bilateral breast/chestwall
patients are treated on the
gantry, and the chin must
also be extended. There is
no head rotation for these

Inclined Beam setup

Patient is positioned with both
arms down, and the ipsilateral
arm slightly akimbo.
Depending on the patients
anatomy, a wedge may be
inserted under the ipsilateral
side to achieve enface
position of the
Patients chin is also up, and
head turned away from the
affected side.

Other views of the IBL setup


Additional step in IBL Simulation Procedure

Before pouring chemicals into the alpha cradle, a quick scan
must be done through the breast tissue to determine the angle of
the breast will be enface with the 30 degree gantry angle. A
reproducible, enface breast position needs to be achieved for the
treatment in the IBL.

If the breast/cw angle is less than 30 degrees a small Styrofoam

wedge will be needed. This will be placed under the patients
affected chest wall area to turn the patient so that the
breast/chestwall is on a 30 degree angle.
If the breast angle is more than 30 degrees the patient may need
to have the hips rolled toward the affected side to decrease the

Patient Marks
Once the breast box has hardened, start making the
treatment marks on the patient and box.
Start with head position first: use the laser and have it
intersect the patients lips. Once this is done use a
marker and draw a line on the box to match; label as
lip line. If an arm is up mark on the patients elbow/
tricep area.
Find the SSN and set sagittal laser to boney anatomy.
Try to make sure the SSN and end of sternum match
with the laser.
Mark a three point set up on patient and box; about at
the end of the rib cage.

Demonstration of patient marks


CT Scan Specifications
Scan from top of head to below inframammary fold.
1.25 mm slice thickness
65 FOV used to get entire treatment device in scan (necessary for
checking for device collisions and to make sure a beam isnt
going through the device)
Cradle will need to be offset in bore to have all of affected side in
scan. Indexing bar with offset is utilized.
No 4D scan is necessary if magnitude of motion is less than
5mm. Breathing motion being in same direction as beam path.
First patients were done with 4D, but has been discontinued, as it
has been demonstrated to no longer be a concern and we want to
minimize excess dose for the patient.
MD places wires for clinical borders and on scar.


The Treatment Planning


Fusions required:
Not usually, unless patient is on BRE-008 protocol. Then
fusion with CT Angiography study is require for cardiac
vessel delineation.
If patient was previously treated, then a deformable fusion is
done between the two treatment planning CTs. The
patients previous electronic DICOM radiation dose files are
requested for help with dose summation.


MD Contours
MD will contour the CTV_50.4, which is comprised of the
ipsilateral supraclavicular nodes, chestwall/breast tissue, axillary
lymph nodes, and internal mammary lymph nodes.
RTOG guidelines for breast/chestwall and nodes are utilized, with
the exception that the entire ribs and chestwall are not included.
These areas were included in RTOG guidelines for simplicity, and
were not used to define regions of disease involvement, paths of
disease spread, nor regions at risk of reoccurrence.

If patient is on the BRE008 study, the MD will also contour the

RCA, LAD 1st diagonal branch, and the LAD 2nd diagonal branch.
If the patient is to have a tumor bed or scar boost, the MD will
draw these structures as well.

Chestwall CTV and Coronary Artery contours


Chestwall CTV on a Multi-Planar View


Dosimetrist Contours

R & L Lungs, plus Total Lung structure

Ipsilateral Brachial Plexus
Ipsilateral Humeral Head
Patient External, including treatment devices


Planning Techniques Utilized

Regardless of which treatment room is used, a
matching fields, 3D forward-planned, uniform
scanning proton treatment plan is utilized.
2 fields used for the supraclavicular and superior axillary
node region
2 fields used for the breast/chestwall region



Planning Techniques Utilized

Why 4 beams per day????

Minimizes risk from daily setup error

Allows for more homogeneous dose distribution,
minimizing hot/cold spots at the junction
Spreads the surface dose between the 2 beams per
section, in order to spare the skin full dose from one
beam entry point.


Beam Selection Criteria Gantry Room

Gantry Technique
Want to utilize beams that are angled slightly off enface


Gantry plan treatment angles


Beam Selection Criteria - IBL

Beam options are limited, therefore we position the
patient to make the angles optimal, having the beams
enter the patient as enface as possible.
1 set of Left or Right anterior oblique matching fields at
1 set of Anterior Superior Oblique matching fields at


Beam Selection Criteria - IBL




Beam Selection Criteria - IBL

of 1 set of the
ASO matching
fields to cover
the entire CTV.


IBL plan treatment angles


Planning Techniques Utilized

In both techniques, all 4 fields are treated per day,
incorporating 2 matchlines between the
supraclavicular and chestwall/breast regions.
Fields are matched at depth using a dosimetric, not
geometric match line.
Junction selection, isocenter placement, and air gaps
tightened as much as possible are crucial for these
types of plans.


Isocenter Placement and Snout Size Restrictions

Largest snout size 25 cm
The CTV extends from the most superior
supraclavicular node to inferiorly just below the
implant or 2 cm below the former inframammary fold.


Isocenter Placement and Snout Size Restrictions

In order to make the most efficient treatment possible,
isocenters are selected so that both the superior and
inferior volumes share the same X and Z coordinates,
and only an inferior Y shift is necessary on a daily
It is also crucial to select an X position so that the
breast/chestwall region is centered in the snout, and
that there is room to add adequate aperture margin.


Isocenter Placement and Snout Size Restrictions


Junction Selection
Crucial to achieving an optimal treatment plan with
well-behaved compensators.
Select junction in region where the supraclavicular
nodes end and the chestwall volume begins.
Want to keep deep portion of nodal volume separate
from breast/chestwall region.
Drastic changes in depth within a compensator can
cause hot spots and steep ridges.

Junction Selection
Matchline 1

Matchline 2

Since there are 4 total fields treated daily, two sets of

fields are matching, and the junctions are about 1 cm

Optimized Air Gaps

It is important in proton therapy to keep as tight of an
air gap between the end of the compensator and the
patients skin as much as possible.
Tighter air gaps = sharper lateral penumbra
Sharper lateral penumbra = matchlines that are easier
to optimize!

However, this is not always achievable, due to the size

of the chestwall/breast volume, and the ability to fit it
in the snout.

Optimized Air Gaps

Air Gap = 10 cm

Air Gap = 25 cm

Take away: keep it as tight as possible, but make sure

your PTV will fit into the snout with adequate margin
for lateral coverage

Plan Optimization
Once all beams are added, isocenters are set, air gaps
are finalized, and the junction areas are determined,
Apertures are added to all beams, and optimized so 95% of
the PTV is covered laterally
Compensators are added, and tapered to remove any ridges
greater than 2 cm
Ranges and modulations are set to cover the CTV by the
100% ISL. Dose coverage specifications are that the D95%
of the CTV must equal 100% of the Rx, and the D99% must
equal 95% of the Rx.
Matchlines are tweaked so that the hot/cold areas are equal
in size

Plan Optimization
Each beam is optimized so that the CTV coverage
constraint is met
Then, uncertainties are added to the range and
modulation for each beam
Our center uses 2.5% + 2 mm for the CT HU to stopping
power conversion uncertainty and cyclotron delivery
precision uncertainty

Organs at risk are now evaluated


Target Dose Constraints


Organs at Risk Dose Constraints


Dosimetric Advantages of

In Isodose Distributions
Proton Doses

Photon Doses


In Isodose Distributions
Proton Doses



In Isodose Distributions
Proton Doses

Photon/E- Doses


In Isodose Distributions
Proton Doses

Photon/E- Doses


In the Dose Volume Histograms


Lt Breast
E- Plan

Photon/E- Plan


In the Dose Volume Histograms

Rt Breast


E- Plan

Proton Plan
Photon/E- Plan


In the Dose Volume Histograms

Lt Breast


E- Plan

Proton Plan

Photon/E- Plan

The Treatment Delivery


Patient Alignment
Alignment Process

Align patients mouth with superior marks on cradle

Line up both superior and inferior patient marks with vac-loc/alphacradle marks
Align 3 point tattoos
Align anterior tattoo with SSN and Navel for straightening


Daily Setup Fields

Once the patient is aligned, the first setup field is
imaged. This is done to make sure that the arm,
head/chin, and humeral head are in the right position.
At this point any directional shifts may be applied for
the set up field.
The setup fields are typically at 0 or 90 degree gantry


Daily Setup Fields


Treatment Order Gantry Room

After filming at site setup, both supraclavicular fields
are treated first.
Then, an isoshift, generally just in the Y direction
inferiorly, is performed.
Finally, after filming post shift, both chestwall fields
are treated.


Treatment Order Inclined Beam Room

Start with Supraclavicular field with Table 0 Gantry 30,
shift inferior
Then, treat the breast/chest wall field at Table 0 Gantry

Swing couch, and treat breast/chest wall field at Table

270 Gantry 30. Then, shift superior.

Finally, treat the supraclavicular field with Table 270

Gantry 30

Daily IGRT Shift tolerances

Site Setup/Supraclavicular field:

anatomy within 2mm in X, Y, & Z

Allow 1 Degree pitch, roll, & rotation
Matching Chestwall field

Anatomy within 4mm in X & Z

No Y, pitch, roll, or rotation, in order to maintain the
geometry for the match


Treatment Times, Setup Films taken

Avg.tx.time table time thus far=49.5 min
Avg.# of setup x-rays= 3.1

Total #breast patients treated to with these techniques

to date: 18


Will continue to offer proton therapy to these
subgroups of breast cancer patients, as the organ
sparing benefits have convinced us that this is a
worthwhile option for these patients.
Continue to look for ways to make the entire planning
process more efficient.
Other indications:
Partial Breast treatment for early stage treated 1 patient
per protocol thus far
Pencil Beam Scanning on the Gantry for the Stage III and
retreat patients


PCG BRE-008 Cardiac-Sparing Post-Mastecomy Protocol
Ares, et al, Postoperative Proton Radiotherapy for Localized and
Locoregional Breast Cancer: Potential for Clinically Relevant
Improvements, Int. J. Radiation Oncology Biol. Phys. 76, No. 3,
pp. 685697(2010)
Fagundes, et al, Abstract poster presentation at PTCOG 2013
H. Paganetti: Range ncertainties in proton therapy and the impact
of Monte Carlo simulations, Phys. Med. Biol 57 R99-R107 (2012)
RTOG Breast Cancer Atlas for Radiation Therapy Planning:
Consensus Definitions

Entire Physics and Dosimetry teams at ProCure
Chicago and Cadence Health.
The Breast Team: Rachel Sewell, RT(T), Dawn Smith,
RT(T), Megan Marshall, RT(T), Jennifer Mitchell, RT(T),
Stephanie Hufnal, RT(T) Minu Vachachira, RT(T),
Lauren Curran, RT(T), Hilary Deeke RT(T), Lindsey
Havron, RT(T)


Thank you for your attention!!!