1

Whole Breast Nodal Irradiation utilizing Supine VMAT and Prone 3D Planning: A
Case Study
Authors: Ashley Coffey, B.S., R.T.(T), Lisa Stevenson, B.S., R.T.(T), CMD, Ashley
Hunzeker, M.S., CMD, Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD
Medical Dosimetry Program at University of Wisconsin- La Crosse, WI

Abstract
Introduction: The purpose of this study is to compare the variations in doses to the
ipsilateral lung and heart between supine whole breast and nodal VMAT technique and the
prone 3DCRT technique.
Case Description: In this study, 3 patients that were simulated in the prone and supine
positions were planned using a supine VMAT and prone 3DCRT technique to compare PTV
coverage as well as dose to OR including the heart and ipsilateral lung.
Conclusion: While all constraints were met, the ideal treatment technique depends on the
patients anatomy and lumpectomy location. Supine VMAT provided excellent coverage to
the target structures but encountered difficulty limiting dose to the ipsilateral lung and heart.
Prone 3DCRT limited dose to the ipsilateral lung and heart but provided less dose coverage
to the target volumes when compared to the supine VMAT technique.

Keywords: breast cancer, prone, supine, 3DCRT, VMAT

Introduction
The cumulative lifetime incidence of breast cancer is 1 in 8 U.S. women.1 In fact,
breast cancer is so common, it has been ranked the second most common malignancy
affecting women living in the United States after skin cancer. Although breast cancer is
prevalent, the survival rates have been steadily increasing since 1989 as a result of earlier
diagnosis and the development of more effective treatments, such as chemotherapy, hormone
targeting drugs, and radiation therapy. The increase in survival necessitates a greater need
for therapies with decreased toxicity to normal tissues, providing better cosmetic outcomes
and decreasing the risk of radiation-induced secondary malignancies.2

Three-dimensional conformal radiation therapy (3DCRT) supine, often treated with

three fields monoisocentrically, was the gold standard for many years. However, the
monoisocentric technique had limitations that included less than optimal planning target
volume (PTV) coverage, problematic junctions between the breast and nodal fields, and
increased radiation dose to surrounding healthy tissues.2 Nearly a decade ago, advances in
technology paved the way for intensity modulated radiation therapy (IMRT) techniques that
increased PTV coverage, better dose homogeneity, and decreased dose to surrounding
structures.3 In 2007, volumetric modulated arc therapy (VMAT) technique was introduced
clinically for breast cancer treatment and has since become a widely accepted method for
treating left sided breast cancer patients with nodal involvement. Although VMAT has
comparable PTV coverage to IMRT, it has better dose conformity, decreasing maximum
dose to surrounding tissues, less monitor units (MUs) and decreased treatment time.2
Recently, 3DCRT prone breast techniques have garnered interest in the radiation
oncology community. The prone position naturally pulls the breast away from the chest wall
allowing for the possibility of greater dose sparing to organs at risk (OR). There is currently
a lack of data comparing supine VMAT to prone nodal breast treatments. In this study, 3
patients that were simulated in the prone and supine positions were planned using a supine
VMAT and prone 3DCRT technique to compare PTV coverage as well as dose to OR
including the heart and ipsilateral lung.
Case Description
Patient Selection and Set-up
Patient selection was based on women with breast cancer and nodal involvement. All
patients in this study were diagnosed with grade 2 or 3 invasive ductal carcinoma and an
intact breast. Patients were simulated in both prone and supine positions to attempt to reduce
organ dose and deliver adequate dose to the breast and nodes. All patients were scanned in a
General Electric (GE) CT large bore scanner head first. For the supine scan, the patient was
placed on a 15 tilt breast board with the ipsilateral arm up and their head turned in the
opposite direction. In the prone scan, the patient was placed on their stomach on top of a
prone breast board that sits 24.5 cm off the CT table. There was an opening on the affected

side that allowed for the breast to fall forward and the supraclavicular area to be exposed in
order to treat nodes without obstruction. The head was also turned away from the affected
side and a VacLok bag was used to support the arms. Radio-opaque CT wires were placed on
the skin to delineate the edges of the breast tissue and tattoos were placed on the patient to
reproduce daily setup. On Board Imaging (OBI) was used daily for each patient.

Target Delineation
Target delineation was performed by the physician and medical dosimetrist on a
Philips Pinnacle v9.8 treatment planning system (TPS). Contours were created on the
planning CT and expanded following the Radiation Therapy Oncology Group (RTOG) 1304
protocol.4 The protocol provided guidelines for contouring all target volumes and structures
which included: lumpectomy, breast, supraclavicular nodes, axillary nodes, and internal
mammary nodes (IMN). All clinical target volume (CTV) contours can be found in the
RTOG anatomy atlas.5 Critical organs contoured included the ipsilateral and contralateral
lung, contralateral breast, heart, and thyroid.
The lumpectomy gross tumor volume (GTV) was contoured with available imaging
and included the lumpectomy cavity, lumpectomy scar, seroma, and surgical clips.
Lumpectomy CTV was created from a 1 cm expansion of the lumpectomy GTV that avoided
the pectoralis muscles, 5 mm from the skin, and did not cross midline. Lumpectomy PTV
was created by expanding the CTV by 7 mm in all directions excluding the heart.
Breast CTV is classified as all palpable breast tissue which was delineated at the time
of simulation with radio-opaque wires in the CT simulation. The Lumpectomy CTV was
included in this contour and excluded 5 mm of skin on the surface, the pectoralis, chest wall,
ribs, and lung. The Breast PTV is the Breast CTV with 7 mm expansions that avoided the
heart and did not cross midline. Breast PTV Eval was created by copying the Breast PTV and
edited to exclude air outside the patient, 5 mm skin, and anything deeper than the anterior
surface of the ribs. Breast PTV Eval was used for constraints in planning and dose volume
histogram (DVH) analysis.
Supraclavicular CTV was contoured using the RTOG Breast Cancer Atlas.5

Supraclavicular PTV was created by expanding the supraclavicular CTV by 5 mm in all

directions. The supraclavicular PTV did not include the thyroid, trachea, esophagus, lung,
and was contracted 5 mm from the skin surface.
Axillary CTV was contoured from the remaining, undissected axillary nodes. The
physician used the operative reports and other diagnostic imaging to determine what axillary
nodes needed to be included in planning. Typically, level I and II axillary nodes are removed
so the level III nodes and any other remaining nodal levels must be included in the axillary
CTV. Axillary levels can be found on the RTOG Breast Cancer Atlas.5 Axillary PTV
included a 5 mm expansion of the CTV excluding lung. Internal Mammary Node CTV
included the internal mammary nodes and thoracic vessels in the first 3 intercostal spaces.
The IMN PTV was 5 mm expansion from the IMN CTV medially, laterally, superiorly, and
inferiorly. The IMN PTV excluded the sternum, lung, or heart.

Treatment Planning
Each patient used for planning had scans performed on the same day in both prone
and supine position. A total of 3 patients were planned with 3DCRT in the prone position and
with VMAT in the supine position. Each patient had a prescription dose of 50 Gy in 25
fractions to the whole breast and nodal regions. The lumpectomy was to receive a boost of 10
Gy in 5 fractions. The conformal plans for all patients utilized single isocenter tangents for
the whole breast along with an anterior and posterior supraclavicular field.
Patient 1 was planned supine using a VMAT technique that utilized four 249 partial
arcs with split beams to allow more adequate multi-leaf collimator (MLC) range. The
prescription dose was normalized to the 100% isodose line resulting in a maximum dose
point of 106.7%. Patient 1 was also planned prone using 6 MV tangential beams and a right
anterior oblique (RAO) and a left posterior oblique (LPO). The beam angles were decided
based on how to achieve acceptable coverage to the IMN PTV and axillary level III nodes
without delivering excess dose to the heart. The prescription dose was renormalized to the
94% isodose line to achieve better dose homogeneity resulting in a maximum dose point of
106%.

Patient 2 was planned supine using a VMAT technique that utilized four 249 partial
arcs with split beams to allow more adequate MLC range. The prescription dose was
normalized to the 100% isodose line resulting in a maximum dose of 113% with less than 1%
of the volume reaching doses higher than 108%. Patient 2 was also planned in the prone
fashion with four 18MV beams to the right breast. The arrangements included medial and
lateral tangents as well as a left anterior oblique (LAO) and a right posterior oblique (RPO).
The beam angles for this patient were selected based on avoiding the contralateral breast and
minimizing the amount of lung in the field. The patient had a separation of more than 30
centimeters at the lumpectomy cavity, which made delivering a uniform dose across that field
difficult. In order to receive adequate coverage, the prescription dose to the tangent fields
was normalized to the 88% isodose line and the prescription dose to the supraclavicular field
was renormalized to the 95% isodose line. The prescription increased the maximum dose to
112%, which is acceptable, but a slightly higher dose than a standard 3-D plan.
Patient 3 was planned supine using a VMAT technique that utilized two 249 partial
arcs with split beams to allow more adequate MLC range. The prescription dose was
normalized to the 100% isodose line resulting in a maximum dose point of 110%. However
only 0.01% of the entire volume received more than 54 Gy thus meeting protocol parameters.
Patient 3 was also planned prone using 6MV and 18MV tangential beams and a RAO and a
LPO. The beams angles were decided based on coverage of the IMN PTV while avoiding as
much heart as possible and providing axillary level III coverage. The dose was prescription
dose was renormalized to the 92% isodose line resulting in a maximum dose 108%.

Plan Analysis and Evaluation

The supine plan for patient 1 was very straight forward. The incline of breast board
combined with the arm on the affected side being raised above the patients head adequately
lifted the involved breast up and away from the contralateral breast resulting in decreased
dose to the contralateral breast. All protocol constraints for target and OR were either met at
the protocol or acceptable variation level; however, there was great difficulty getting the
ipsilateral lung to meet the 65% 5Gy without losing Breast PTV Eval per protocol

coverage. The acceptable variation of 70% 5Gy was finally attained after special contours
were created and optimized to decrease lung dose. All heart constraints met the per protocol
parameters except the mean dose which met the acceptable variation mean dose of 4.65Gy.
Patient 1 was a fairly easy prone plan to meet constraints with. The positioning on the board
was straight and leveled; the contralateral breast was properly pulled away from the affected
breast, which gave clearance for tangent fields without the contralateral breast receiving any
dose. All of the constraints for the heart and lung were met exceedingly below the ideal per
protocol constraints. The dosimetric results for OR and PTV targets for both plans on
Patient 1 are listed in Table 1.
Patient 2 was difficult to plan in the supine position. Although all protocol constraints
for targets and OR were either met at the protocol or acceptable variation level, there was
great difficulty getting the ipsilateral lung to meet the 65% 5Gy without losing Breast PTV
Eval coverage. This was largely due the close proximity of the lumpectomy site to the chest
wall. The acceptable variation of 70% 5Gy was finally attained after special contours were
created and optimized to decrease lung dose. This did decrease coverage to all 4 PTV
structures, however, from per protocol to acceptable variation levels. Patient 2 provided a
challenge planning in the prone fashion as well. At the lumpectomy site, the patient had a
33.2 separation making it difficult to achieve a homogeneous dose distribution with tangent
fields. After various methods such as adding smaller fields and using multiple energies, the
end result came from 18MV tangents with multiple control points and prescribing to a lower
isodose line than normal. Prone position pulled the patients breast away from the chest wall
but it then rested on the table which resulted in a bolus effect that increased dose to that
portion of the breast. The patient also had the contralateral breast hanging off of the opposite
side of the breast positioning device; poor positioning in simulation meant that consideration
needed to be taken when selecting tangent angles in order avoid entrance and exit dose into
the contralateral breast. Even with positioning challenges, all of the dose constraints were
met for the ipsilateral lung and heart in the per protocol category while still adequately
covering all PTV structures. The dosimetric results for the OR and PTV tangents for both
plans on Patient 2 are listed in Table 2.

Patient 3 was successfully planned in the supine position. All protocol constraints for
target and OR were either met at the protocol or acceptable variation level. While trying to
decrease the mean heart dose to under 5 Gy and bring the lung dose to 70% 5Gy, IMV
PTV coverage decreased from per protocol level to the acceptable variation level. Patient 3
was not in the most efficient position for prone planning. The contralateral breast was not
positioned correctly on the board and therefore was partially in the board opening utilized for
the affected breast. The contralateral breast was avoided by adjusting the angles utilized;
however, it was not ideally positioned for accuracy and reproducible treatments. With the
prone planning, IMN PTV coverage had to be compromised to only acceptable coverage in
order to meet the acceptable heart mean of 5 Gy. Even with the challenges presented in
positioning and heart location, all dose constraints were met and the coverage to remaining
nodal PTVs and the lumpectomy site were met. The dosimetric results for OR and PTV
targets for both plans on Patient 3 are listed in Table 3.
After evaluation of the ipsilateral lung and heart doses for each patient, there was not
a clear method as to which treatment type was better. A few factors contribute to the decision
of treating a patient in the supine or prone technique. One factor is where the patients cavity
is located. When the cavity is closer to the chest wall, it is easier to receive better target
coverage and lower OR doses in the prone conformal fashion than it is with supine VMAT.
Another factor to consider is the challenges posed in planning a prone 3D plan for a patient
with a larger separation. With the breast falling away from the patient, the field becomes
large to cover the nodal targets as well as the whole breast. With larger patients, there also
tends to be a roll towards the affected breast which causes more lung and heart to fall into the
tangent fields in a prone setup. In a study performed by Huppert et al,6 patients with left sided
breast cancer were found to have their heart falling into the prone breast field due to an axial
rotation. Their solution was turning the patients head toward the affected side which
straightened out the patients roll and pulled the heart out of the tangential fields. Based off
Huppert et al6 results, NYU Trial 05-181 was developed. The NYU trial 05-181 enrolled 400
patients with breast cancer to be simulated both supine and prone. The heart dose was
evaluated and found that prone position decreased the amount of heart in the field by 11cc.

This complements the results found in the current retrospective study. In figure 1, the mean
heart doses are compared for both prone and supine; although not significant, the prone plans
all produced lower mean heart doses than the supine plans.
Supine VMAT technique provided great target coverage of the breast and nodes but
posed challenges with higher low level doses to the lung and heart. This aspect of the supine
VMAT breast technique has been observed in other studies comparing supine IMRT to
supine VMAT as well and has been attributed to the increased exit dose given to the lung and
heart due to the beam emitting radiation during the entire semi arc of the VMAT field as
opposed to stationary IMRT beams arranged to avoid these structures.7 This is of
significance because each additional Gy added to the heart mean dose can increase the rate of
cardiac toxicity by as much as 4%.3 Prone conformal technique kept the OR structure doses
very low; however, the target structures were only adequately covered. Overall, the ideal
treatment method changes on a patient by patient basis. It should be determined by the
physician and the patient as to which method should be used.

Conclusion
The purpose of this study was to compare supine VMAT versus prone 3DCRT in the
delivery of external beam radiation therapy for patients with breast and nodal disease. This
study demonstrated that while supine VMAT plans achieved better PTV coverage than prone
3DCRT, supine VMAT techniques generated higher doses to the ipsilateral lung and heart.
The most striking variation was the increased mean dose given to the heart during supine
VMAT treatments. The increase often times resulted in supine VMAT technique delivering
double the heart mean dose than that of the prone 3DCRT. The average increased mean
dose per patient was 1.6 Gy.
This study was performed retrospectively, which is not ideal. Patient positioning
could have been improved and results could be more beneficial if the study was conducted
prospectively. In the prone scans, the patients were often rolled or did not have the
contralateral breast positioned out of the field resulting in planning challenges such as

limitations of ideal gantry angles. Even with working around these issues and achieving
treatable plans, it would have been ideal to have the patients set up correctly on their initial
planning scan.

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References
1. Breast Cancer. American Cancer Society website.
http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics.
Accessed June 5, 2016.
2. Teoh M, Clark CH, Wood K, Whitaker S, Nisbet A. Volumetric modulated arc therapy: a
review of current literature and clinical use in practice. Br J Radiol. 2011; 84: 967-96.
http://dx.doi.org/10.1259/bjr/22373346
3. Zhao H, He M, Cheng G, et al. A comparative dosimetric study of left sided breast cancer
after breast-conserving surgery treated with VMAT and IMRT. Radiat Oncol.
2015;10(231):e10. http://doi.org/10.1186/s13014-015-0531-4
4. Mamounas E, White J. NRG Oncology NSABP Protocol B-51/RTOG Protocol 1304.
Radiation Therapy Oncology Group (RTOG).
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=1304.
Published 2013. Updated 2016.
5. RTOG Breast Cancer Atlas. Radiation Therapy Oncology Group website.
https://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx. Accessed
June 7, 2016
6. Huppert N, Jozsef G, DeWyngaert K, et al. The Role of a Prone Setup in Breast
Radiation Therapy. Front Radiat Ther On. 2011;1(31):e10.
http://doi.org/10.3389/fonc.2011.00031
7. Ali MA, Babaiah M, Madhusudhan N, George G, Jain S, Ramalingam K, Kumar SA,
Karthinkeyan K, Anantharaman A. Comparative dosimetric analysis of IMRT and
VMAT (Rapid Arc) in brain, head and neck, breast and prostate malignancies. Int J
Cancer Ther Oncol 2015; 3(1):03019. http://doi.org/10.14319/ijcto.03019

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Figures
Figure 1: The mean heart dose for each patient in both prone and supine position is graphed
below. The prone 3D consistently showed less heart dose than supine VMAT.

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Tables
Table 1. Below are constraints for the target volumes and organs at risk for Patient One. The
green signifies meeting the ideal per protocol constraint and yellow correlates to the
acceptable variation.
Constraints
Breast PTV Eval

Per Protocol
95% of
47.5Gy

Acceptable
Variation

Patient 1
Prone

Patient 1
Supine

90% of 45Gy

95.9%

97.6%

SCL PTV

95% of
47.5Gy

90% of 45Gy

98.5%

96.8%

Axillary PTV

95% of
47.5Gy

90% of 45Gy

97.6%

99.1%

IMN PTV

95% of 45Gy

90% of 40Gy

99.0%

98.7%

Heart

<5% at 25Gy

<5% at 30Gy

0.10%

1.1%

Heart mean

4Gy

5Gy

2.1Gy

4.7Gy

IpsiLung

<30% at 20Gy

<35% at 20Gy

25.4%

23.4%

Table 2. Below are constraints for the target volumes and organs at risk for Patient Two. The
green signifies meeting the ideal per protocol constraint and yellow correlates to the
acceptable variation.
Constraints

Per Protocol

Acceptable
Variation

Patient 2
Prone

Patient 2
Supine

Breast PTV Eval

95% of 47.5Gy

90% of 45Gy

95.7%

96.8%

SCL PTV

95% of 47.5Gy

90% of 45Gy

94.9%

97.3%

Axillary PTV

95% of 47.5Gy

90% of 45Gy

98.7%

98.2%

IMN PTV

95% of 45Gy

90% of 40Gy

90.7%

99.9%

Heart

<5% at 25Gy

<5% at 30Gy

1.04%

0.5%

Heart mean

4Gy

5Gy

1.8 Gy

3.7Gy

IpsiLung

<30% at 20Gy

<35% at 20Gy

16.8%

21.0%

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Table 3. Below are constraints for the target volumes and organs at risk for Patient Three.
The green signifies meeting the ideal per protocol constraint and yellow correlates to the
acceptable variation.
Constraints

Per Protocol

Acceptable
Variation

Patient 3
Prone

Patient 3
Supine

Breast PTV Eval

95% of 47.5Gy

90% of 45Gy

97.0%

95.7%

SCL PTV

95% of 47.5Gy

90% of 45Gy

98.7%

98.3%

Axillary PTV

95% of 47.5Gy

90% of 45Gy

98.4%

97.7%

IMN PTV

95% of 45Gy

90% of 40Gy

90.3%

99.9%

Heart

<5% at 25Gy

<5% at 30Gy

4.35%

0.8%

Heart mean

4Gy

5Gy

4.4Gy

4.7Gy

IpsiLung

<30% at 20Gy

<35% at 20Gy

15.6%

17.9%