Keith Larsen

Clinical Practicum II

Breast Planning Practice

The plan selected for this project is a 4-field breast treated to a dose of 5000 cGy over 25
fractions. The tangent planning technique used for both the mono-iso and match line plans is
ISC. The nodal fields are MLC fields with no wedges.

 What was the final hotspot in each of your plans and where was it located? Why do you
think the hot spot is in this location for each plan? 

Figure 1: Mono-Iso Plan Hotspot

The hotspot for the mono-iso plan is 5783 cGy (16%). It is located approximately 1.5cm
superior to the half beam blocked match line. This hot spot is located here as the nodal fields
on their own have a hotspot of 112.8%. Scatter dose from the tangential fields contribute to
an increased hot spot in that same area.
 Figure 2: Dual Isocenter Shift Plan Hotspot

The hotspot for the dual isocenter plan is in an almost identical spot as the previous plan. The
hotspot is nearly identical at 5804 cGy, 20 cGy higher than the mono-isocentric plan. The nodal
fields themselves are exactly the same in both plans so the location of the nodal hotspot is
identical. The tangential plans are different with the change in isocenter position, but I was able
to create very similar hotspot values as ISC planning allows you to adjust the dose levels along
the match line to very specific values.

 Was there a cold spot in either plan? If so, where? and what may have caused it?

Figure 3: Mono-Iso Sagittal View, Cold Spot

The cold spot on the mono-iso plan measures approximately 4830 cGy. It is located on the match
line. Typically, we see cool spots on the match line. This may be due to the fact that even if the
node and tangential fields are aligned perfectly, the field edge is defined as 50% dose and could
possibly be lower due to penumbra. Scatter contribution from the other fields help bring the dose
back up to near prescription dose.

Figure 4: Dual-Iso Cold Spot

On the dual-iso plan, the cold spot measures 4750 cGy, slightly lower than the mono-iso plan but
still very close.

 How did you assure that the bottom of your supraclav field met the top of the tangent
fields in each setup?

The mono-isocenter match line is created with the half beam block creating an even union of the
nodal and tangential fields where there is no beam divergence from one field into the other. The
dual isocenter match line is created by setting the jaw size, table rotation and collimator rotation
on the tangential fields to create a clean match line on the patient’s skin surface (see Figure 5).
The table rotation and collimator rotations are necessary to account for the beam divergence
from the tangential fields. The less variables involved in the mono-isocentric technique make it
easier to create a clean match line, though both methods should give a good end product as can
be seen in Figures 4 and 5.
Figure 5: Eclipse View of Dual-Isocenter Match line

 Which plan did you prefer and why? Did you see an advantage of one technique over
another?

(See below)

 Have you seen the dual iso technique (table rotation) used in your clinic? Do you think
this technique is useful? Why or why not?

The mono-isocentric technique is far superior in my opinion. Along with the cleaner match
line from the lack of divergence, it is a far superior setup for the therapists. Having
personally been a therapist prior to mono-isocentric setups being the standard, I can attest to
the fact that dual isocentric breast setups were one of my least favorite to treat of any setup.
The technique involved marking the match line on the patient’s skin with a marker and
physically needing to move the tangential field’s superior border to that match line after
applying the couch rotation. This resulted in multiple opportunities for small variances, in
that placing the match line on a breathing patient provided a range of location for the match
line to be drawn and then physically matching the fields provided further opportunity to align
the fields imperfectly. Add in the increased amount of time for treatment with the extra trips
into the room leading to more opportunity for patient movement, and I never felt confident
the match lines were as exact as I would have liked. The main advantage of dual-isocentric
planning is for patients where you would need a longer tangential field size than 20cm which
is the maximum size, but this is very rare. In comparison, mono-isocentric treatments go
much more quickly and eliminate the opportunity for the small variances in patient setup
discussed previously as the half beam block does a much better job of ensuring precise match
line location without the opportunity for human error.