Dakota Sturgess

Dosimetry Practicum II
Breast Lab
 Find a breast patient in your clinic that was treated with 3-4 fields: Supraclav-(anterior
only or anterior + PAB) and Tangents.
 Create a plan utilizing the mono-isocentric technique following the prescription and
guidelines most commonly used in your clinic.
 Create a second plan utilizing the dual isocenter technique with isocenter at the bottom of
the supraclavicular field and the table rotated to match the top of the tangent fields to the
bottom of the supraclavicular field. Use the same prescription and guidelines as in the
mono-isocentric plan.
Submit the answers to the following questions to earn a total of 25 possible points. Each bulleted
question below is worth 5 points each.
How did the two plans differ? (illustrate with images when possible).
The plans differed by the placement of the isocenters. The dual isocenter plan involved a few
more steps to assure there is no overlap between the two isocenters. This included matching field
borders, collimator rotations, and table rotations. The mono isocenter used a half beam block at
the level of the clavicle, to separate the SCLV and tangential fields. The dual isocenter plan had
one isocenter at the level of the clavicle and another isocenter 5cm inferior for the tangential
fields. The dose coverage of the plans was similar.
Image 1. Mono Isocentric
Image 2. Dual Isocentric

 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?
The final hotspot in each plan was in the supraclavicular (SCLV) region @ 114%. This is hotter
than a typical plan. In this plan, I used a supraclavicular and post axillary boost field to cover the
nodes that were involved. I believe the hot spot is in this location for each plan because of the
patient's separation and the location of the SCLV field.
Image 3.

 Was there a cold spot in either plan? If so, where? and what may have caused it?
Before adding the PAB field, it was slightly under covered. By adding the PAB field, this helped
bring the 90% IDL more posterior to help cover the nodes. Also, near the chest wall and lungs
tend to get cooler due to the tissue density. It is cooler near the match line of the inferior border
of the SCLV and the superior border of the MED field at the level 1 axillary nodes. By opening
the MLCs right below the inferior border of the SCLV field, it helped increase the dose in the
region compared to keeping those MLCs closed. I did the same for the MED, LAT and PAB
fields.
Image 4. SCLV Field.
Image 5. PAB Field

Image 6. MED Field.

Image 7. LAT Field.

 How did you assure that the

bottom of your supraclav?
First, I attempted matching the
MED field to the SCLV field by
contouring the slice of the body
where the inferior border of the
SCLV ends. Below is an image of the match line.

I had a minor issue with trying to use this method. The line is thicker, so it was difficult for me to
be visually certain.
The method that worked for me was turning on the setting that shows the field entry shape on the
body of the SCLV field. Then, I adjusted the collimator and table rotation to match that inferior
border.
  Which plan did you prefer and why? Did you see an advantage of one technique over
another?
I prefer the mono iso plan because planning the mono case is not as tedious as the dual iso, as in
matching the borders of both fields and matching the divergence of the beam. Not only the
planning, but the therapist will value a mono iso plan, as well. It is advantageous to use the dual
isocentric technique when the length of the field exceeds the limit of the MLCs.

 Have you seen the dual iso technique (table rotation) used in your clinic? Do you think
this technique is useful? Why or why not?
I have not seen the dual iso technique used in the clinic. The plan I used had been planned for
both mono and dual isocenters due to the patient's anatomy. The physician ultimately chose the
mono isocentric plan. I do think the dual isocentric technique is practical, patient's anatomy
varies from patient to patient and if the fields cannot extend far enough to cover the whole breast
and the supraclavicular field then using this technique will be beneficial.