Brittni McKane

DOS 531– Clinical Oncology

April 22, 2022

Introduction

Breast cancer is the most common cancer in women with at least one in eight developing
it in their lifetime.1 Treatment options can include surgery, chemotherapy, radiation therapy, and
immunotherapy depending on the stage and can have various treatment phases.2 Radiation
therapy is a common adjuvant treatment for breast cancer patients.

A 43-year-old female patient presented to their local provider after noticing enlargement
and tenderness in the right breast. The local hospital completed a mammogram and ultrasound
guided biopsy. The pathology after biopsy confirmed the presence and diagnosis of an invasive
ductal ER/PR/HER2 positive carcinoma of the right breast. The patient referred to my clinical
site for a second opinion and further treatment options. Additional testing included a bilateral
breast MRI that found a 4.7 x 3.4 x 8.1 cm multicentric irregular mass throughout the right
breast. This was larger than previously noted on the outside mammogram and ultrasound
imaging. Clinical staging was T3N0 ER positive, HER2 positive. Further imaging included a
bone scan and CT of the chest/abdomen/pelvis, which did not find evidence of distant metastasis.

Treatment recommendations included neoadjuvant chemotherapy prior to surgery with

the possibility of adjuvant radiation therapy. The patient completed chemotherapy and opted for
a double modified mastectomy without reconstructive surgery. At time of surgery, sentinel
lymph node biopsies and surgical margins were negative for residual disease. Surgery was then
followed by further adjuvant chemotherapy as well as radiation therapy. Staging after surgery
was Stage IB- T3N0M0, G3, HER2/ER/PR Positive.

Simulation

Simulation is a crucial first step in the radiation therapy planning process as a

reproducible setup ensures for a more accurate treatment. For simulation, this patient was
positioned headfirst supine on the scanner couch with arms up utilizing a breast board. The arms
were positioned up out of the way of the treatment fields on the attached wing board holding
onto the provided handles for stability and comfort. The board was angled up 5 degrees with a
headrest, large knee cushion, and base bar adjusted to prevent the patient from sliding down.
Slanting of the breast board is generally used to shift the breast tissue down when the breast is
more pendulous and adjusts the slope of the chest to be more parallel for treatment. The
physician placed wires on the patient’s skin prior to scanning to outline the treatment field as
well as the surgical scar. These wires assist the physician in contouring the target volume as well
as the medical dosimetrist in creating bolus when needed. An infrared box was placed on the
lower abdomen as the simulation scan and corresponding treatments utilized deep inspiration
breathhold (DIBH) to reduce dose to normal tissues. Often, left-sided breast treatments utilized
DIBH as there is a known benefit in reducing heart doses. Recent studies have also found DIBH
useful with right-sided breast treatments (especially when treating the internal mammary nodes)
in lowering dose to the right coronary artery, ipsilateral lung, and liver doses.3

Target Doses

The use of radiation therapy for postmastectomy T3N0 patients is controversial; however,
in this case, the risk of recurrence is increased with high tumor grade and premenopausal status.4
The radiation therapy prescription was daily photon treatment over 3 weeks for 15 fractions at
267 cGy per fraction, totalling 4005 cGy to the target volume. Radiation therapy for
postmastectomy patients is typically given over 5 weeks to 5000 cGy, although for non-
reconstructed early stage patients hypofractionation is being more frequently used as a
reasonable option as it demonstrates similar toxicity to conventional fractionation with added
convenience for the patient.5,6

The target volume included the right chest wall, supraclavicular, axillary, and internal
mammary nodes as recommended per RTOG.4 The radiation oncologist considered several
factors when determining this patient’s treatment regimen including tumor size and
prechemotherapy clinical stage, mastectomy without reconstruction, and chemotherapy response.
As this patient opted for mastectomy without reconstruction, bolus of 0.5 cm thickness was used
for the first 10 fractions ensuring adequate skin dose. The physician then removed it for the last 5
fractions and differences in dose with and without the bolus were slight. The bolus was created
using the treatment planning system and the clinical reference wires placed during simulation
and then cut by the radiation therapists the first day of treatment.
Avoidance Structures

Long-term toxicity concerns that can be associated with multifield breast or chest wall
treatments can include such conditions as radiation pneumonitis, radiation-induced heart disease
(more so for left-sided cases), and hypothyroidism.4 For right sided chest wall treatments with
nodal regions, the normal tissues considered while planning are the heart, left, right and total
lungs, spinal cord, esophagus, humeral head, brachial plexus, and right coronary artery. Figure 1
shows an anterior view of the patient with the contoured structures and planning tumor volume
(PTV) outlines. Figures 9-12 demonstrate the treatment fields in relation to these OARs.
 Figure 1: Case study contoured OARs

Current QUANTEC recommendations as well as my clinical site’s specific dose

constraints for the OARs are listed in the following table. Contraindications for exceeding these
tolerance doses are also listed.7 It is worth noting that the QUANTEC data recommendations are
based off conventional fractionation7, thus the prescribed dose constraints in this case are more
strict with a hypofractionated approach. The anterior coronary artery and thyroid OARs did not
have a specific dose constraint, only report values with the goal of keeping dose as low as
reasonably achievable (ALARA).

Organ at Risk Prescribed Dose Objective QUANTEC Contraindication7

(OAR) Constraints Met? Data7
Heart Mean < 2 Gy Y Mean < 26 Gy pericarditis
pericardium
V25Gy[%] < 5% Y V25 < 10% radiation induced heart
whole organ disease

V50Gy[%] < 1% Y V30 < 46% pericarditis

pericardium
Contralateral V5Gy[%] < 10% Y V20 < 30% symptomatic pneumonitis
lung Mean 7 Gy
Ipsilateral lung V5Gy[%] < 65% Y (increased toxicity
rate with increased
V10Gy[%] < 50% Y
mean dose)
V20Gy[%] < 25% Y Whole organ
Total lung V20Gy[%] < 15% Y
Cord V45Gy[cc] < 1cc Y Dmax 50 Gy myelopathy
Esophagus D0.01cc[Gy] < 32 Gy Y Mean 34 Gy Grade 3 acute esophagitis
D1cc[Gy] < 29 Gy Y V35 < 50% Grade 2 acute esophagitis
V50 < 40% Grade 2 acute esophagitis
V50Gy[cc] < 1cc Y Whole organ
Brachial plexus V42Gy[cc] < 1cc Y - -
Humeral head D0.01cc[Gy] < 35 Gy Y - -
D1cc[Gy] < 25 Gy Y - -
Anterior No specific constraints - - -
coronary artery listed (ALARA)
Thyroid No specific constraints - - -
listed (ALARA)
Lymph Nodes

For postmastectomy radiation therapy, the target volume should include the internal
mammary, supraclavicular, and axillary lymph node chains as recommended by the RTOG.4 At
my clinical site, physicians do not routinely contour each lymph node chain on its own. These
regions are included within the clinical tumor volume (CTV). In some cases, the internal
mammary nodes are included within the CTV but are also contoured and reported on separately.
See Figures 2-4 for the nodal chains and their general regions included with this chest wall
radiation treatment case study.

Figure 2: Supraclavicular lymph nodes (red) included within drawn CTV (cyan). Axillary lymph
nodes are also seen (purple, green, and blue).
Figure 3: Supraclavicular (red), level I (purple), level II (green), and level III (blue) axillary

lymph nodes within drawn CTV.

Figure 4: Internal mammary (orange) and level I axillary (purple) nodes drawn within the CTV.

Anatomy- Treatment Borders

Post mastectomy chest wall treatment borders often rely on a combination of anatomical
landmarks and clinical reference by the physician. Per RTOG recommendations4, the cranial
border of the tangent fields is set at the caudal border of the clavicle head extending inferiorly to
either a clinically referenced point or where there is a loss of breast tissue on the CT scan. The
anterior border will encompass the skin while posteriorly extending to include the rib-pleural
interface along with muscles of the chest wall. The lateral border will either run along the mid
axillary line or utilize a clinical reference point extending medially to include the sternal-rib
junction. The surgical scar should be included within these borders. For this case study, the wires
placed at sim were the clinical reference points determined by the physician and can be seen in
the digitally reconstructed radiograph (DRR) in Figure 5. Figure 6 demonstrates the tangent field
borders on the CT image set. These borders were also used to create the bolus within the
treatment planning system.
Figure 5: An anterior DRR with the clinical reference wires placed outlining the tangent
treatment field and bolus field.

Figure 6: Field borders for tangent fields on case study CT image set.

The borders for the supraclavicular field should extend from the caudal edge of the
cricoid cartilage to the caudal border of the clavicle head. The anterior border includes the
sternocleidomastoid muscle extending posteriorly to include the anterior scalene muscle. The
lateral border will include the edge of the sternocleidomastoid muscle and junction of the first
rib-clavicle extending medially avoiding the thyroid and trachea. Figure 7 demonstrates the field
borders determined clinically by the physician for this case.
Figure 7: Field borders for supraclavicular fields on case study image set with CTV outline.

The RTOG also provides recommendations for contouring the internal mammary nodes
(IMNs) such that the cranial border should begin at the superior aspect of the medial first rib
extending inferiorly to the cranial aspect of the fourth rib. Similar to other lymph node regions,
in this case the IMNs are included within the PTV as viewed above in Figure 4.

Treatment Technique

The standard approach for treating a breast or chest wall with lymph nodes is to use a
multifield 3D conformal approach. Multifield breast or chest wall cases utilize a beam split
technique. Meaning the isocenter and corresponding jaw are placed to allow the use of different
field arrangements above and below isocenter while minimizing beam divergence. In order for
the beam split to work properly, the collimator cannot be rotated for any fields. For these cases,
isocenter is placed around the caudal head of the clavicle or the region where the anatomy shifts
from treating the breast or chest wall to the deeper supraclavicular and axillary nodes. The
position of this isocenter can affect lung dose as the supraclavicular fields treat the apex of the
lung. An isocenter that is placed too inferiorly will increase lung dose. See Figure 8, specifically
the sagittal view, which best demonstrates the relationship of the PTV and relative patient
anatomy. This arrangement is best for maintaining target coverage while simultaneously
reducing OAR dose, specifically to the heart and lungs.
Figure 8: Multifield isocenter placement at caudal border of clavicle head as well as where target
volume begins to shift deeper to treat supraclavicular and axillary lymph node chains.

Volumetric Arc Therapy (VMAT) is a type of intensity modulated radiation therapy

(IMRT) that can be used for some chest wall cases, especially those that require full coverage of
the IMNs.4 For this case study; a 3D conformal static IMRT multifield approach was able to
provide therapeutic treatment dose while minimizing dose to the heart and lungs. The static
IMRT portion comes from using a step and shoot field-in-field technique with the multileaf
collimator (MLC) which adjusts the intensity of the dose across the target with each field
segment. This case used two to four segments per treatment field modulating dose to the volume.

Multifield cases treat the supraclavicular region with some sort of angled anterior field
and a posterior, while the breast or chest wall is treated with a pair of oblique tangent fields. The
angle of the fields depends on specific patient anatomy. For the tangents, once a reasonable
medial field is selected the lateral is opposed and adjusted slightly to match the posterior beam
divergence to reduce dose to the heart and lungs. In this case, the fields used were an A15L
(anterior oblique 15° gantry angle), posterior axillary boost (PAB) (straight posterior field at
180° gantry angle), A57L (medial tangent 57° gantry angle), and a P52R (lateral tangent 232°
gantry angle).

The tangent fields to the chest wall were designed using a 0.2 cm margin to the medial
PTV (PTV is a 0.5 cm expansion from CTV per physician) ensuring the MLCs blocked the heart
and maximum amount of lung. Then there was anterior flash with the MLCs and jaw, open 3 cm
past the PTV and then a 0.5 cm margin inferiorly. The superior margin was set to zero at the
match line for the beam split. At my clinical site it is standard to open four MLCs above the
match line to allow for variation in setup. With the addition of the IMNs, the superior portion of
the tangent fields near the match line was wide and exposing a large portion of the right lung. Per
the physician, and to reduce excess lung dose, the MLCs and jaw were brought in blocking a
portion of the superior PTV as seen in Figures 9 and 10. As this case was a post mastectomy
chest wall with a thin PTV, adequate dose was a concern. Therefore, 6 MV beams were used for
both tangent fields along with 0.5 cm bolus for a portion of the treatment.

The supraclavicular fields were designed using a 0.4 cm margin around the PTV for the
superior, medial, and lateral borders. The inferior border was set to zero at the match line.
Similar to the tangent fields, four MLC were open inferior to the match line for setup variability.
The MLC’s were adjusted to block the right humeral head and as much of the thyroid as
possible, without blocking the PTV. In this case, the 15° oblique for the anterior field effectively
moved the treatment field off the cord and esophagus. In some situations, additional blocking
may be required. The posterior field was also effective in avoiding the cord and esophagus for
this case. This field assisted in pulling the dose posteriorly to cover the deeper supraclavicular
nodes. Certain scenarios may benefit from a slight posterior oblique. Another structure that is not
contoured or reported on that physicians will sometimes try to minimize dose to is the trachea. In
most situations, and for this case study, the trachea is in line with the cord, esophagus, and
thyroid and does not require changes to the field. Field shape and their relation to contoured
OARs can be seen in Figures 11 and 12. As the nodal regions are deeper, 10 MV beams were
used for both of the supraclavicular fields.
Figure 9: Medial tangent (A57L)
Figure 10: Lateral tangent (P52R)
Figure 11: Anterior supraclavicular field (A15L)

Figure 12: Posterior supraclavicular field (PAB)

DVH Analysis

A typical prescription at my clinical site for a breast or chest wall case is 90% of the
volume to receive 90% of the prescribed dose. This is at a minimum; if we are able, we try for
95% of the volume to receive 95% of the prescribed dose. Coverage requirements can vary
depending on various factors including stage, tumor grade, positive/negative surgical margins or
lymph nodes, and chemotherapy response.

The plan met the main target objective with 95.6% of the volume receiving 90% of the
prescription dose. In this case, the physician elected to treat the internal mammary,
supraclavicular, and axillary lymph nodes. As a result, these nodal regions did not require full
prescription coverage. Rather 90-95% prescription covering the majority of the supraclavicular
region was clinically acceptable. In the end, 93.4% of the target volume received 95% of the
prescription dose because the nodal regions were contoured together within the PTV and the
patients thin chest wall. Once again, this objective was not the primary goal although we often
times try to achieve it. For this case, the physician approved a slight loss in higher prescription
coverage in favor of decreased dose to the lungs.

Other target objectives included the volume receiving 110% < 1 cc and the volume
receiving 115% < 0.3 cc, both of which were met as the maximum dose was 108.6%. Dose to the
OARs was kept as low as possible thereby meeting all prescribed objectives. For this case, the
dose to the heart and lungs was the main concern. The primary objectives for the lung were the
V20 or volume of lung receiving 20 Gy as increased V20 is associated with symptomatic
pneumonitis.4 The right lung V20 objective was <25% with the plan achieving 21.3%. The total
lung objective was V20 < 15% with the plan achieving 11.1%. The primary objective for the
heart was a mean < 2 Gy, as increased mean dose is associated with radiation induced cardiac
disease.4 The plan achieved a heart mean of 0.78 Gy. Figure 13 displays the final dose volume
histogram (DVH) for the dose received by the PTV and all contoured OAR structures for this
case study.
Figure 13: DVH for right chest wall case study.
Conclusion

The treatment of breast cancer benefits from a multimodality approach often including
chemotherapy, surgery, and radiation therapy. Radiation therapy prescriptions and modalities can
vary. For this case study, the patient was prescribed hypofractionated treatment of 267 cGy per
fraction for 15 fractions totalling 4005 cGy to the PTV. The PTV included the supraclavicular,
internal mammary, and axillary lymph nodes. The patient was simulated in a reproducible
position on a breast board using breath hold to minimize lung and heart dose. Bolus was added to
maintain surface dose along the chest wall for a planned 10 fractions and without bolus for the
last 5 fractions. Treatment technique utilized a multifield static IMRT field-in-field approach to
modulate the dose. Fields included a posterior and anterior oblique covering the supraclavicular
region beam split with opposed tangents for the chest wall. The primary prescription objective
for the target was met as the volume receiving 90% of the prescription was over 90% at 95.6%.
Dose to the OARs was kept as low as possible and thereby met all objectives.
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