Breast Cancer with Supraclavicular & Axillary Node Involvement

Cortney Cashner

University of Wisconsin-La Crosse

DOS 531-001

April 24, 2022

Introduction and Diagnosis

Unfortunately, common cancers do not always stay within the organ that they originate from. The longer a cancer goes

undiagnosed the greater the probability for metastatic spread of the disease. One of the most common ways for cancer to

metastasize is through a nearby lymphatic system. When involved lymph nodes are a concern, and radiation therapy (RT) is one of

the treatments of choice, RT can treat both the organ housing the primary disease and the secondary lymphatic system involved.

This limits the chance of metastasis to other sites or recurrence of disease later in the patient’s life. Care and consideration must be

taken by the physician prescribing the dose, the dosimetrist creating the treatment plan, and the therapists delivering the treatment

to affectively kill cancer cells while sparing surrounding organs at risk and limiting adverse side effects the patient may experience.

The following case study details one type of cancer, its associated lymph node involvement, and how the patient was treated

using RT. The disease was first detected when the patient palpated a mass in her right breast. The first test ordered for the patient

was a bilateral mammogram where the abnormal density was found. The following study was a right breast ultrasound (US) that

identified 2 enlarged lymph nodes and thickened parenchyma of the right axilla. The US guided biopsy revealed grade two invasive

ductal carcinoma. This is the most common histology for breast cancer. 1 An MRI, CT, and nuclear medicine bone scan were ordered

to identify any possible metastatic lesions. This is a common work-up step when identifying the stage and advancement of disease.

Breast cancer in young patients is more aggressive, with this patient being only 39 years old, these imaging studies were a very
important step to look for metastasis. These studies found no metastatic disease to other organs and no internal mammillary node

(IMN) involvement, however a second smaller mass in the same breast was identified on the MRI. This patient’s diagnosis for billing

purposes was malignant neoplasm of overlapping sites of the right breast in a female with positive estrogen receptors. The patient

had invasive ductal carcinoma with metaplastic features. The route of treatment started with chemotherapy using an Adriamycin

and Cytoxan combination with a Taxol and Carboplatin combination. Next, the patient had bilateral simple mastectomies with

bilateral tissue expanders. A simple mastectomy means all the breast tissue is removed, and potentially the nipple, areola, and skin

over the breast. The surgery revealed 3 folci of invasive ductal carcinoma and irregular nests of cells showing squamous cell

differentiation, the largest measuring 4.5 cm. The next step for this patient was to receive RT to the right breast, supraclavicular

lymph nodes, and axillary lymph nodes.

Setup and Prescription

Starting her radiation therapy treatment, one of the first steps for the patient is to have a CT, performed in the radiation

oncology department with all the devices and setup positions that will be used for each treatment. For CT simulation, a wingboard

was placed on the CT table. The purpose of the wingboard is to move the arms away from the potential field, particularly the lateral

tangential beam. It also allows the patient to hold onto the handles above their head making the position easier to maintain for the
duration of the treatment. On top of the wingboard is a vaclock bag. When the patient is holding onto the wingboard and

comfortable, air is vacuumed out of the vaclock and simultaneously formed to the unique shape of the patient. The purpose of the

vaclock back is to increase reproducibility of the patient's position for each treatment. For the same purpose, and to provide patient

comfort, a knee sponge is also placed under the patient’s knees. Had we been treating the left breast, a free breathing CT and a

deep-inspiration breath hold (DIBH) CT would have been taken. The purpose of the DIBH CT is to move the heart as far away from

the treatment area as possible. The dosimetrist plans on this CT and the patient performs DIBH for each treatment. However, the

area of concern is the right breast, and the heart is already far enough away from the breast. Therefore, the patient was able to

breathe freely during the CT scan.

Once the scan is complete, the dosimetrist and physician can contour and begin the planning process. For this plan, the

target dose was 200 cGy per fraction for 25 fractions, totaling to 5000 cGy. This is a cumulative dose to the breast planning target

volume (PTV), the axillary lymph nodes, and the supraclavicular (SCV) lymph nodes. With the patient's atypical histology of nests of

squamous cell differentiation and widely negative surgical margins, postmastectomy literature did not directly apply to her case. The

physician used a retrospective study from 2018 that reviewed the effectiveness of RT in patients with metaplastic breast cancer

post-op from a lumpectomy and mastectomy. The study specified patients under 50 years old with pT3-4/N+. 2 Our patient did not

have a pathological T3 tumor, but she did have 3 folci after a full course of chemo, with the largest measuring 4.5cm suggesting had

she had a mastectomy before chemo, the size would have been greater than 5cm. This was the rationale behind delivering
specifically 5000 cGy to the breast, supraclavicular nodes, and axillary nodes.

Planning Preparation and Tolerance Doses

Contours

Several structures were contoured for this plan. Below is a screenshot of each contoured structure on the CT dataset.
Figure 1: All contoured structures on the CT data set.
Figure 2: Contoured structures on axial, sagittal, and coronal views. Emphasized are the PTVS; breast eval, LN supraclavicular, and LN axillary.
Also demonstrated are the density override, expander core, contralateral breast, lungs, esophagus, spinal cord, heart, trachea, and liver
contours.

The only specific avoidance structures that needed to be contoured were the right humeral head and the contralateral

breast. Irradiation of the humeral head leads to shoulder issues, particularly decreased mobility. 3 Irradiation of the contralateral

breast results in a small but significant increased risk of radiation induced malignancy in the contralateral breast. 4 The expander core

of the patient’s right breast expander is metal and was creating some artifact in the breast tissue. I contoured the core and the

expander not as avoidance structures, but simply as structures in the body. Because this is a 3D plan and the expander is centralized

in the breast, avoiding this structure would result in significantly decreased coverage, hence it is not an avoidance structure. I also

contoured the artifact and gave it a density override of 0 Hounsfield units, meaning tissue equivalent. This is important to note

because, had we left the artifact alone, our final dose calculations would have been inaccurate, because the treatment planning

system (TPS) would assume densities close to air were present in the breast.

OAR Tolerances
 Below is a table of the PTV and organs at risk (OAR) constraints. This table is developed from the plan sum of each plan.

Because of the difficulty of treating all three locations we make two plans with the same isocenter. One isocenter for all treated

areas decreases the total treatment time and helps simplify the setup process for both the patient and the therapists. One plan half

beam blocks the nodes and is open to the breast, the second plan half beam blocks the breast and is open to the nodes. The plan

sum of the two plans is created to accurately demonstrate the combination of dose from each plan. This combination of dose is our

target dose, 5000cGy. All of the constraints are from Alliance A011202 and were met, no tolerances were exceeded. The PTV

prescription was adjusted due to the difficulty of the plan. The breast PTV objective was that 95% of the prescription dose reached

95% of the target volume as opposed to a more traditional 95% of prescription dose to 100% of the target volumes. The axillary and

SCV volumes required a range of 90-95% of the individual volumes to receive 95% of the prescription dose.

PTV and OAR Desired Planning Objective Planning Objective Outcome Contraindications of Tolerances

Spinal Cord (Alliance A011202) D0.1cc ≤20% 17.4% meets Myelitis

Esophagus (Alliance A011202) D0.01cc ≤95% 65% meets Esophagitis

Esophagus (Alliance A011202) Mean ≤800cGy 238.9cGy meets Esophagitis

Heart (Alliance A011202) V1500cGy ≤10%% 0% meets Pericarditis

 Heart (Alliance A011202) Mean<400-500cGy 92.5cGy meets Pericarditis
PTV Breast Eval/CW (Alliance Risk of recurrence
V95%>95% 99.6% meets
A011202)

PTV Breast Eval/CW (Alliance Risk of recurrence

D10cc<115-130% 109.0% meets
A011202)

SCL PTV (Alliance A011202) D95%>95-90% 95.8% meets Risk of recurrence

Axillary PTV (Alliance A011202) D95%>95-90% 95.5% meets Risk of recurrence

Ipsilateral Lung (Alliance Basic lung function, pneumonitis

V2000cGy<34-38% 23.5% meets
A011202)
Ipsilateral Lung (Alliance Basic lung function, pneumonitis
V1000cGy<50-60% 31.4% meets
A011202)
Ipsilateral Lung (Alliance Basic lung function, pneumonitis
V500cGy<65-70% 46% meets
A011202)
Contralateral Lung (Alliance Basic lung function, pneumonitis
V500 <10-15% 9% meets
A011202)
Humeral Head (Alliance Tissue stiffening, lack of range of
Max<100% 96.54 meets
A011202) motion
Contralateral Breast (Alliance Risk of recurrence
V300cGy<5-8% 0.7% meets
A011202)
Table 1: All dose constraint objectives for the plan sum of each plan. 5
 PTV and OAR Desired Planning Objective Planning Objective Outcome Contraindications of Tolerances

Heat (QUANTEC) V25<10% 0% meets Pericarditis

Lung (combined lung) Mean <20-23Gy 690 cGy meets Basic lung function,
(QUANTEC) pneumonitis
Lung (combined lung) V20<30-35% 12.4% meets Basic lung function,
(QUANTEC) pneumonitis
Table 2: QUANTEC breast constraints.1
Figure 3: ClearCheck visual of constraints and tolerances all being met. All data is the same as the data in Table 1.

Treatment Ports and Boundaries

Below is a 3D rendering of the PTV and involved lymph nodes which include the axillary and supraclavicular nodes. Also

visible is the right humeral head. The proximity of the humeral head to the axillary lymph nodes demonstrates the need for this

contour and to use MLCs to block this OAR.

Figure 4: 3D rendering of PTVs and the humeral head.

 The following figures represent the beam’s eye view (BEV) of each beam. In Figures 5 and 6, we can see the half-beam block

allowing dose to be delivered primarily to the breast PTV only. Figures 7 and 8 demonstrate where dose will be delivered to the

involved lymph nodes only.

Figure 5: Medial Breast Tangent: half beam blocked to exclude most

Figure 6: Lateral Breast Tangent: half beam blocked to exclude most of
of the nodal regions. Approximately half the axillary node volume is
the nodal regions. Approximately half the axillary node volume is
included in this port.
included in this port.
 Figure 7: LAO SCV Field: half beam blocked to include nodal regions
Figure 8: RPO SCV Field: half beam blocked to include nodal regions and
and exclude breast tissue along with half the axillary node volume.
exclude breast tissue along with half the axillary node volume.

Boundaries

Treatment boundaries are critical in this case, especially considering the beam blocking between the two plans. It is of

utmost importance that the beams are perfectly matched. With overlap, dose would be too great in this region. If there was a gap

between the fields, dose would not be high enough in this region. For the breast tangents, the inferior boarders are approximately 1

cm inferior to the breast PTV. Near the chest wall, the tangent beams’ MLCs block the ipsilateral lung and are tight to the breast PTV,
approximately 0.3 cm. In the opposite direction, there is 2 cm of flash between the anterior portion of the breast PTV and the edge

of the treatment port. Because the breast can swell throughout the treatment process, the flash allows the plan to still be used if

this occurs. The superior boarder of the tangent fields ends at isocenter. However, this is not the boundary of what is being treated

because the combination of these fields and the SCV fields allow dose into this area. On the plan sum, it is obvious that this is not the

boundary of what is being treated. This junction is determined by the dosimetrist when placing isocenter. Isocenter is placed evenly

between the top of the breast PTV and the bottom of the SCV nodes. However, this is not a rigid rule, the goal is to place isocenter

high enough that we can reach the top of the SCV volume, but low enough that we can reach the bottom of the breast PTV without

needing to move isocenter.

For the SCV fields, the inferior boundary is the level of isocenter, matched with the breast tangent beams. The medial

boarder is placed just beyond the medial most point of the SCV nodes, and lateral enough to block the esophagus and spinal cord.

Laterally, the boarder is 1 cm lateral to the lateral most part of the axillary nodes. Additionally, MLCs are blocking the ipsilateral

humeral head. The superior boarders for the SCV fields are 1 cm superior to the superior most point of the SCV contoured structure.

This point coincides with the acromion process of the scapula, which is the superior boarder of the SCV nodes. 1 Below is a slice of the

CT data of the plan sum within external beam that visually represents these boundaries with the location of the beams and isodose

lines.
Figure 9: CT data representing boundaries of fields.
Treatment Technique

The technique used for this plan is 3D, also called conformal. This means the gantry and collimator rotate to the position

determined by the dosimetrist while the beam is off. Once in the desired location, the beam turns on for the required number of

monitor units (MU). Two variations, or dose delivery modifications can occur. One is with segments or control points and the other is

with enhanced dynamic wedges (EDW). With segments, the beam is off, and the gantry and collimator do not move while the MLCs

move to a new desired location determined by the dosimetrist. The dosimetrist determines these positions by figuring out which

MLCs to move and to which location in order to block areas of excessively high dose. If an EDW is used, the gantry and collimator do

not move, but the MLCs move across the field while the beam is on to modulate the beam and simulate a physical wedge without

actually having to place a physical wedge in the path of the beam. This will result in less dose to the patient under the thick end of

the beam or where the EDW starts moving across the path of the beam. The change from segments to EDWs is that while the MLCs

move, the beam is on which results in the desired modulation of dose.

Specific Steps

When planning this type of plan, we start with the medial beam. We find the gantry rotation that most optimally will cover

the breast PTV by matching the divergence of the beam to the shape of the PTV near the chest wall. Then, MLCs are added with
boundaries previously discussed. Using this field to create a parallel opposed beam is an efficient way to make the lateral tangent.

The gantry rotation for the second beam will need to be adjusted slightly to perfectly match the divergence of the medial beam.

Then the MLCs will likely need adjusted to match the new appearance of the shape of the PTV from this new gantry angle. Because

of the shape and size of the patient and her PTV, we needed to duplicate each beam, this time at a higher energy of 15x as opposed

to 6x. The next step was to adjust field weighting until the isodose lines appeared as evenly distributed as possible throughout the

PTV. Then we normalized the plan to a value. This is because the next step is to add control points. In Eclipse, adding control points

while normalized 100% to 95% of the target volume does not remove dose, it simply pushes it over. Normalizing to a value allows

control points to block dose and decrease hot spots without making other areas of the target hot. After doing this step, dose was still

greater than 110% in the hot spots. We were able to clean this up slightly with 30-degree wedges on both 15x beams. This also

benefited the plan by pushing dose toward the isocenter and half-beam block, we were missing coverage here and while the SCV

fields will be overlapping this area, there still would not have been enough dose at this junction.

At this point, we could create the second plan with the SCV fields. Again, the isocenter needs to be the same on this plan as it

was on the original tangential plan. The anterior field needs to be about 15-degrees into an LAO in order to avoid spinal cord and

esophagus. We also need to rotate the collimator in order to add an EDW with the heel towards the medial aspect of the patient.

This is to compensate for the decreased tissue as the breast slopes down toward the sternum. The PA field needs to be about 5
degrees into an RPO to avoid spinal cord and esophagus. Each SCV field has MLCs to block the humeral head and each field is 15x in

order to reach the depth of the axillary nodes. The AP will be weighted slightly more because the nodes are more anteriorly located.

Now a plan sum can be made, this is where segments can be used to bring our overall dose below 5500 cGy. After combining

the two plans, it is important to analyze field weighting and normalization values to make sure coverage is still optimal. This can be

done by going back to the individual plans or done in plan sum. At this point our normalization value was 79% which was chosen

because it allowed ample coverage to begin adding segments. When adding control points, coverage often decreases, therefore the

normalization value should allow greater than 95% of the PTV covered by the 100% isodose line. Because wedges are placed on the

15x beams, the control points are added on the 6x tangent beams and the RPO SCV beam. After using control points to bring overall

dose below 5500 cGy, we must check the coverage on the DVH to make sure we are still getting 100% of dose to 95% of the breast

target volume. The plan was slightly cool, with 100% of dose to 93% of the breast target volume. However, these plans are difficult

and after discussing with the physician, the prescription was adjusted to 95% of dose to 95% of each target volume (breast, SCV, and

axillary). This plan met these goals and the physician was satisfied with the total dose to each target volume.
Table 2: Demonstrates specific setup information of the plan sum including kV setup fields.
Figure 10: Wedge orientation and field boarders demonstrated in the axial, sagittal, and coronal fields with a BEV of the medial beam for the
breast tangents.
Figure 11: Wedge orientation and field boarders demonstrated in the axial, sagittal, and coronal fields with a BEV of the anterior beam for the
SCV fields.
Results
Figure 12: Final plan sum DVH.

It is common for these types of plans to require adjustment of the prescription from 100 to 95, to 95 to 95. Meeting this

constraint while minimizing the hot spot was the most difficult part of this plan. In this case, we did require an adjustment to the

prescription in order to create an acceptable plan. The adjustment was minimal, and the target volumes are still receiving adequate

dose while OARs are below tolerances, therefore this is a good plan. The physician expressed appreciation for the time and care we

took with this plan and the ability to get appropriate coverage while minimizing OAR doses. This patient is relatively young to have

breast cancer and to require radiation therapy. It was extra important to keep her OAR doses low, particularly the contralateral

breast. She has more life to live and therefore a greater chance of developing malignancy in the left breast due to the radiation she

is receiving for the disease in her right breast. The OAR with the highest dose was the trachea, this makes sense because in some

slices, the patient’s trachea was to the right of the spine and directly in the path of the beam. While this was not an OAR that had

associated tolerances, a recent Timmerman report indicates tolerance is a volume max of 58 Gy, which this plan meets. 6 Both the

right humeral head and lung constraints were met, protecting these organs was possible through shielding them with our MLCs. The

rest of the OAR were far enough away from the primary beam that their doses are appreciably low.
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