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Clinical Oncology Assignment

Keegan Sanborn
UWL Medical Dosimetry
April 24, 2022
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Introduction:
This patient is a 40 year old female who was diagnosed with clinical T2N1M0 stage IIA
invasive ductal carcinoma (IDC) of the left breast. A diagnostic mammogram showed a clinical T
size of 4.4cm. A biopsy revealed a grade 2 ER/PR positive HER2 negative carcinoma, with
positive lymphovascular space invasion (+LVSI). The patient underwent neoadjuvant
chemotherapy before a scheduled surgery. A lumpectomy was attempted, but unsuccessful
which led to a full mastectomy with a sentinel lymph node biopsy (SLNB). Residual T size was at
least 2.2cm, with another focus of 2cm, 5% cellularity, and 2 of 5 nodes with isolated tumor
cells (ITC). The plan will be radiation therapy followed by anti-endocrine therapy.

Simulation:
The patient was positioned on a CQUAL breast board with no elevation, with a butt
stopper in place to prevent sliding. A red headrest was used to offer the most comfortable
position for the patient, along with a knee bolster to take tension off the lower back. The
patient’s feet were also banded together to ensure proper alignment and reproducibility. The
patient’s arms were positioned above her head in a comfortable position, which was held in
place by an arm vac fix to ensure proper realignment for treatment. This position is preferred
for breast treatments to avoid treating through the arms. A chin strap was used to elevate the
chin away from the treatment fields because of supraclav/PAB field irradiation. The breast
board will be indexed at F1 on the treatment machine, and the therapists will check that the
CQUAL laser is aligned with the 22 mark on the board as a double check for correct patient
position. Two scans were taken in the CT simulation, one with the patient free breathing and
another with deep inspiration breath hold (DIBH) to increase the space between the heart and
chest wall. DIBH was chosen because the left breast is being irradiated, which is closer to the
heart.
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Dose and Fractionation Regimen:

The total dose fractionation regimen chosen for this patient was 50Gy in 25fx delivered
to the chestwall and lymph nodes. There is large debate in the radiation oncology field
regarding the best approach to treating breast cancer patients. Data has been investigated to
better understand how hypofractionated treatments affect the overall survival and normal
tissue toxicity for breast patients. For decades, conventional radiation doses ranged from 50 to
50.4Gy, given in 25–28 fractions over a course of 5–6 weeks. 1 This schedule assumed that 50Gy
would offer the best tumor control, while limiting dose to neighboring critical structures. New
ASTRO guidelines now recommend hypofractionated whole breast irradiation for most cases.
This would include a fractionated regimen of 4256cGy delivered in 16fx. 2 In discussion with the
physician, he stated that it wouldn’t come as a surprise if all breast treatments used the
hypofractionated regimen in the near future. Research has shown that hypofractionated doses
are safe and effective in treating breasts, along with treatments which require lymphatics to be
included. The physician decided on 50Gy in 25fx for this case because the patient received a
mastectomy. He said that there isn’t concrete evidence that shows hypofractionated regimens
can effectively treat the chest wall, so he felt more comfortable with conventional
fractionation. Additional research is being conducted each month to find the best way to treat
breast cancer, which means radiation oncology staff should be ready for inevitable changes.

Organs at Risk and Target Volumes:

There was a large list of contoured structures for this breast treatment plan. Dose
constraints were placed on more important critical structures including the lungs, heart,
brachial plexus, and spinal cord. The dosimetrist’s objective was to provide adequate dose
coverage to the chestwall and three lymph node groups, while trying to limit dose to
surrounding organs at risk. The physician provided a wishlist that explained what DVH statistics
the dosimetrist could work towards or use to evaluate the plan.
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Figure 1: Contoured Structures

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Figure 2: Breast Irradiation Wishlist Provided by Physician

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Figure 3: QUANTEC Dose Constraints for OARs Near Breast 4

If any of these dose constraints were exceeded, complications could arise. If the heart
receives dose higher than recommended, it will increase the risk of pericarditis or long-term
cardiac mortality.4 The lung constraints are low and can sometimes be hard to achieve
depending on the size of the breast and how much lung is having to be treated through. If the
recommended dose constraint is not met, it would increase the risk of pneumonitis. If the
brachial plexus max dose is exceeded, it can lead to a greater risk of clinically apparent nerve
damage.4 The spinal cord is a very important critical structure and will lead to myelitis necrosis
if the constraints aren’t met. If large doses are given to the esophagus, the patient could
experience severe sore throat, trouble swallowing or even stricture or perforation. 4

Lymph Node Regions:

The supraclavicular, axillary and internal mammary lymph nodes are contoured for this
plan and are considered target volumes. Supraclavicular lymph nodes are located superior to
the clavicle. Internal mammary lymph nodes are located inside the chest around the sternum.
Axillary lymph nodes are divided into 3 levels based on how close they are to the large muscle
of the chest, the pectoralis major.3 Level 1 nodes are located along the outer border of the
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pectoralis minor. Level 2 nodes are beneath the pectoralis minor and level 3 nodes are located
along the inner border of the pectoralis minor. The spread of cancer usually starts in the level 1
nodes and moves to the level 2 and 3 nodes after.3 The supraclavicular lymph nodes are treated
with the supraclav/PAB fields to ensure proper coverage. The axillary nodes are treated with by
both tangent fields and the supraclav/PAB fields because of the odd shape they present in the
body. The internal mammary lymph nodes are treated with the tangent fields or an additional
internal mammary field that abuts the tangential fields.

Figure 4: Contoured Lymph Nodes

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Anatomical Boundaries:
For tangent fields, the medial border goes to the midline while the lateral border is
roughly the mid-axillary line or 2cm beyond all breast tissue. The inferior border is 1.5cm below
the inframammary fold. The superior border abuts the inferior border of the supraclav/PAB
fields and is located around the first intercostal space.5

The supraclav field has a medial border around the edge of the spinal cord while still
including the lymph nodes. The superior border extends laterally across the neck to include the
supraclavicular fossa. The lateral border blocks out the humeral head. As mentioned prior, the
inferior border of the supraclav field abuts the superior border of the tangent fields. The PAB
field has a superior border that bisects the clavicle and humeral head. The medial border needs
to include the axillary nodes. The lateral border goes to roughly the latissimus dorsi muscle and
the inferior border abuts the superior border of the tangent fields.5

These are by the book anatomical guidelines, which may change based on anatomy and
coverage of targets in the treatment plan.

Figure 5: Supraclav Field

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Figure 6: PAB Field

Figure 7: Tangent Field

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Treatment Technique:
This breast plan was designed using a monoisocentric technique. The dosimetrist
wanted to place the isocenter in an area around the 1st intercostal interspace but took note of
how much inhomogeneous lung tissue would play a part in each field if the isocenter was
placed too low. The plan was split into two separate prescriptions, each to 50Gy in 25fx. The
supraclav and PAB fields were in one prescription. Due to the half-beam block technique seen
in monoisocentric breast plans, a calc point was created specifically for these two beams. The
calc point was centrally located in the fields, and positioned a little more anterior, because
that’s where most of the lymph nodes are situated. Both fields used high energy, 15x, which
helps cool off the plan and provide adequate coverage to deeply situated axillary nodes. The
beams were weighted 60/40 in favor of the supraclav to make the plan cooler and more
conformal to the anteriorly situated targets. Both fields were rotated 15 degrees to decrease
dose to the spinal cord and esophagus. A wedge was used on the PAB field to push dose more
lateral, where we were missing coverage.

The other prescription acted as a normal breast tangential plan. A calc point was created
for this plan because of the half beam block technique, and was placed posterior to the
chestwall contour, helping push dose to the thickest part of the breast. MLCs were used to
follow the chestwall contour and limit dose to the lung and heart. 6x and 15x energies were
used to cool off the plan and provide a more homogenous dose distribution. The weighting for
each beam was altered based on which side of the breast was receiving too much or too little
dose. Wedges were unable to be used for this part of the plan because the field length
exceeded the limit for wedges to be effectively used. Field in fields were used from both
tangent angles to chase hot spots and help meet the max dose constraint provided by the
doctor. Axillary node PTV coverage was severely lacking due to a cold spot generated from the
monoisocentric match line. The dosimetrist attempted to scale the plan as well as change the
weighting for each beam, but nothing was working. He proposed doing something uncommon,
which was added two new high energy beams that were shaped just to cover the area that
wasn’t receiving any dose. These two beams wouldn’t take weight away from the other beams,
which would have hurt coverage elsewhere, but instead allowed him to manually input Mus to
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increase coverage to the axillary nodes. He mentioned that technically, the patient would be
getting more than prescribed dose, but this was acceptable because these new fields weren’t
increased OAR dose or the max dose, they were simply increasing the heat in an area that had
no coverage.

Figure 8: Field Arrangement

Figure 9: SCLV and PAB Field Labels

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Figure 10: SCLV Field

Figure 11: PAB Field

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Figure 12: Tangent Field Labels

Figure 13: Tangent Field

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Figure 14: Tangent Field in Field

Figure 15: Extra MU Field

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DVH Analysis:
Figure 16: DVH Summary

Figure 17: DVH Statistics

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When looking at the figure, you can see that any numbers in red font indicate a
constraint that was not met. Green font numbers indicate that the ideal constraint was met,
even though there was also an acceptable limit that was added in case the dosimetrist needed
it. The physician approved the plan, even when not meeting all the constraints because of the
increased difficulty of the plan. The desired coverage, nor max dose was met for the
chestwall_eval structure that was contoured by the physician. Due to the patient having
expanders in and the breast being rather large, conformality was difficult to achieve. The
planning dosimetrist was struggling to get proper coverage to the breast, as well as the three
lymph node chains that were contoured. The dosimetrist decided to find a middle ground
between these two constraints, because if coverage was increased, so would the max dose and
vice versa.

The right chestwall constraint was also not met by less than half a percent. Dose that is
deposited to the contralateral chestwall mainly comes from scatter and is situated on the
superficial portion of the contour. This is of little concern to the physician and does not require
any plan modification to meet the objective. The constraint that seemed to be the most difficult
to achieve was for the axillary nodes. The way the plan was designed, there was a cold spot
situated near the match line between the tangent and supraclav fields. This cold spot was
positioned along a few slices of the axillary nodes contour, which really hurt the coverage of the
plan. There was nothing to be done to increase the target coverage without blowing the plan
up or drastically increasing the hot spots. As discussed, the dosimetrist created two beams that
were intended to increase dose to the axillary nodes without hurting coverage in other areas of
the plan. This isn’t a technique that is commonly used and should only be used in situations
where no other solution is available. Overall, not every objective was met, and this was
explained to the physician who approved the plan anyway based on their knowledge of patient
history and disease progression.
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Conclusion:
A four-field breast plan using a single isocenter is a common way to treat a breast with
lymph nodes. Mixed energies, wedges and field in fields are techniques that can be used to
decrease hot spots, increase coverage, and allow the plan to meet every dose constraint. In
discussion with the physician, it was noted that this was a rather difficult treatment to plan. The
physician was fine with the DVH numbers, and was focused on covering areas of concern, while
making sure to limit dose that could possibly lead to side effects in the future. This was a great
plan to observe because breast cancer is incredibly common and should be a site that any
dosimetrist can generate a plan for when asked.
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References

1. Marta GN, Coles C, Kaidar-Person O, et al. The use of moderately hypofractionated post-
operative radiation therapy for breast cancer in clinical practice: A critical review.
Critical Reviews in Oncology/Hematology. 2020;156:103090.
https://doi:10.1016/j.critrevonc.2020.103090

2. Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: Executive
summary of an american society for radiation oncology (astro) evidence-based
guideline. Practical Radiation Oncology. 2018;8(3):145-152.
https://doi:10.1016/j.prro.2018.01.012
3. Radiation Oncology/Toxicity/QUANTEC. Wikibooks.
https://en.wikibooks.org/wiki/Radiation_Oncology/Toxicity/QUANTEC. Accessed April
20, 2022.

4. Lee S. What is breast cancer? Canadian Cancer Society. https://cancer.ca/en/cancer-

information/cancer-types/breast/what-is-breast-cancer/the-breasts. Published 2022.
Accessed April 20, 2022.

5. Vann AM, Dasher BG, Wiggers N, Chestnut S. Breast Cancer. In: Portal Design in
Radiation Therapy. Augusta, GA: Phoenix Printing.; 2013:65-77.