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Clinical Oncology Assignment

Introduction and Diagnosis:

A 79-year-old woman with stage IIA (pT2(m) N1a Mx) of the right breast upper outer
quadrant grade 2 invasive ductal carcinoma. She is Her2neu negative status post lumpectomy
and axillary lymph node dissection with estrogen receptor 95% and progesterone receptor 95%.
Her pathology showed a 2.8cm multifocal tumor with lymphovascular invasion that was resected
with negative margins. This patient also has extensive extranodal extension in 3 out of 13
involved nodes. She is undergoing adjuvant radiation therapy.

Simulation:

The patient was positioned supine on a breast immobilization board with her arms held
over her head. The immobilization board that she laid on every day for treatment had an incline
angle of 10 degrees. The tilt of the immobilization board helps isolate the breast tissue below the
clavicle.1 One accessory used was a ring to keep her arms a consistent width apart and stable.
Other devices used were a knee cushion and head rest for patient comfort. Due to precise
radiation delivery, it is extremely important that the patient is simulated in a comfortable and
reproducible position.
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Figure 1 Immobilization
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Fractionation Regimen:

This patient’s course of radiation is hypofractionated and planned for 20 fractions. The
target dose defined by the physician is 2.66 Gy delivered in 16 fractions for a total of 42.54 Gy.
After the initial 16 fractions are delivered the patient will receive an additional boost of 2.50 Gy
delivered in 4 fractions to the tumor bed. A standard treatment fractionation schedule for breast
is 45 to 50 Gy in 25 to 28 fractions at 1.8 to 2 Gy but hypofractionated radiotherapy has
demonstrated noninferiority.1 The physician took into account her age and ability to tolerate a
long course of treatment and decided that a shorter course would be best for the patient.
Hypofractionation has been shown to yield lower rates of acute toxic effects as well as less
fatigue and less trouble meeting family needs 6 months after completing radiation therapy
compared to conventional fractionation.2

Organs at Risk:

The specific avoidance structures that were contoured were the heart, liver, right lung,
spinal cord, and the left anterior descending artery (LAD). The trachea was contoured as well but
did not have a constraint specified by the physician. The whole breast (Breast PTV) and the
surgical bed (PTVsb) were the targets.

Figure 2 Organs at Risk

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Figure 3 Physician OAR Tolerance Doses

Organ at Risk (OAR) Normal Tissue Tolerance for Planning Result

Standard Fractionation1
Heart Dmean (Gy) < 26 0.72 GY
Liver Dmean (Gy) <30 4.28 Gy
Right Lung V20<31% 28.23%
Spinal Cord Dmax (Gy) 50 2.41 Gy

Lymph Node Regions:

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For this plan multiple lymph node regions were targeted which include the
supraclavicular, axillary levels I, II, III, and internal mammary nodes.

Figure 4 Supraclavicular Treatment Field

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Figure 5 Medial Treatment Field

Figure 6 Lateral Treatment Field

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Figure 7 Posterior Axillary Boost Field

Anatomical Boundaries:

During the simulation process the physician places radiopaque markers to outline
boundaries of the treatment fields. The superior breast limit is located just below the clavicle to
include all visible breast tissue. The inferior breast limit is located below the inframammary
crease or breast tissue with a margin of 1.5 centimeters. The medial breast boundary is located
midline on the patient along the sternum. The lateral limit is midaxillary to include all breast
tissue with a 1.5 centimeter margin. These anatomical boundaries are guidelines and after the
computed tomography data set is contoured, they might need to be altered to accommodate
physician target structures and organs at risk. For this case the physician contoured nodal regions
and the treatment fields were shaped around them.
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Figure 8 Field Boundaries

Figure 9 Supraclavicular Nodal MLC Block

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Radiation Treatment Technique:

The technique used to treat this case was a mono isocentric plan with 4 treatment fields. The
fields used were a supraclavicular (SCLAV), medial (MED), lateral (LAT) and posterior axillary
boost (PAB) field. All fields had 6x energy expect the SCLAV used 16x because the physician
wanted to reduce superficial hot spots and provide dose deeper in the patient. The isocenter was
placed approximately at the level of the sternoclavicular joint between the 1st and 2nd rib. The
isocenter is used in this location to create a half beam blocked match-line between the
SCLAV/PAB and the MED/LAT fields. All treatment fields have a collimator angle of 0 degrees
to maintain a perfect match-line. The SCLAV field was shaped around the contoured nodal
regions at a gantry angle of 10 degrees to stay off the trachea and spinal cord of the patient.
Consideration was taken to use the multileaf collimator (MLC) to follow along the vertebral
bodies and block the humeral head. The MED and LAT fields used a tangential technique and
were fit to the radiopaque markers as discussed in the anatomical boundaries section and shown
in figure 8. The MED field had a gantry angle of 56 degrees and the lateral 234 degrees. The
initial dose distribution had significant hot spots in the tangential fields, but they were reduced
using field in field technique. The hot spots were displayed in the beam’s eye view (BEV) of the
fields and systematically blocked with each additional field segment. It is important to reduce the
hot spots as much as possible while maintaining therapeutic coverage of the PTV’s in a plan. The
PAB gantry angle was 180E degrees which rotates down the right side of the patient instead of
180 degrees which would rotate down on the left side. This is done for clearance reasons because
if it was 180 degrees, the therapist would have to enter the room and move the treatment table
out of the way. The SCLAV field did not adequately cover the nodal regions with enough dose
due to their depth, so the PAB was added.
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Figure 10 Isocenter

Figure 11 SCLAV Field

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Figure 12 MED and LAT Tangential Fields

Figure 13 MED Field MLC Block Figure 14 LAT Field MLC Block
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Figure 15 Isodose Lines

Figure 16 Before Field in Field Example

Figure 17 After Field in Field Example

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Figure 18 PAB & SCLAV Dose

Plan Dose Volume Histogram:

All the organs at risk tolerances doses were met and all the target volume received the objective
outcomes except internal mammary nodes, and PTVsb. Even though the goal of D90%[%] ≥ 90
was 84.02% the physician acceptable amount is >80%. Also, after reviewing the plan it was
determined by the physician that the PTVsb was adequately covered.

Figure 19 Final DVH

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Figure 20 Target Goals

Conclusion:

The physician ultimately thought this was a great plan and it was sent to the physics staff for a
final quality assurance check before being administered to the patient. This project allowed me to
research and understand in greater detail what is involved in the decision making of a
prescription and the planning process of medical dosimetry. I learned a lot from this assignment
and am currently learning how to plan the boost portion of the prescription.
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References

1. Khan FM, Gibbons JP, Sperduto PW. Treatment Planning in Radiation Oncology.

Philadelphia i pozostałe: Wolters Kluwer; 2016.
2. Shaitelman SF, Schlembach PJ, Arzu I, et al. Acute and Short-term Toxic Effects of
Conventionally Fractionated vs Hypofractionated Whole-Breast Irradiation: A

Randomized Clinical Trial. JAMA Oncol. 2015;1(7):931-941.

doi:10.1001/jamaoncol.2015.2666