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Effects of target volume coverage in superficial medial and lateral breast tissue using
flattening filter free beams: a case study

Authors: Sunhee Lee, Simran Rai, Janice Chuang, Ashley Hunzeker, MS, CMD, Nishele
Lenards, Matt Tobler, RT (T), CMD, FAAMD Commented [MT1]: Please add all titles to Authors.

Affiliation: I would like to thank the Statistical Consulting Center at UW-La Crosse for its
assistance with statistical data for this paper; however, any errors of fact or interpretation remain
the sole responsibility of the author. Commented [AH2]: This is not an affiliation, this is an
acknoldgement and should be placed at the end of the
manuscript. Review the sample outline provided to you to
I. Abstract review what you should put for the affiliation.
II. Introduction
a. PI: The role of radiotherapy in breast conserving therapy and its benefits
(Reference: Wrubel et al1)
b. PII: The problems that arise for the treatment planner when tangential separation
increases
i. The need for homogenous breast treatment. How hot spots in breast
treatment reduces overall cosmesis (Reference: Vargas et al2)
ii. The difficulty of minimizing hot spots when tangential separation
increases (Reference: Gustafson et al3)
iii. The loss of dose near the surface when mixed energies are used
iv. How mixed energies cannot perfectly solve the problem because although
they minimize hot spots dose near the surface is also lost due to the skin
sparing effect (Reference: Lief et al4)
c. PIII: The need for increased surface dose of the breast tissue
i. Many physicians include nearly the whole breast when delineating their
target volumes despite the typical breast evaluation structure excluding
some of this structure. (Reference: Li et al5)
ii. Medial and lateral superficial lumpectomy beds also create the need for
greater dose near the surface of the breast since the surgical cavity is the
most common area of recurrence.
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d. PIV: Introduce the benefits of flattening filter free beams and how they can
increase dose for medial and lateral breast tissue (Reference: Kragl et al6, Commented [AH3]: Review order of , and superscript
7
Takakura et al )
i. Increased dose at surface
ii. Decreased depth of Dmax
iii. How flattening filter free beams can provide advantages over mixed
energy including faster planning times and treatment times.
e. PV: Summary of introduction
i. Problem: The problem is that these higher energies can lead to a loss of
peripheral dose in the outer region of breast tissue which is of concern for
patients with a medial or lateral lumpectomy cavity when receiving whole
breast radiation.
ii. Purpose: The purpose of this study is to determine if 10MV Flattening
Filter Free (FFF) beams can increase peripheral dose coverage in outer
region of breast tissue and the lumpectomy cavity compared to mixed
energy treatment techniques for patient receiving whole breast irradiation.
iii. Hypothesis: The first research hypothesis is that FFF beams for breast
radiotherapy will increase the volume of the whole breast receiving 95%
of the prescription dose. The corresponding null hypothesis is that FFF
beams for breast radiotherapy will not increase the volume of the whole
breast receiving 95% of the prescription dose. The second research
hypothesis is that FFF beams for breast radiotherapy will increase
minimum cavity dose by 5%. The corresponding null hypothesis is that
FFF beams for breast radiotherapy will not increase minimum cavity dose
by 5%.
III. Case Description
a. Patient Selection
i. PI: Inclusion criteria
1. Retrospective
2. Patients receiving whole breast radiation supine
3. Intact Breasts
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4. Patients with tangential separation greater than 21 cm (Table 1)

5. Patients with a surgical cavity less than 1 cm from the surface
ii. PII: Simulation procedures
b. Target Delineation
i. Targets include whole breast and cavity
1. Both drawn by physician
c. Treatment Planning
i. PI: Planning methods
1. Use of EZ fluence and electronic compensators
ii. PII: Planning details (Table 1)
1. Mixed energy weighting used in each plan
2. Plan normalization of 95 of prescription dose covering 95 of breast
PTV.
3. Constraints used (Table 2)
d. Plan Analysis and Evaluation
i. PI: Breast analysis metrics (V95 of breast and minimum cavity dose)
1. 7 patient cases
2. Mean cavity volume of 20.2 cubic centimeters (cc)
3. Figure 1. example cavity location for patient 1
4. Figure 2. Example DVH for patient 1
5. Statistics: Two tailed t-test and 95 confidence interval for both
metrics
a. P<0.05 for null hypothesis to be rejected
ii. PII: V95 of breast tissue results (table 1.)
1. Mixed energy provided greater coverage in all cases
a. 95% Confidence interval = between 4.0864% and
1.6565%. greater coverage for mixed energy
b. P<.001
i. Null hypothesis H10 failed to be rejected
ii. Mixed energy provides significantly greater
coverage
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iii. PIII: Minimum cavity dose results (table 1.)

1. Comparable between FFF and mixed energy
a. FFF provided greater coverage in 4 of 7 cases
b. 95% confidence interval = -2.8 and 1.32 for difference
between FFF and mixed energy
c. P=.207
i. Null hypothesis H20 failed to be rejected
iv. PIV: Maximum dose Results
1. Greater for FFF in all 7 plans
a. P=.0107 Commented [AH4]: You shouldn’t have a P value for this,
it wasn’t a hypothesis. It’s ok to mention “other” things that
v. PV: Summary of results were found but should have statistical interpretation.

1. Mixed energy had a statistically significant increase in V95 of

breast tissue
2. No statistical difference in minimum cavity dose
a. FFF may provide similar superficial cavity coverage to
mixed energy
3. Mixed energy plans possessed significantly lower maximum dose
4. Monoenergetic FFF plans are limited in target coverage compared
to mixed energy beams
IV. Conclusion Commented [AH5]: Was there a positive trend for either
hypothesis with FFF planning, even if it didn’t reach
a. PI: Summarize purpose of study significance?

b. PII: Summarize results

c. PIII: Possible limitations
i. All patient contours were from the same physician
ii. Small sample size and all patients came from a single clinic
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References

1. Wrubel E., Natwick, R., Wright, P.G. Breast conserving therapy is associated with
improved survival compared with mastectomy for early-stage breast cancer: A propensity
score matched comparison using the national cancer database. J Ann Surg
Oncol;2020;28(2): 914–919. https://doi.org/10.1245/s10434-020-08829-4
2. Vargas L, Solé S, Solé CV. Cosmesis after early stage breast cancer treatment with
surgery and radiation therapy: experience of patients treated in a Chilean radiotherapy
center. Ecancermedicalscience. 2018;12(1):819-826.
https://doi.org/10.3332/ecancer.2018.819
3. Gustafson NR, Burrier T, Butler B, Hunzeker A, Lenards N, Culp L. Correlation of hot
spot to breast separation in patients treated with postlumpectomy tangent 3D-CRT using
field-in-field technique and mixed photon energies. Med Dosim.2020;45(2):134-139.
https://doi.org/10.1016/j.meddos.2019.08.004
4. Lief EP, Hunt MA, Hong LX, Amols HI. Radiation therapy of large intact breasts using a
beam spoiler or photons with mixed energies. J Med Dosim. 2007;32(4):246- 253.
https://doi.org/253.10.1016/j.meddos.2007.02.002
5. Li XA, Tai A, Arthur DW, et al. Variability of target and normal structure delineation for
breast cancer radiotherapy: an RTOG multi-Institutional and multiobserver study. Int J
Radiat Oncol Biol Phys. 2009;73(3):944-951.
https://doi.org/10.1016/j.ijrobp.2008.10.034
6. Kragl G, Wetterstedt S, Knäusl B, et al. Dosimetric characteristics of 6 and 10MV
unflattened photon beams. Radiotherapy oncol. 2009;93(1):141-146.
https://doi.org/10.1016/j.radonc.2009.06.008
7. Takakura T, Koubuchi S, Uehara A, et al. Evaluation of beam-on time and number of
breath-holds using a flattening-filter-free beam with the deep inspiration breath-hold
method in left-sided breast cancer. J Med Dosim. 2020;45(4):359-362.
https://doi.org/10.1016/j.meddos2020.05.002
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Figures

Figure 1. Axial view of patient 1 shows the location of the cCavity (red) and lLeft bBreast
evaluation (orange).

Figure 2. Frontal view of patient 1 shows the location of the cCavity (red), lLeft bBreast
evaluation (orange), and hHeart (pink).
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Figure 3. Dose volume histogram (DVH) comparisons for the PTV cavity (blue), lLeft bBreast
evaluation (orange), lLeft lLung (green), hHeart (pink) FFF(square markers) and mixed energy
(triangle markers) plans for patient 1.
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Tables
Table 1. Measured results comparing 10FFF and mixed energy.
Patient Mixed Energy
Separation Breast V47.5 Weighting
Cavitymin (%)
(cm) (%) (6MVx:10MVx)
(%)
Mixed 22 91.4 92.1 45.5:54.5
FFF 22 89 92.2
Mixed 22.3 95.2 95.4 49.2:50.8
FFF 22.3 90.2 90.7
Mixed 26.1 89.4 95.7 55.5:44.5
FFF 26.1 88.3 95.0
Mixed 24.5 91.6 94.3 57.8:42.2
FFF 24.5 87.5 93.9
Mixed 21 93.7 86.5 53.8:46.2
FFF 21 90.6 84.6
Mixed 25.8 92.8 94.7 49.4:50.6
FFF 25.8 90.6 97.3
Mixed 22.7 91 91.9 46.5:53.5
FFF 22.7 88.8 91.9
*FFF (Flattening Filter Free); Breast Tissue covered by 95% prescribed dose of 47.5Gy (Breast V47.5); Mixed energy 6 MVx and 10MVx
(Mixed); Minimum cavity dose (Cavitymin); Mixed Energy Weighting ratio of 6MV to 10MV ratio in percentage

Table 2. Physician specified dose constraints for OAR evaluation.

Structures Constraints
Heart (left breast) Mean < 3.0 Gy
Heart (right breast) Mean < 1.0 Gy
LAD Maximum < 3.0 Gy
Ipsilateral Lung V20 < 30%
*Organs at risk (OAR); Volume of lung receiving 20 Gy (V20); LAD