Clinical Oncology Assignment

Margaret Koehn
In Partial Fulfillment of DOS 531
University of Wisconsin – La Crosse, Medical Dosimetry Program
Introduction

A 70-year-old female presents with a multifocal invasive ductal carcinoma of the left

breast. Invasive Ductal Carcinoma (IDC) is the most common form of breast cancer, and

accounts for 80 percent of all breast cancers.1 This type of breast cancer occurs when malignant

cells start to grow in the lining of the milk ducts of a breast, and start to grow into the breast

tissue beyond the walls of the duct.1 A diagnosis was given to the patient of her having stage IIIB

cT2N1cM0 IDC. This means that the patient’s tumor is “larger than 20mm, but not larger than

50mm”, and that it has spread to axillary lymph nodes, but has not metastasized elsewhere in the

body.2 In addition, a sample of the patient’s breast cancer cells were analyzed for hormone

receptors. This patient’s cancer was found to be estrogen receptor negative, progesterone

receptor negative, and human epidermal growth factor receptor negative. Being negative for all

three hormone receptors means that this patient’s cancer is not growing because of

overexpression of hormones.

Given these parameters, the patient’s physician decided that she will receive 5000cGy in

25 fractions over the course of five weeks, this is the national standard fractionation for IDC.1

Since the cancer has also spread to the axillary lymph nodes, this fractionation scheme will be

targeted to both the chest wall and lymph nodes. In addition, since this patient’s cancer is located

on the left side of the body, extra caution must be taken to avoid treating the heart. This is done

with respiratory management, or deep inspiration breath hold (DIBH). Information about the

treatment scheme is relayed to the patient at the time of consult since the tumor profiling has

been done ahead of time. After the consult, the patient will be contacted to set up their simulation

scan, which is a computed tomography (CT) scan that is done to set the patient up in the correct

treatment position and get image registration information to plan from.

Simulation

During the patients CT simulation appointment, the patient was set up headfirst supine

with her arms above her head on an angled breast board, the arms are placed above the head so

that we do not treat through the arms when aiming at the breast tissue. The breast board was

angled to 12.5-degrees, this compensates for the slope of the patient’s chest, allowing the chest

wall to be parallel with the collimator. The patient was then instructed to turn her head to the

right, this helps avoid radiation going through the chin since it will be turned away from the

breast that is being treated. For comfort, a knee sponge was put underneath the patients’ knees,

and the standard head rest was adjusted to better fit the patient’s stature. After the patient is

properly set up in treatment position, the physician arrives to place metal wire around the breast

tissue and on top of the patient’s scar. This is done so that the planning team can better delineate

the structures during planning. Finally, the patient is coached to perform DIBH. This is done by

the radiation therapists asking the patient to take in a deep breath and hold it, reminding her that

she will be doing this during treatment daily. After a few practice breaths, the CT scan is

performed while the patient is in DIBH.

Once the scan is complete, the patient is told that she will be contacted by the scheduling

team once her plan is complete, and the CT scan is sent off to dosimetry for contours and

planning.

Treatment Planning

Several normal structures are contoured when planning a left breast treatment. Structures

that are drawn to be avoided are called organs at risk (OARs). Specific OARs that are contoured

for patients that are getting left chest wall and lymph node treatments are the esophagus, heart,
bilateral lungs, and the spinal cord, Table 13 explains the tolerance doses for these structures. If

these tolerance doses were to be exceeded, significant damage could be done to the patient. If the

esophagus dose was exceeded, the patient would likely develop a sore throat, but in extreme

cases could also experience perforation of the esophagus.3 If the heart tolerance was exceeded,

radiation induced inflammation of the heart could occur.3 If the lung dose was exceeded,

radiation induced pneumonitis, or inflammation of the lung parenchyma could occur.3 Finally, if

the spinal cord tolerance dose was exceeded, the patient could experience loss of sensation or

paralysis.3 Several other OARs are considered based on which area of the body is being treated.

With this patient being treated in the thorax, the most important OARs to focus on are the ones

near the tumor volume. The treatment planner will choose beam and collimator angles to best

avoid the OARs. In addition, the dosimetrist will use multi leaf collimation (MLCs) to block

OARs and spare healthy tissue. With all of this in mind, a half beam blocked technique was used,

using tangential fields for the breast tissue and a wedged pair for the lymph node volume.

Planning with conformal modality is sufficient for breast treatments and is considered the

standard. This patient’s physician got insurance authorization for conformal planning technique,

and specified in the prescription that conformal technique is to be used. The use of a half beam

block is extremely helpful in treatment planning when using a conformal technique. Half beam

blocking is where the dosimetrist chooses an isocenter position that is in between both areas to

be treated. When this is done, the dosimetrist can pull the jaws closed on one side of the

isocenter, this prevents overdose to any tissues, and allows for both sites to be treated with one

isocenter. In breast planning, this is called a monoisocentric plan. Figure 2 shows the isocenter

placement for this plan, it was chosen based on the patient’s anatomy, specifically at the level
where her clavicles articulate with the sternum. Placing the isocenter here ensures that the

dosimetrist can treat both the lymph node regions and the breast adequately.

Treating the breast tissue with tangential technique is achieved by having two opposed

beams, where the posterior beam edges are parallel to reduce divergence into the lung space.4

This technique is commonly used for whole breast or chest wall treatments because you can

adequately treat the breast tissue while also sparing the lung. As shown in Figure 3, the gantry

angles chosen were 311 and 133, making the posterior edges of the beams nondivergent into the

lungs. The borders of these tangential fields were chosen to have the superior edge at the level of

isocenter, then include 1cm margin around the tumor volume (which was drawn by the

physician) in the inferior and posterior direction, plus a 2cm margin for the anterior surface of

the breast to account for swelling. The medial jaw must not cross midline, this prevents the dose

from reaching the contralateral breast that is not meant to be treated. Small MLC adjustments

were made to give the beam corner blocks that help spare the lung tissue (Figure 4 and Figure 5).

The tangential fields have an energy of 10MeV, this was chosen because the patient’s separation

is relatively thick, so 10MeV will penetrate deeper than 6MeV would. The collimator was

rotated to 90 degrees for each beam to accommodate a wedge on both fields. The inclusion of a

wedge pushes the high dose areas away from the patient’s surface and more towards the thicker

part of the patient, near the chest wall. Figure 3 shows how the wedges were placed; the medial

tangent has a 20 degree in wedge (with the heel pointed towards the anterior of the patient, as

show in Figure 4), and the lateral tangent has a 20 degree out wedge (with the heel pointed

towards the anterior of the patient, as shown in Figure 5). These two beams provided adequate

coverage of the breast, but the maximum dose to the breast was still relatively high. To remedy

this, two field in fields (FIF) were placed to reduce the higher dose. These FIFs are created by
copying the original tangent and using MLCs to cover areas of high dose. As shown in Figures 6

and 7, the FIFs are significantly smaller than the tangential fields, this allows for the hot spots to

be covered and reduce the overall dose to the breast. The weighting of the plan is significantly

weighted towards the tangential beams, with only a slight weight to the FIFs to cool off the dose.

Because of this slight weighting, the FIFs only deliver 6 monitor units (MU) each, where the

tangential fields deliver 115MU each. This means that the tangential beams have much more

impact on the treatment than the FIFs do, allowing for better target coverage while keeping the

plan cool.

Once the tangential treatment beams are in place, the nodal volumes are planned. The

physician draws which nodal volumes they would like to irradiate, and it is up to the dosimetrist

to properly dose the nodes while avoiding the OARs in the area. For this patient, the physician

asked for the supraclavicular and axillary nodes to be treated on the left side, since that is where

her cancer spread to. Figure 8 shows the lymph node chains that are found in the breast and that

may be treated when a patient has extensive lymph node involvement. Figure 9 shows the

supraclavicular lymph nodes and axillary lymph nodes contoured in this specific patient’s

treatment plan. As stated earlier, this is a monoisocentric plan, so the isocenter location is the

same as it is in the tangential treatment field. As shown in Figure 104, the treatment field to is

shaped to include all the nodal volume, plus half of a centimeter of margin around the structures.

Ideally, when treating these nodes for breast irradiation, the planner should block all the humoral

head with MLCs, which was also done in this plan. A wedged pair technique includes two beam

angles that are obliqued, or off center, which will both have a wedge with the heels pointing

towards each other to even out dose. In this plan, gantry beam angles of 345 and 15 were used to

prevent overexposure of the esophagus and spinal cord, the collimator was turned to 90 degrees
for each beam to accommodate a wedge. Figures 11 and 12 show these angles with MLCs in

place to block OARs and corresponding wedges. Wedges were used on both fields to evenly

spread the 100 percent dose line and push the higher dose laterally to cover the lateral axillary

nodes. A wedge of 20 in (with the heel side towards the patient’s lateral) was used on the right

anterior oblique (RAO) beam, and a steeper wedge of 45 out (with the heel side towards the

patient’s medial) was used on the left anterior oblique (LAO) to push the dose farther towards

the patient’s lateral. This plan remained adequately cool with little to no extreme hot spots,

therefor FIFs were not required, and the plan was deemed complete.

Plan Evaluation

This plan was evaluated by creating a plan sum which combines both plans into one

visual. This makes it easier for the dosimetrist to see all the beam angles and dose shape in one

view. Figure 13 shows the plan sum with all beam angles turned on, the dose profile shows that

the 100 percent line is covering all the prescribed targets, and the OARs are receiving minimal

dose. Once the visual is acceptable, the dosimetrist will create a dose volume histogram (DVH)

to evaluate the plan. A DVH allows the dosimetrist to visualize the OARs and targets and what

dose they are receiving compared to the prescription dose. Figure 14 shows the DVH for this

patient’s plan sum.

The target volumes (CTV_WB_L, CTVn_SCL_L, and CTVn_Ax_L) are receiving

proper coverage as shown by the DVH. 95 percent of the target volume CTV_WB_L (the left

whole breast) is receiving 96.691 percent of the prescribed dose, which is acceptable. 95 percent

of the target volume CTVn_SCL_L (left supraclavicular nodes) is receiving 97.616 percent of

the prescribed dose, which is acceptable. Finally, 95 percent of the target volume CTVn_Ax_L

(left axillary nodes) is receiving 95.966 percent of the prescribed dose, which is acceptable.
 The most important OAR to consider in the treatment of a left breast is the heart. In this

plan, the heart mean dose is 157.7cGy, which is lower than the required mean and therefor

acceptable. The left lung is also considered in the treatment of a left breast. In this patient’s plan,

the constraint was not met on the left lung, this is because the physician requested that in order

for the nodal volumes to receive proper coverage, the lung dose could be exceeded in order for

the jaws to be as open as needed to cover the nodes. In this plan, the left lung volume that

received 2000cGy is 35.632 percent, which is 0.632 percent over the constraint limit. This unmet

constraint was signed off by the dosimetrist and approved by the physician and physics team.

The specific constraints in numerical form is shown in Table 2 with the unmet constraint signed

off on.

Conclusion

Breast cancer is one of the most common cancers and is very regularly treated with

radiation therapy. Since breast cancer commonly spreads to lymph nodes, it is important to

understand how to properly cover both the whole breast or chest wall and the lymph nodes that

are involved. Using a monoisocentric technique with a half beam block is a reliable way to treat

all targets that are prescribed. Using a plan sum with a corresponding DVH will allow the

dosimetrist to evaluate the plan and ensure that all OARs are receiving doses that are acceptable

and will not give the patient adverse effects of radiation.

This patient’s treatment plan was achieved by using a monoisocentric technique with

tangential fields and a wedged pair. All targets were properly covered and all OARs were spared

to the physician’s satisfaction.

Figures Legend
Figure 1. Contoured OARs

Important OARs that are contoured for left breast treatments are the heart, right lung, left lung,

esophagus, and spinal cord.

Figure 2. Isocenter Placement

The isocenter is placed in the middle of the areas to be treated (the lymph node chains and the

whole breast). This ensures that the dosimetrist can cover both sites of disease properly and

allows the use of a half-beam blocked technique.

Figure 3. Tangential Beams

Tangential beam technique is used to treat the whole breast tissue, gantry angles chosen allow for

the posterior edge of the beams to be nondivergent into the lung space, further protecting the

lung tissue.

Figure 4. Medial Tangent Beam’s Eye View

The medial tangent field has a gantry angle of 311 degrees and a collimator angle of 90. This

tangential field also includes a 20 degree in wedge, the heel edge is towards the patients anterior.

Figure 5. Lateral Tangent Beam’s Eye View

The lateral tangent field has a gantry angle of 133 degrees and a collimator angle of 90. This

tangential field also includes a 20 degree out wedge, the heel edge is towards the patients

anterior.
Figure 6. Medial Field-in-Field Beam’s Eye View

The medial FIF is significantly smaller than the medial tangent field, this is to control hot spots.

Figure 7. Lateral Field-in-Field Beam’s Eye View

The lateral FIF is significantly smaller than the lateral tangent field, this is to control hot spots.

Figure 8. Common Lymph Node Chains

The breast tissue includes many lymph node chains that cancer is able to spread to if it goes

unregulated at early stages.

Figure 9. Contoured Lymph Node Chains

The supraclavicular and axillary node chains were contoured by the physician to be included in

the patient’s treatment.

Figure 10. Lymph Node Beam’s Eye View without MLC

The lymph node treatment field was shaped to include both lymph node chains and cover the

humoral head without crossing midline.

Figure 11. RAO Beam’s Eye View

The RAO field has a gantry angle of 345 and a collimator angle of 90. This field also includes a

20 degree in wedge, the heel edge is towards the patients lateral.

Figure 12. LAO Beam’s Eye View

The LAO field has a gantry angle of 15 and a collimator angle of 90. This field also includes a

45 degree out wedge, the heel edge is towards the patients medial.
Figure 13. Plan Sum with Beam Angles

Full plan sum includes all beam angles from both the tangents and wedged pair. The dose

distribution is a good visual for the dosimetrist to see the coverage the targets are receiving.

Figure 14. Full DVH

Labeled DVH with all OAR and targets labeled. The targets are receiving adequate coverage and

the OARs are being spared properly.

Figures

Figure 1. Contoured OARs

Figure 2. Isocenter Placement

Figure 3. Tangential Beams

Figure 4. Medial Tangent Beam’s Eye View

Figure 5. Lateral Tangent Beam’s Eye View

Figure 6. Medial FIF Beam’s Eye View

Figure 7. Lateral FIF Beam’s Eye View

Figure 8. Common Lymph Node Chains

Figure 9. Contoured Lymph Node Chains

Figure 10. Nodal Treatment Beam’s Eye View without MLC

Figure 11. RAO Beam’s Eye View

Figure 12. LAO Beam’s Eye View

Figure 13. Plan Sum with Beam Angles

Figure 14. Final DVH

Tables
Table 1. QUANTEC Organs at Risk with Dose Limits.3
Esophagus Heart
Ipsilateral Contralateral Breast Spinal Cord
Lung
Acceptable V15<50Gy Mean<4Gy V20<35% Mean<8Gy <30Gy
Goal V15<45Gy Mean<2Gy V20<30% Mean<5Gy <20Gy
Limit V15<54Gy >4Gy >35% >8Gy <45Gy

Table 2. Dose Constraints Evaluated with ClearCheck Software

References:

1. Invasive ductal carcinoma (IDC). Invasive Ductal Carcinoma (IDC) | Johns Hopkins

Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/breast-

cancer/invasive-ductal-carcinoma-idc. Published March 21, 2023. Accessed April 29,

2023.

2. Breast cancer - stages. Cancer.Net.

https://www.cancer.net/cancer-types/breast-cancer/stages. Published May 24, 2022.

Accessed April 29, 2023.

3. Thomsen MS, Berg M, Zimmermann S, et al. Dose constraints for whole breast radiation

therapy based on the quality assessment of treatment plans in the randomized Danish

breast cancer group (DBCG) HYPO trial. Clin Transl Radiat Oncol. 2021;28:118-123.

Published 2021 Apr 6. doi:10.1016/j.ctro.2021.03.009

4. Washington CM, Leaver DT, Trad M. Lymphatics in the Breast. In: Principles and

Practice of Radiation Therapy. St. Louis, MO: Elsevier; 2021:551-552.