Clinical Oncology Assignment

Amanda Tabar

Introduction
The diagnosis of the patient I chose to discuss is primary left breast cancer with

infiltrating ductal carcinoma; involving the whole left breast, IMN, left axilla and SCF. This plan

is post-op curative with a prescription of 5,000cGy and included a 1,000cGy tumor bed boost.

The relevant treatment plan information can be seen on the clinical treatment plan created by the

Physician in the image below.

The patient was positioned for simulation in a supine head-first position; with both arms

overhead, chin to the right, straight legs supported with a wedge and on a flat breast board
immobilizer. All of this information was available on the Simulation Note, shown below, along

with attached images of the patient’s position and BB wire locations.

Plan Parameters
The target dose set by the Physician was a dose of 200cGy per fx, at 25 fx a day, equaling

a total dose to the left whole breast and IMN of 5,000cGy. The dose for the left axilla/SCF was

identical at 5,000cGy. The dose for the tumor bed boost was a dose of 200cGy per fx, at 5 fx a

day, for a total dose of 1,000cGy and a cumulative dose of 6,000cGy. The specific radiation dose
and fractionation schedule are determined by a variety of factors, including the size and location

of the tumor, the patient’s age and overall health, and the type of therapy being utilized. In this

instance, the clinical treatment intent coincides with the American Society for Radiation

Oncology guidelines, noting that the recommended dosage to patients with early-stage breast

cancer is 50Gy in 25 fractions of 2Gy.1 This also rings true in the article NCCN Clinical Practice

Guidelines in Oncology: Breast Cancer; where the recommended total dose is 4500-5000 cGy

delivered in 22-25 fractions of 180-200cGy.2

The avoidance structures that were contoured was the lungs, both contralateral and

ipsilateral, the heart, the humeral heads, the spinal canal, the esophagus, and the trachea. Below

is a screenshot of the contouring tab in Eclipse, demonstrating both the OAR and target contours.

The OAR tolerance doses based on the Physician prescription can be viewed on the

completed “4 field intact breast” dose tolerance table used by my clinic, INOVA. As is visible on
the below tables, all OAR dose constraints were met in the initial plan and the associated

QUANTEC values are also displayed.

 No tolerances were exceeded in this plan, however there are contraindications to exceeding

the recommended dose limits. Exceeding radiation dose tolerance can result in radiation-induced

toxicity or damage to normal tissues, and the contraindications depend on the specific organ or

tissue that is affected.4 For instance, exceeding the radiation dose tolerance of the skin can cause

skin toxicity, which may include redness, blistering, and skin breakdown, whereas exceeding the

radiation dose tolerance of the heart can result in a variety of cardiac problems, including

inflammation of the pericardium, myocardial fibrosis, and coronary artery disease. Similarly,

exceeding the radiation dose tolerance of the lungs can cause pulmonary fibrosis, whereas

exceeding the radiation dose tolerance of the spinal cord can cause neurological problems such

as weakness, numbness, and loss of bladder or bowel control. Radiation-induced damage to other
organs such as the kidneys, liver, and digestive system can lead to nausea, vomiting, diarrhea,

and organ failure.5

The lymph nodes that are associated with this treatment site can be seen on the below

screenshots, with their corresponding labels.

The anatomical references that can be used to define the region for breast radiation therapy

can be described anatomically as the area between the clavicles superiorly, the sternum medially,

and the midaxillary line laterally. The inferior boundary can vary depending on the extent of

disease and the clinical target volume, but typically includes the inframammary fold. The breast

tissue extends to the anterior axillary line laterally and to the edge of the pectoralis major muscle

inferiorly.2
 In the screenshots below, the top image is typically where the anatomical boundary of breast

planning begins. The wire shown on the left anterior aspect of the patient, shown by the blue

circle, demonstrates the top of the breast field and was marked by the radiation therapists during

sim. On the second image, the end of the field can be shown again, marked with a wire circled in

blue.

The radiation treatment technique used to treat this anatomical region is Conformal

Radiation Therapy (CRT). This type of radiation uses advanced imaging techniques to precisely

target cancerous cells, or conform to tumor shapes, while minimizing damage to healthy tissue.
One of the main benefits of CRT is the reduction in tissue toxicity, which is accomplished by the

minimization of dose to healthy tissue by allowing the targeting of tumors from multiple

individual beams directed at the site through use of a 3-dimension image such as CT.5

For the primary breast plan, medial and lateral fields of mixed energies were used. The

open fields used a combination of both 6X and 10X energy, whereas the in fields used 10X

energy. This is a standard arrangement for breast cases at INOVA. The number of in-fields used

in this case was 6, but this number is entirely case dependent. The full set-up specifications for

this plan can be seen below, along with the dose distribution and beam alignment on the merged

axial view.
 For the L Ax/SCF plan, an RAO and LPO field arrangement was used. This beam

arrangement was used to keep dose off of the OAR such as the trachea and spinal cord. 10X

energy was used for both fields, and the set-up information and dose distribution can be seen on

the following screenshots:

The final boost plan was accomplished using photons, and included an RAO and LAO

field, with the LAO field using 6X energy and the RAO field using 10X. This variation in energy

is due to the location of the treatment area, and subsequently the energy needed to accomplish

appropriate dose distribution. The field arrangement also included the use of 60-degree wedges,

with the RAO wedge facing in and the LAO wedge facing out. The collimator was also rotated to

90° on both beams to allow for the appropriate wedge use. The set-up information can be seen on

the image below, including the wedge set-up and dose distribution on the axial image.
 The DVH of the plan sum, including the L breast plan and the L Ax/SCF can be seen

below and includes the spinal canal, esophagus, trachea, heart, and ipsilateral lung as OARs. At

our site, our Physicians ask that we contour the esophagus, trachea, and spinal canal but they are

not included on our dose tolerance sheet for 4 field breasts (seen above). This is because the dose

to these areas is case dependent, and ultimately up to the guide of the Physician, although dose to

OARs should always be as low as reasonably achievable.

 On our Breast IMRT dose tolerance sheet, however, the esophagus is defined at dmax

(Gy) < 40 as shown on the image below. This plan had an esophageal dmax of 565.7cGy, or 5.6

Gy, representing that it was well within the dose tolerance limits.

All constraints were met with the initial plan per the dose tolerance table seen on page 4.

For the cumulative dose, including the boost plan, another tolerance table was completed. As
shown below, the heart tolerance was ever so slightly exceeded at 2.01Gy. The PTV dmax was

also slightly above goal, at 107.3%. Both constraints that exceeded recommended doses were

minor, and the Physician approved all plans without further adjustment.
Conclusion
The use of Conformal Radiation Therapy to treat 4-field nodal breast cases is a highly

precise and effective method for targeting cancerous cells while minimizing damage to healthy

tissue. With the use of advanced imaging techniques such as CT and MRI, and sophisticated

treatment planning software, Dosimetrists and Radiation Oncologists are capable of developing

treatment plans that precisely target the tumor while sparing surrounding healthy tissue. This can

lead to improved treatment outcomes and fewer side effects for patients.6

Studies have shown that CRT can lead to improved disease control and overall survival

rates in patients with breast cancer. For example, a study published in the Journal of Clinical

Oncology found that CRT improved survival outcomes for patients with early-stage breast

cancer who had positive lymph nodes.7 Additionally, a study published in the International

Journal of Radiation Oncology Biology Physics found that CRT was associated with lower rates

of acute skin toxicity in patients undergoing radiation therapy for breast cancer.8

Overall, the use of CRT for breast nodal cases is a valuable treatment option for patients,

providing a high degree of precision and effectiveness in targeting cancerous cells while

minimizing damage to healthy tissue.

References
1. Pignol JP, Truong PT, Rakovitch E, Sauerbrei E, Rakovitch E. The American Society for

Radiation Oncology (ASTRO) clinical practice guidelines for the treatment of breast

cancer. Int J Radiat Oncol Biol Phys. 2016;96(5):961-964.

doi:10.1016/j.ijrobp.2016.08.006

2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in

Oncology: Breast Cancer. Version 3.2021. Accessed April 25, 2023.

https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

3. Khan FM, Gibbons JP. Khan's the physics of radiation therapy. Lippincott Williams &

Wilkins; 2014.

4. Rubin P, Constine LS, Marks LB, Williams JP. ALERT-Adverse Late Effects of Cancer

Treatment: Volume 2: Normal Tissue Specific Sites and Systems. Springer; 2014.

5. Van den Begin R, Engels B, Gevaert T, et al. Conformal radiation therapy: a corner stone

in modern radiation oncology. Acta Oncol. 2018;57(10):1257-1263. doi:

10.1080/0284186X.2018.1461698. Epub 2018 Apr 16. PMID: 29658823.

6. Whelan TJ, Olivotto IA, Parulekar WR, et al. Regional nodal irradiation in early-stage

breast cancer. N Engl J Med. 2015;373(4):307-316. doi:10.1056/NEJMoa1415340

7. Formenti SC, Hsu H, Fenton-Kerimian M, et al. Prone accelerated partial breast

irradiation after breast-conserving surgery: preliminary clinical results and dose-volume

histogram analysis. Int J Radiat Oncol Biol Phys. 2012;82(5):1993-2002.

doi:10.1016/j.ijrobp.2011.03.059
8. Tran TA, Brown S, Hsia A, et al. Four-field breast nodal irradiation technique using

conformal radiation therapy. Pract Radiat Oncol. 2017;7(5):e327-e333.

doi:10.1016/j.prro.2017.03.011