Allison Wright

ProKnow Left Chest Wall Plan Assignment

Write Up:
The first thing I did when loading this patient was review the target volumes. Typically,
when I see that the PTV is outside of the body, I create an opti structure cropping the volume 4
mm from the body, however I realized the EVAL contour was that exact thing. I gathered that I
would be planning with a 4 or 5 field technique based on the supraclavicular, axillary, and
intramammary PTV volumes. I went into Contouring and created a couple new structures. I
created a superior structure with the supraclav and axillary volumes Boolean, then I created an
inferior structure with the chest wall and IM volumes together.
I started with placing isocenter in between the supraclavicular and the chest wall volumes. I
chose an area that was more medial and below the base of the clavicle knowing that the
superior border (Y1 axis) would be the shared border between the AP/PA and tangential plans. I
then inserted a new field with gantry 0 with new MLCs fitted around the superior volume plus 1
cm margin. I note that the humeral head is blocked but I see the spinal cord is in the field. I start
to block the cord with MLC but it creates a very tight margin around the volume making it very
hot. So I reset my MLCs back and rotated the gantry medially to 353 in order to miss the cord
and happened to decrease dose to the esophagus as well. I then added a PA beam for the
posterior axillary boost at 180 with the same 1 cm margin. I did not directly oppose the AP
beam to treat less esophagus. Due to the thickness of the patient and treatment volumes, I
decided to use 18X for both fields with 88% of the weighting on the AP field and 12% on the PA.
Next, I started on the chest wall volume including intramammary nodes with large tangent
fields. I made sure to put this patient on our Trilogy machine as it has a maximum field size of
40x40 versus 20x20 on a Truebeam or Edge. With the inferior volume turned on, I inserted a
field starting at gantry 315. I adjusted this angle until I was covering more of the medial portion
of the chest wall volume and intramammary volume. I opposed this field and manually moved
the MLCs to block lung up to the target volume. I left about 1 cm open below the volume and
about 2 cm of flash anterior to the patient. I started with 6X on both medial and lateral fields.
After calculating this plan just to see where dose was going, I realized that the heart and left
lung were getting quite a bit of dose. I turned on the inferior volume to see if rotating the
gantry a bit more could increase coverage while decreasing dose to heart and lung. I took a risk
of sacrificing coverage and blocked some posterior target volume covering the heart to achieve
heart goals. To my surprise, clipping some target volume to spare heart did not hurt my
coverage too much. I continued with the same medial and tangent fields but with 18X. I ended
up at 117% Dmax at this point. I then started Field in Fields to cool the plan down to 110%.
I was satisfied with these plans, so I created a Plan Sum to review total dose to my OARs
and target volume objectives. Since I did not see the Eclipse document to combine plans until
after I submitted my score card, I created a whole new plan with all my fields. I then created a
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PTV_ALL structure with every target volume given in order to normalize. At my clinic, we start
out with 95% covers 95% of the volume. The 95% isodose line is shown in a thick green contour.

 How the fields were matched (include a visual)

o SCL+PAB Fields

o CW+IM Fields

 Images from the plan showing the isodose coverage of your volumes (this may require
multiple views).
o SCL+PAB isodose lines
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o CW+IM Isodose lines (Superior portion)

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o CW+IM Isodose lines (Inferior portion)

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 NOTE: Place all images WITHIN the text of the paper where they are being referenced so
that the assignment is easy to read and to follow. Keep things simple – use images,
when possible, it is often much easier to show a picture when you want to describe
something accurately. Make sure that every image is easy to see, useful, and labeled
with all necessary information. Your images can be one full page if needed.
 Embed your ProKnow plan score card within your assignment.

 Provide a DVH with the target volume(s) and important surrounding critical structures
with clear labels.
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Discussion:
 How did you match the supraclavicular field to the tangent fields?
o I matched these fields by using the jaws at isocenter like a split beam approach.
Because the target volumes were being split with the jaw, I needed to crop
volumes 4 mm away from each other to allow for gradient dose to occur,
otherwise it would be very hot trying to get dose at the edge of the jaws.
 How did you reach the coverage required (energy and technique) for the axillary nodes?
o For the axillary nodes, I made sure to give about a 1 cm margin around the
volume on both AP and PA fields. When I initially calculated with 6X, it was very
hot with not the best coverage so I changed the energy to 18X. This cooled down
the plan and gave adequate coverage to the axillary volume. I also weighted the
beams more on the AP beam (88%) to reach more axillary and supraclav while
decreasing lung dose.
 What technique did you use to treat the internal mammary nodes?
o I treated the internal mammary nodes with the tangent fields.
 Identify any cold spots (dose less than prescription), where are they located, and explain
if its location was acceptable.
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o There is a cold spot where the supraclavicular fields and tangent fields match.
This makes sense and is acceptable due to the volume cropping that I did to
allow for dose gradient in that area.
 Identify the maximum dose location and explain if its location was acceptable.
o The maximum dose location is in the base of clavicle but within the PTV. This is
acceptable because it is not in an organ at risk or outside of our target volumes.
 What was the dose to the LAD (left anterior descending artery)? Were you able to spare
it? Is there any way to decrease the dose to it? What are the possible long-term effects
based on the dose that is given? Is there a LAD constraint that you can find in literature
when treating left sided breasts?
o The max dose to the LAD is 4810.7 cGy. I was not able to spare it as it lies right in
the problem area of the heart where I had to block some PTV in order to meet
heart dose. I could have tried harder to decrease dose to it by blocking more PTV
in that area but I had already sacrificed a good amount of coverage to save the
heart. According to the article cited below, the Dmax for the LAD should be less
than 45.4 Gy, V15≤40%, V20≤36.2%. Surprisingly, I met the V15 and V20 but not
the Dmax constraint. The article does not specify what the possible long-term
effects would be at this dose but significant alteration of cardiac enzymes or
cardiac death may be a possible result.
o Y. Kirova, A. Tallet, M.C. Aznar, P. Loap, A. Bouali, C. Bourgier. Radio-induced
cardiotoxicity: From physiopathology and risk factors to adaptation of
radiotherapy treatment planning and recommended cardiac follow-up.
Cancer/Radiothérapie. 2020; 24(6-7):576-585.
https://doi.org/10.1016/j.canrad.2020.07.001.
 Explain how your plan was normalized or explain why no normalization was required.
o At first, when I was planning this patient with two plans, I wasn’t sure how I
would normalize two different volumes together. So I created calc points for
each plan, but this is an older technique and I did not prefer it. I combined the
plans and target volumes into one structure and normalized the plan to 95% of
the dose to cover 95% of the target volume as this is our standard in my clinic for
breast treatment.
 Was there a metric you were unable to meet, and if so, how did you try to fix it?
o I was not able to meet the dose constraint for the esophagus. As I explained
above, I tried to decrease dose by changing the gantry angle and manipulating
MLCs to block out nearby OARs while maintaining a decent amount of PTV
coverage. I did my best and was satisfied with a marginal dose.
 Did you sacrifice points on a specific metric to improve your plan in other areas? What
was your rationale?
o Yes, I sacrificed points on my esophagus to improve my plan as I was already
blocking PTV volume to decrease dose to the heart and LAD. Although I was not
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successful in constraining the LAD, I was able to decrease mostly heart and a
little bit of the esophagus. My reasoning is that as long as the major organs, such
as heart and lung, are meeting dose constraints as well as adequate PTV
coverage, I believe the esophagus dose was a appropriate metric to sacrifice.