High Dose Rate Brachytherapy

• HDR Brachytherapy is a form of internal radiotherapy were an oncologist:

o temporarily implants a catheter (a small plastic tube or balloon) in the tumor
area
o places highly radioactive material inside the body for a short time and the
retracts it using a remote control.
o removes the catheter after you’ve completed the entire course of treatment.
You may need multiple sessions of HDR brachytherapy
• Clinical Applications
o This can be used in combination with other therapies such as surgery,
EBRT or chemotherapy
o Brachytherapy has been mostly widely applied in the treatment of
▪ Cervical
▪ Prostate
▪ Breast
▪ Skin Cancers
• Type of Brachytherapy
o Brachytherapy can be characterized according to 3 main factors
▪ Source placement
▪ Treatment duration
▪ Dose rate
o Source placement
▪ Interstitial – the sources are placed directly in the target tissue of
the affected site such as the prostate or breast
▪ Contact – involves placements of the radiation source in a space
next to the target
• Intracavitary – a body cavity such as cervix, uterus or vagina
• Intraluminal – a body lumen such as the trachea or esophagus
• Surface (mould) – external (skin)
• Intravascular – blood vessels
o Treatment duration
▪ Temporary – Dose delivered over short period of time and the
sources are removed after the prescribed dose has been reached.
The specific treatment duration will depend on many different factors
including the required rate dose delivery and the type, size and
location of the cancer.
▪ Permanent – also known as seed implantation, involves placing
small LDR radioactive seeds or pellets in the tumor or treatment site
and leaving them there permanently to gradually decay.
• Widely used in the prostate cancer
 o Dose Rate
▪ Low dose rate (LDR) – emits radiation at a rate of of 0.4 – 2 Gy per
hour
• Cesium-137 (137Cs)
▪ Medium dose rate (MDR) – ranging between 2-12 Gy per hour
▪ High dose rate (HDR) – exceeds 12 Gy per hour
▪ Pulse dose rate – involves short pulses of radiation, typical once an
hour, to simulate the overall rate and the effectiveness of LDR
Treatment.
Note: LDR and HDR are the dose rates used in the Philippine setting.
Characteristic Type Description Clinical
example(s)
Source Placement Interstitial Source place within Breast, Prostate
the tumor

Contact Source placed next Cervix, trachea,

to the tumor skin

Duration Permanent Source implanted Prostate “seed”

permanently implants

Temporary Source implanted Most brachytherapy

for a specific treatments are
treatment duration temporary for a
wide variety of
cancers

Dose Rate High 12 Gy per hour Breast, cervix,

prostate, skin

Medium 2-12 Gy per hour Cervix

Low 0.4-2 Gy per hour Prostate, oral

Radiation Source
Radionuclide Type Half-Life Energy
*Cesium-137 (137Cs) γ-ray 30.17 years 0.662 MeV

*Cobalt-60 (60Co) γ-rays 5.26 years 1.17-1.33 MeV

Iridium-192 (192Ir) γ-rays 73.8 days 0.38 Mev (mean)

 *Iodine-125 (125I) γ-rays 59.6 days 27.4, 31.4 and 35.5
keV

Palladium-103 (103 Pd) γ-ray 17.0 days 21 keV (mean)

Ruthenium-106 β-particles 1.02 years 3.54 MeV

(106Ru)

Note: * commonly used radiation sources (radionuclides) for brachytherapy

Cobalt-60 (60Co)
• Half-life: 5.26 years
• Energy: 1.17-1.33 MeV
• Long range emission
• In the form of wire which is encapsulated in a sheath of platinum, iridium or
stainless steel
• Available as pellets with a typical activity of 18.5 Gbq (0.5 Ci) per pellet
Iridium-192 (192Ir)
• Half-life: 73.8 days
• Energy: 0.206 and 0.485 MeV
• Short range emission
• Available in the form of seeds, 0.5 mm in diameter and 3 mm long, Low Dose Rate
Brachytherapy (LDR BT)
• Also used in the form of wire consisting of an iridium-platinum radioactive core
encase in a 0.1 mm sheath of platinum.
Afterloader Machine
• In terms of the high dose rate (HDR), the afterloader machine is controlled
remotely. So, we have a control console. We also have computers.
• A computerized medical device that drives a small radioactive source through
catheters to predetermined dwell positions for a specific time in a patient’s body
during brachytherapy
Samples of Afterload Machine
 Latest afterloader machine
Applicator
• A device used to hold a radioactive source in place during brachytherapy
• Applicators are non-radioactive and are typically needles or plastic catheters. The
specific type of applicator used will depend on the type of cancer being treated and
the characteristics of the target tumor.

Left (Manchester); Right (Fletcher suite); Middle (vaginal cylinder)

1. Treatment planning - a clinical examination is performed and the tumor is
imaged; the radiologic technologist can use C-Arm, Ultrasound guided, CT
Scan, MRI.

2. Placement of the brachytherapy source applicators - Source applicators

are placed in the body. Further imaging ensures correct positioning of the
applicators.

3. Creating a virtual patient and optimizing the treatment plan - A 3D

visualization is created of the patient and the applicators to refine the planned
delivery of the radioactive sources.

4. Treatment delivery - The radioactive sources are delivered to the treatment

site; the radiologic technologist will be the one to do treatment delivery.

Typical stages of a brachytherapy procedure

Endometrial; applicator used is the Fletcher

 Tandem

Ovoids

Applicator used in low dose radiation therapy; A tandem can have 2 or more radioactive
sources (depending on the physician); each ovoid (horseshoe-like appearance) can
only have 1 source.

Low dose radiation therapy; Manual afterloader

Radioactive pellets are being inserted into the tandem straw.

Monitor detects radiation

HDR OR; Interstitial brachytherapy; While being guided by the ultrasound, doctors place
tiny radioactive pellets inside or next to the tumor. The pellets give off radiation that
destroys cancer cells. If the doctors are already aware that the needle is being inserted
into the tumor, then they will secure the placement. We also have a stabilizer for our
needle, together with the fletcher suite. Use the interstitial needle, then, after securing
the placement, perform a CT scan, then create a plan with the physicist. The treatment
will be approved by the doctors.
 Brachytherapy in Davao Doctors College

Brachytherapy storage room (this is the area where we store the radioactive materials)
Note: Wear proper shielding (lead gown, thyroid shielding and lead goggles) before
entering.

Storage Box for the radioactive sources. The radioactive source used is the cesium-
137. Use tongs to hand radioactive source.
One of the cardinal principles, distance, should be applied.

Survey meter – this is used to detect levels of radiation

This is where we keep the radioactive sources that will be delivered to the patient via a
cart.

Getting the radioactive source using tongs from the storage box
Transition of radioactive source to brachytherapy room

Brachytherapy room
 Insertion of radioactive source

Equipment used for brachytherapy specifically the low dose brachytherapy

Fletcher suite applicator

Insertion
 Close; Once you insert the radioactive sources into the patient, apply the cardinal
principles (STD; shielding, time, and distance) to ensure that the radiologic technologist
receives only the least amount of exposure (less exposure) possible.
 Radiation Therapy for Brain Metastases

External Beam Radiation Therapy Machine (Linear Accelerator)

10-30 % of Cancer Patients
Most common primary tumors
• Lung Cancer
• Renal Cell Cancer
• Melanoma
• Breast Cancer
• Colorectal Cancer

Note: Brain Metastases sometimes called secondary brain cancer or a metastatic brain
tumor.
 Tumor cells metastasize by
• Hematogenous spread through blood vessels.
• Usually become lodge to grey-white matter
junctions where blood vessels decrease in size.

Note: Cancer cells spread to lymph nodes, and cancer spreads through blood circulation.
The higher the blood circulation, the higher the percentage of the brain that will
metastasize.
Note: The distribution of brain metastases in the brain roughly corresponds with the
amount of blood flow receives by that part of the brain.
• 80% going to the cerebral hemispheres
• 15% going to the cerebellum
• 5% going to the brain stem
The tumor and surrounding edema can lead to increased intracranial
pressure.
Signs and symptoms of patient with brain metastases:
• Headache
• Focal weakness (change of movement, loss of muscle control,
paralysis)
• Altered mental status (confusion, amnesia, poor emotion)
• Seizures
• Ataxia – lack of body movement
• Stroke
Note: That’s why we need to treat the brain cancer to shrink (lower; minimize) the tumor
to avoid ICP.
Note: ICP – Intracranial Pressure
Diagnostic Approach of Brain Metastases
• History taking
• Physical
o Neurological examination
▪ Neurological deficits
▪ Fundoscopy for Papilloedema
o Full physical exam
▪ To assess for other metastases
• Imaging
o CT reasonable as 1st step (for computation of MU (Hounsfield unit);
standard imaging for brain metastases, it’s easy to locate the tumor.
o MRI for tumor localization
• Biopsy
o Based on the biopsy, glioblastoma multiforme is the type of tumor was
suspected to the patient.
Note: Hounsfield unit – to detect the treatment planning system of what organ is being
scanned.
Note: Different organ, different attenuation
Note: Biopsy is needed to determine if the tumor is benign or malignant.
CT Simulation
• The first step in radiation treatment process is to have a
CT simulation or CAT Scan.
o The doctor will request the patient for a
stereoscopic CT scan.
• For the CT, we are going to use the information to aim and
shape the radiation.
o The patient will have a mask made for them for their initial CT simulation;
the mask is flat if it’s not used; heated in the hot bath.
o Patient must be comfortable and takes 5 minutes for it to dry and contours
specifically the patient’s face; put marks (gold seed or lead CT markers) to
assist the radiographer or radiologic technologist in identifying where the
tumor is to be treated.
o They will mark where your tumor or lesion is located.
Note: A hot bath has certain degrees. If it reaches 70 degrees, we can now put the
thermoplastic mask inside the hot bath. Once the thermoplastic mask is inside the hot
bath, the patient can wear it.
Treatment Planning
• Patient underwent computed tomography simulation in the facility following
immobilization with thermoplastic masks in the supine position.
• CT images were obtained from the vertex of the skull to the top of the thoracic
spine at 2.5 mm intervals. The right and left parotid glands were contoured.
o Superior border = vertex of the skull, 2 cm
o Inferior border = thoracic spine, 2 cm
o Slice thickness of the CT scan = 2.5 mm intervals
• Given the variations in the PCI and WBRT doses employed, plans were generated
for prescription doses of 25 Gy, 30 Gy and 37.5 Gy.
o PCI = Prophylactic cranial irradiation
o WBRT = Whole Brain Radiation Therapy

Thermoplastic mask (head and neck masks)

An example of
differences in
parotid coverage
when the lower field
is set at C1 vs. C2.
An example of a
WBRT plain with
coverage of C2
(panel A) vs. C1
(Panel B). The parotid volume is shown in yellow. The portion of the parotid blocked by
the inferior primary jaw of the C1 plan is indicated by the white arrow.
Note: 2 treatment plans were produced for each patient using the CT simulation images.
• In each plan, treatment was delivered using 6 MV photons in an opposed lateral
configuration with the first plan extending the inferior field border to include all of
C1 while the second plan set the inferior border to include all of C2.
• The WBRT plans were otherwise standard, with MLCs used to create a 1 cm field
edge margin on the bony landmarks demarcating the inferior border of the cranial
contents, and isocenters placed within the posterior orbit to create a quasi-half
beam technique and limit divergence to the contralateral lens.
Note: Multileaf collimator (MLC)
Management
• Need urgent treatment to prevent complication such as deterioration, intracranial
pressure (ICP), herniation
• Initial management also focused on patient’s airway, breathing, circulation
dexamethasone (a drug to prevent symptomatic edema)
Dose Distributions
• Red colored dot represents the hotspot which is 106% or 6% higher
than the prescribed dose.
• Hotspot or coldspot is acceptable if within 5-7%
• Green color represents the 100% dose or 3000 cGy which is the
prescribe dose
Note: One can notice that no color on the eyes since this region was blocked
using MLC to avoid side effects.
Note: Hotspot (exceed) = volume outside the planning target volume (PTV) which
receives dose larger than 100% of the specified PTV dose
Note: Coldspot (lack) = In radiation oncology, a tissue region that is exposed to much
less radiation than neighboring tissues.
Treatment option for Whole Brain Radiation Therapy (WBRT)
• Standard treatment for Brain Metastases
• The whole brain is irradiated by targeting only metastatic lesion
• To treat potential microscopic disease to prevent future widely disseminated
disease throughout the brain.
Dose and Fractionation
• Most common dose/fractionation schedule used is 30 Gy delivered in 10 fractions
over the course of 2 weeks (3000 cGy)
 • So, 10 radiation therapy treatments for 2 weeks, 3 cGy per day within 5 days. 2
days break for the recovery of the healthy cells.
Treatment protocol
• According to the case, the patient is admitted in pain. The best treatment protocol
that we can give is the shortest using 4000 cGy. It will help the immediate relief of
the patient.
• 3 Gy x 10 days (shortest)
• 2 Gy x 15 days
• 2 Gy x 20 days
Note: The higher the dose, the faster the effect.
Dose distribution
• Lateral view of the WBRT dose distribution
• For this case, represented 100% of the dose.
• Field boundaries are evident, one can say that eyes
are outside the area being treated.

Patient Preparation
• Patient in supine position, both arms down
• Inform the patient what to expect on the treatment
• Mask should be on the right spot
• Patient must be comfortable
As the patient lie on the table, LINAC moves around you
to deliver radiation from several angles. The linear
accelerator can be adjusted for your particular situation
so that it delivered the precise dose of radiation your
doctor has ordered.

When LINAC was not yet invented, Cobalt-60

(60Co) has been used in the treatment of
cancer for over 60 years. It is also used to treat
brain tumor and vascular malformations.

Whole Brain Radiation Therapy (WBRT) side effects

• Fatigue
• Increase cerebral swelling
• Alopecia (hair loss)
• Late effects (6 months to 1 years)
• Cognitive changes
 Breast Cancer

Normal Anatomy of Breast

• Breast tissue extends from the collarbone, to lower ribs, sternum (breastbone) and
armpit. Each breast contains 15-20 glands called lobes, where milk is produced in
women who are breastfeeding. These lobes are connected to the nipple by 6-8
tubes called ducts which carry milk to the nipple.
• The breast and armpit also contain lymph nodes and vessels carrying lymph fluid
and white blood cells, which are part of the immune system. Much of the rest of
the breast is fatty tissue.
Breast Cancer
• Breast cancer is cancer that forms in the cells of the breasts.
• Breast cancer can occur in both men and women, but it's far more common in
women.
• Breast cancer most often begins with cells in the milk-producing ducts (invasive
ductal carcinoma). Breast cancer may also begin in the glandular tissue called
lobules (invasive lobular carcinoma) or in other cells or tissue within the breast.
• Can be inherited or developed.
Lymphatic Drainage
• Axillary Lymph nodes
o Between 10 and 38 lymph nodes are in each axilla
o Can be divided into three major sections (levels I, II, III) based on location
and sequential drainage patterns. Nodes in level I are located lowest or
most superficial in the axilla. These are followed by nodes in levels II & III.
• Internal Mammary Lymph nodes
o Located near the edge of the sternum, embedded in fat in the intercostal
space.
o Most internal mammary nodes are in the first, second and third intercostal
spaces, with the average person having approximately eight small nodes
(four per side)
• Supraclavicular Lymph Nodes
o Lymphatic drainage occurs from the breast to the supraclavicular nodes,
liver, and contralateral IM nodes.

Normal

With cancer
 Breast Cancer
Mastectomy
• Mastectomy is the removal of the whole breast.
• There are five different types of mastectomies: "simple" or "total" mastectomy,
modified radical mastectomy, radical mastectomy, partial mastectomy, and
subcutaneous (nipple-sparing) mastectomy.
• 5 types:
o Simple or total mastectomy concentrates on the breast tissue itself.
o Modified radical mastectomy involves the removal of both breast tissue
and lymph nodes.
o Radical mastectomy is the most extensive type of mastectomy. The
surgeon removes the chest wall muscles under the breast.
o Partial mastectomy is the removal of the cancerous part of the breast
tissue and some normal tissue around it. While lumpectomy is technically a
form of partial mastectomy, more tissue is removed in partial mastectomy
than in lumpectomy.
o Nipple-sparing mastectomy - All of the breast tissue, including the ducts
going all the way up to the nipple and areola, are removed, but the skin of
the nipple and areola is preserved.
Note: A mastectomy for the breast cancer is the surgery performed on patients. It will
remove the entire breast and may include the removal of the muscle and skin. This
surgery includes removing the breast tissue and the breast may be removed due to
cancer or fibrocystic disease. The mastectomy for the breast cancer is referred as local
therapies that target the area of the tumor as opposed to the systematic therapies such
as hormonal therapy, chemotherapy or immunotherapy.
Pathology: Causes and Staging
• Risk Factors
o Being female - Women are much more likely than men are to develop
breast cancer.
o Increasing age - Your risk of breast cancer increases as you age.
o A personal history of breast conditions - If you've had a breast biopsy
that found lobular carcinoma in situ (LCIS) or atypical hyperplasia of the
breast, you have an increased risk of breast cancer.
o A personal history of breast cancer - If you've had breast cancer in one
breast, you have an increased risk of developing cancer in the other breast.
o A family history of breast cancer - If your mother, sister or daughter was
diagnosed with breast cancer, particularly at a young age, your risk of breast
cancer is increased. Still, the majority of people diagnosed with breast
cancer have no family history of the disease.
o Inherited genes that increase cancer risk - Certain gene mutations that
increase the risk of breast cancer can be passed from parents to children.
o Radiation exposure - If you received radiation treatments to your chest as
a child or young adult, your risk of breast cancer is increased.
o Obesity - Being obese increases your risk of breast cancer.
o Beginning your period at a younger age - Beginning your period before
age 12 increases your risk of breast cancer.
o Beginning menopause at an older age - If you began menopause at an
older age, you're more likely to develop breast cancer.
o Having your first child at an older age - Women who give birth to their
first child after age 30 may have an increased risk of breast cancer.
o Having never been pregnant - Women who have never been pregnant
have a greater risk of breast cancer than do women who have had one or
more pregnancies.
o Postmenopausal hormone therapy - Women who take hormone therapy
medications that combine estrogen and progesterone to treat the signs and
symptoms of menopause have an increased risk of breast cancer. The risk
of breast cancer decreases when women stop taking these medications.
o Drinking alcohol - Drinking alcohol increases the risk of breast cancer.

A personal history of Breast condition

Beginning period at early age

Beginning menopause at older age

 Having your first child at an older age
Stage 5-year survival rate
0 100%
I 98%
IIA 88%
IIB 76%
IIIA 56%
IIIB, IIIC 49%
IV 16%
Note: 5-year survival stage of disease
Diagnosis
• Initial Evaluation
o Initial evaluation requires a complete medical history and physical
examination. The medical history will include a detailed history pertaining of
the breast cancer and associated risk factors. A complete physical
examination with special attention to the breast exam and draining lymph
nodes must be performed. The breast exam should be completed both in
sitting and supine positions.
o Most patients who present with early-stage breast cancer are
asymptomatic and the cancer is detected by screening mammography. In
other instances, patients may present with a palpable breast lump, and
rarely report bloody nipple discharge as the only presenting symptom.
Inflammatory breast cancer, which is an aggressive sub-type, presents
with a cluster of clinical symptoms including erythema and an inflammatory
type of reaction with skin edema. Paget’s disease presents with an eczema
change involving the nipple areola and associated mass or bloody nipple
discharge.
 • Indications
o The most common presentation of breast cancer is a painless lump.
Unfortunately, the time a breast lesion is palpable, it has grown already to
about 0.5 cm.
o Small lesions can be difficult to detect, especially if they are deep within
breast tissues.
o The assessment of a breast mass must address the size, shape,
consistency, mobility, pain or tenderness, location in the breast, and relation
to skin and surrounding tissue.
• Laboratory Tests
o Initial laboratory tests should include a complete blood count, basic blood
chemistry, liver function tests, and creatinine.
• Tumor extent
o The size of the primary tumor is another aspect of the staging system.
o Larger tumors increase the likelihood of the skin, muscle, chest wall regional
lymph nodes, resulting in a worse overall prognosis.
Simulation
Many institutions now use CT simulator for breast
setup.
The patient is placed with an immobilization device.
• L-shaped arm board or breast step or breast
board, custom model foam casts, Alpha cradle
(phased out) can be used.
Many postoperative patients (surgery involved mastectomy) experience initial difficulty in
raising the arm to an acceptable position for radiation treatment. Therefore, the simulation
and start of therapy should be delayed (usually after 6th week after post operation) until
the patient's arm moves appropriately.
Note: The patient is taken to the CT scanner where slices are taken to include all the
borders. The scan information will be transferred to treatment planning computer and
used for field design.
• The target volume can then be verified using a DRR (Digitally Reconstructed
Radiograph)
• Target volume includes chest wall, axilla, mastectomy scar and supraclavicular
fossa (SCF)
o Chest wall (mediastinum)
o Axilla (lateral part)
o Supraclavicular fossa (superior part of the clavicle)
• Wire all surgical scars and drain sites.
• Entire mastectomy scar, flaps, surgical clips, and drain sites included in
treatment field.
Patient Positioning
The patient lies supine in the selected positioning device
on the simulator-treatment table.
The patient's body must be straight (in the sagittal plane)
and level from side to side.
Laser triangulation points are marked on the patient's
anterior and side surfaces in the area between the waist
and inflammatory fold to assist in the daily positioning
process. Patient must not place the contralateral hand
on the abdomen or grasp the belt or waistline of their
clothing. Preferably, the contralateral arm should be
positioned the same as the ipsilateral arm.

Note: The patient's head should face the opposite side of the treatment.
• This is to have a better visualization of the SCF.
Note: The feet should be held together with a band or masking tape around the toes.
• This helps eliminate rotation of the patient's lower abdomen, thereby enhancing
reproducibility.
Note: A triangular sponge or bolster may be placed under the patient's knees to relieve
pressure on the lumbar region.
Note: The same immobilization devices must be used each patient is treated.
 • Breast Board or Alpha Cradle or Plastic moulds
Breast Board
• Advantages
o Allow comfortable arm support
o Brings arm out of the way of lateral beams
• Position of arms
o The preferred arm position is bilateral arms to be abducted 90 degrees or
greater & externally rotated.
o Advantage of raising both arms vs only ipsilateral arm:
▪ Patient is more comfortable and relaxed
▪ Position is more symmetrical and easily reproducible with lesser
chances of rotation of the torso
▪ More precise matching of the previously irradiated field if
contralateral breast requires radiation in the future

Treatment Planning
• 3-Dimensional Conformal Radiation Therapy
o All patients were planned by 3D-Conformal RT (3D-CRT)
technique with megavoltage beams on a multiple energy
ELEKTA Linear Accelerator
o The critical structures and the clinical target volumes (CTV)
were contoured and reviewed by a radiation oncologist
specializing in breast cancer. The nodal regions including
the supraclavicular fossa, the axilla (AX) and internal
mammary (IM) nodes were contoured.
o The photon energy used was either 6 MV or 15 MV.
▪ If not superficial, use lower energy
▪ The higher the energy, the higher the penetrability (vice versa); direct
relationship
o Beam arrangement included medial and lateral opposed tangential fields to
irradiate the chest wall, with or without the use of a single anterior field (with
 a gantry tilt of 5-10 degrees to avoid the spinal cord and esophagus) for the
supraclavicular region using mono iso centric technique.
o The treatment was planned with a goal of 100% volume of PTV to be
covered by 95% isodose line. Dose homogeneity was optimized using
wedges and field-in-field technique using multi leaf collimators.

Image of CT Planning and Evaluation of a Patient. A, axial image of isodose

evaluation of chest wall coverage by a 3-D conformal plan using wedges and field-in
field technique for reducing hot spots. B, single anterior beam to cover the
supraclavicular fossa with angulation to avoid spinal cord and esophagus. C, coronal
section of isodose coverage.; green (beam entry; area to be treated)
Definition of Target Volumes
• Clinical Target Volume
o Chest wall
▪ The skin flaps from 5mm below the skin surface, including the soft
tissues down to the deep fascia but not including the overlying skin
or underlying muscle and rib cage.
o Medial SCF
▪ Contents of the medial SCF
o Axilla
▪ Contents of the axilla
o SCF + Axilla
▪ Contents of SCF and Axilla (armpit)
 Structures Dose (Gy)
Planning Target Volume 50.4
Internal Mammary Nodes 50.4
Supraclavicular Nodes 50.4
Axillary level I, II, III 50.4
Left lung 10
Right lung 5
Heart 30
Right Breast 2
Note: Dose-volume constraints utilized for the PTV and
normal critical structures

• Normal critical structures that were specifically analyzed included the heart, the
lungs, the brachial plexus and the contralateral breast.
• Mean dose was prescribed as 50.4 Gy in 1.8 Gy increments for the PTV.
• Esophagus and Spinal cord must not receive exceeding to 45Gy.
Radiotherapy (RTx) treatment
• Aim
o Decrease chances of later recurrence
o To increase local control and increase surviva
• Total dose or daily dose
o Phase 1 (SCF field and Axilla)
▪ 180 cGy x 28 fractions = 5040 cGy or 50.4 Gy
o Phase 2 (Scar boost)
▪ 200 cGy x 5 fractions = 1000 cGy or 10 Gy
▪ Total Dose = 6040 cGy or 60.4 Gy
Irradiation of Chest Wall
• Irradiation of the chest wall after mastectomy can be accomplished with tangential
photon fields (as in the intact breast) or with electron beams
• Bolus may be necessary over the entire field for part of the treatment.
o A bolus is a tissue equivalent material used to reduce depth of the maximum
dose.
• Alternative for tangential photon treatment:
o Single appositional field using 6-12 MeV electrons.
Indications of SCF Irradiation
• 4 or more positive axillary nodes
• 1-3 positive lymph nodes – strongly recommended
• Positive margin of T3 or T4 lesion at physician’s discretion
SCF Field
• Single anterior field is used
• Field borders:
o Upper border: thyrocricoid groove
o Medial border: at or 1 cm across midline
o Lateral border: medial to the humeral head
o Lower border: just below the clavicle head
Note: Field is approximately 10-15 degrees laterally to spare the
cervical spine dose.
• For obese patients, target is deeper than 3 cm. Higher energy or AP/PA can be
used.
Scar Boost
• Phase 2
• 200 cGy x 5 fractions = 1000 cGy
• Electrons – for superficial treatment
• Appropriate energy selected to allow 85-90% isodose line to encompass target
volume and decrease dose to the lung.
• Clinical set up - scar on skin + 3 cm in all directions
• Energy: 9-16 MeV
Patient Care Management
• Complications
o Acute skin reaction, treated with:
▪ Erythema alone
• Antifungal and hydrocortisone creams
▪ Dry Desquamation
• Treated with moisturizing and Vitamins A and D creams
▪ Wet Desquamation
• Treated with Zinc Oxide and Bacitracin
▪ Dysphagia
• Caused by irradiation of the part of the esophagus
• Treated by mouthwash (product prescribed by Physician)
Anemia
• A decrease in number or red blood cells (RBC) which may lead to low blood count.
• May cause fatigue, headaches and chest pain.
• It is caused by irradiation of tissue cells.
• How to treat low blood count:
o Iron supplement
o Multivitamin
o Epoetin alfa