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Dustin Melancon May Case Study June 14, 2012 3D CRT for Male Invasive Ductal Carcinoma of the Left Breast History of Present Illness: Patient JH is a 65-year-old male who noticed pain in his left chest wall six months ago. He palpated a small mass beneath his left nipple. Following this, the lesion slowly grew in size. He brought this to the attention of his primary care physician who suggested further workup. A core biopsy was performed in October 2012, and it was significant for grade 3 invasive ductal carcinoma. The patient underwent a left sided total mastectomy with sentinel lymph node biopsy and axillary lymph node clearance October 2012. The tumor was 5.1 centimeters (cm) invasive ductal carcinoma that was estrogen receptor (ER) positive, progesterone receptor (PR) negative and HER/2neu (human epidermal growth factor receptor 2) positive. It was pathologically staged T3N2aM0. There was no lymphatic invasion and margins were widely negative. The lesion was noted to involve the dermis and there was a component of Pagets disease noted on the epidermis. It was determined that 5 out of 14 lymph nodes were positive with extranodal extension. Proliferation rates can be used as a prognostic indicator in early breast cancer because it provides useful information on prognosis and aggressiveness of tumors.1 Proliferation is estimated by the assessment of the nuclear antigen Ki-67. The antigen was identified in 1991 by a group in the city of Kiel (Ki) after immunization of mice with a Hodgkins lymphoma cell line. The 67 refers to the clone number on the 96-well plate in which it was found. High Ki-67 scores are associated with higher chance of response to chemotherapy, but high Ki-67 also correlates with poor prognosis overall. On the other hand, a complete pathological response is associated with a good long-term prognosis. The patient had a Ki-67 score of 12%. Past Medical History: JH has a history of hypertension, diabetes mellitus type 2, and osteoarthritis. He had a cholecystectomy in February 2008. A mastectomy and axillary lymph node dissection were performed in October 2012. Social History: The patient stated that he drinks alcohol socially. He denied illicit drug use. The patient currently works as a highway construction contractor. The patient is married with

2 three children. Family history includes his father, grandfather, and uncle with prostate cancer. His maternal aunt had breast cancer and leukemia. Medications: JH uses the following medications: Toproll XL, Amlodipine/Benazepril, Hydrochlorothiazide, Simvastatin, and Janumet. Diagnostic Imaging: Upright posterior-anterior (PA) and lateral chest radiographs were obtained in December 2012. The patient underwent a diagnostic bilateral mammogram. There was a high density irregular mass in the subareolar region of the last breast as well as a 13 millimeter (mm) mixed density mass in the axillary tail. The patients right side was normal. In addition, computed tomography (CT) scans of the chest, abdomen, and pelvis were acquired. Radiation Oncologist Recommendations: The radiation oncologist noted that JH was doing well after his total mastectomy with axillary lymph node dissection. The patient had no evidence of peripheral lymph edema. He no longer required any narcotic pain medication. The patient mentioned tenderness at the incision site and slightly impaired mobility in his left upper extremity. The patient had a discussion with his medical oncologist about adjuvant chemotherapy and agreed to the treatment. The patient was prescribed a regimen of Taxotere, Carboplatin, and Herceptin (TCH) for 4 cycles. The radiation oncologist met with JH and discussed the role of adjuvant post mastectomy radiation therapy for this disease. Stage III breast carcinoma in males are managed with combined-modality therapy similar to female breast cancer.2 The patient was told he had multiple high risk factors that put him at high risk for local regional recurrence, including the fact that he is male. Additional risks factors were his large primary tumor and the multiple lymph nodes that were pathologically positive. The radiation oncologist told the patient he would significantly benefit from the administration of post mastectomy radiotherapy. The radiation oncologist also discussed the risks and side effects of radiotherapy. The patient then received a follow-up appointment scheduled four months after this day to coordinate care after he received chemotherapy. The Plan (prescription): About four months later, the patient was close to the end of his cytotoxic chemotherapy regimen. He had done well with no major complications during this process. The radiation oncologist met with JH once again to provide counseling and coordination of care. The radiation oncologist prescribed a total dose of 50 gray (Gy) in 25 fractions. He planned to use the 3-field monoisocentric technique; which would treat the chest

3 wall and regional lymph nodes of the supraclavicular fossa and axilla. The radiation oncologist also planned on continuing the treatment with a 10 Gy boost to the mastectomy scar. The radiation oncologist planned to treat with complex blocking and beam splitting techniques for field matching. The patient was then scheduled to start radiotherapy in April 2013. Patient Setup / Immobilization: In April 2013, JH underwent a CT simulation scan. The patient was placed in the supine position on the CT simulation couch on a tilt board immobilization device (Figure 1). The patients head was turned to the right and supported with a tilt board headrest. The left upper arm was extended and positioned above the patients head while his right arm was positioned akimbo. The patient had a sponge under his knees for support. The radiation oncologist marked the superior, inferior, medial, and lateral regions of the left breast tissue. Anatomical Contouring: After completion of the CT simulation scan, the CT data set was transferred into the Varian Eclipse 10.0 radiation treatment planning system (TPS). The medical dosimetrist contoured organs at risk (OR) which included the right and left lungs, a total lung volume, spinal cord, and the heart. The radiation oncologist reviewed the OR and made final adjustments to the left breast contour in order to begin radiation treatment planning. Beam Isocenter / Arrangement: The radiation oncologist placed the isocenter in the left breast volume on the TPS, which was located in the superior portion of the patients left breast tissue. The medial and lateral conventional tangential photon beams of the breast plan utilized gantry angles of 310 degrees and 130 degrees respectively. For the supraclavicular field, a slight right anterior oblique (RAO) field was angled away from the spinal cord at 345 degrees. The lower left and bottom borders met at the isocenter for the tangential field. The boost plan included a left anterior oblique (LAO) electron field to cover the surgical scar with the gantry at 35 degrees and a collimator rotation of 10 degrees. Treatment Planning: The radiation oncologist outlined the dose prescription and objectives for the breast plan (Figure 2). The objective was to reduce radiation toxicity to the heart and left lung while maintaining the prescription dose evenly throughout the breast tissue. The prescription dose for the conventional tangential fields was prescribed to a calculation point placed by the medical dosimetrist at a depth of 12.1 cm within the left breast tissue. The medical dosimetrist placed the calculation point near the mid-plane depth of the medial and lateral tangential beams, in the center of the superior and inferior extents of the left breast volume, and

4 approximately 1.5 cm from the left chest wall (Figure 3). The dosimetrist used custom blocking to match the tangential and supraclavicular fields with non-divergent beams. In order to do this, the beam was split along the central-axis. The multi-leaf collimators were used to block dose to critical structures, such as the heart and lung (Figures 3, 4). Both unequally weighted tangential beams were assigned to the calculation point and computed to deliver the prescription dose. Mixed beam energies of 6 megavolts (MV) and 18 MV, multi-leaf collimators, and the field-infield technique were used to improve dose homogeneity in the target (Figures 5, 6). The hot spot was 109.9% (Figures 7-9). The supraclavicular field included a calculation point placed at a depth of 3 cm. The medical dosimetrist placed this point within tissue and made sure it was not near the field edge. The multi-leaf collimators were used to reduce dose to the spinal cord and humeral head. This supraclavicular field had a hot spot of 105.8% (Figures 11-16). A boost was ordered because most local recurrences are near the primary site.3 The external beam electron radiotherapy boost used 9 mega-electron volts (MeV) was then planned for a total dose of 1000 centigray (cGy) with 200 cGy per fraction for 5 fractions to the tumor bed (Figure 17). The patient was set up to a source to skin distance (SSD) of 105 cm with a 1 cm bolus (Figure 18). The dosimetrist placed the calculation point at a depth of 2.1 cm in the TPS. The 1 cm tissue-equivalent bolus material was created in the treatment planning system. The bolus was placed directly on the patients skin surface during the boost treatment to reduce the skin sparing of megavoltage photon beams. The boost hot spot was 103.9% Figures 19-22). Once adequate prescription dose coverage was achieved to the left breast volume with each plan, the medical dosimetrist reviewed the OR doses, the isodose lines, and the dose volume histograms (DVH) (Figures 10, 16, 22). The OR on the sum plans DVH (Figure 23) reflected doses of 803.3 cGy in the heart, 123.9 cGy in the spinal cord, 4815.3 cGy in the left lung, and 121.2 cGy in the right lung. Mean doses include 129.9 cGy in the heart, 59.2 cGy in the spinal cord, 857.6 cGy in the left lung and 11.8 cGy in the right lung. The plan of the left breast utilized conventional tangent and supraclavicular fields to achieve adequate prescription coverage and a homogeneous dose distribution throughout the left breast tissue. Quality Assurance/Physics Check: The monitor units (MU) were reviewed and a second check was completed with a quality assurance (QA) computer program called MUCheck. The MU were within 5% tolerance and passed. The plan treatment plan was reviewed by a medical

5 physicist for a final check before treatment began. Diodes and weekly physics chart checks were employed for quality assurance. Conclusion: The planning technique presented the medical dosimetrist with several challenges. One challenge was determining desirable gantry angles that would provide adequate coverage to the target. Another challenge was to spare critical structures without compromising the target coverage. The medical dosimetrist used conformal blocking to protect the heart and lung from the primary beams. Blocking was also used in the supraclavicular field to block the spinal cord and humeral head. In addition, the hot spots areas presented another problem for the medical dosimetrist. The field-in-field technique with mixed energy beams helped provide homogeneous dose in the target. I really enjoyed this case study because male breast cancer is very rare, and it provided me with a good learning opportunity.

6 Figures

Figure 1. CT simulation setup.

Figure 2. Left chest wall plan summary.

Figure 3. Left chest wall plan in the beams eye view for the left medial tangent field.

Figure 4. Left chest wall plan in the beams eye view for the left lateral tangent field.

Figure 5. Left chest wall plan in the beams eye view for the left medial tangent field with the field in field technique.

Figure 6. Left chest wall plan in the beams eye view for the left lateral tangent field with the field in field technique.

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Figure 7. Left chest wall plan in transverse view.

Figure 8. Left chest wall plan in frontal view.

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Figure 9. Left chest wall plan in sagittal view.

Figure 10. Left chest wall plan DVH.

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Figure 11. Supraclavicular plan summary.

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Figure 12. Supraclavicular field in the beams eye view.

Figure 13. Supraclavicular plan in transverse view.

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Figure 14. Supraclavicular plan in frontal view.

Figure 15. Supraclavicular plan in sagittal view.

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Figure 16. Supraclavicular plan DVH.

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Figure 17. Boost plan summary.

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Figure 18. Boost plan in the beams eye view of the electron field.

Figure 19. Boost plan in transverse view.

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Figure 20. Boost plan in frontal view.

Figure 21. Boost plan in sagittal view.

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Figure 22. Boost plan DVH.

Figure 23. Plan sum DVH. This DVH combines the data from the chest wall, supraclavicular, and boost plans.

20 References 1. Beresford MJ, Wilson GD, Makris A. Measuring proliferation in breast cancer: practicalities and applications. Breast Cancer Research. 2006;8(216):1-11. doi:10.1186/bcr1618. 2. Chao K, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011. 3. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.