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Dustin Melancon July Case Study July 27, 2013 3D CRT for Invasive Ductal Carcinoma of the Left Breast History of Present Illness: CS is a 60-year-old female who detected a mass in June 2012 that was approximately the size of a small egg. She ignored this until October after noticing it continued to grow. There was no nipple discharge or skin ulceration; however, she mentioned swelling of the breast, dimpling of the skin, and redness overlying the mass. The patient had this mass biopsied in October 2012 and it was consistent with invasive ductal carcinoma, estrogen (ER) positive, progesterone (PR) negative and human epidermal growth factor receptor 2 (HER2) negative. She did have a punch biopsy of the skin that showed only chronic inflammation with no carcinoma. An ultrasound guided fine needle aspiration of a lymph node was negative. The patient started neoadjuvant chemotherapy in November 2012 and had an immediate dramatic clinical response of her tumor. She went on to a bilateral mastectomy in May 2013 with a prophylactic contralateral mastectomy. She had 4 axillary lymph nodes that were all negative for tumor and negative for treatment effect. She had a complete pathologic response with the tumor bed measuring 5.5 centimeters (cm) in greatest dimension. There was no evidence of invasive or in situ carcinoma in the specimen. The role of post mastectomy radiation therapy is determined by pathologic staging, with surgery as the first treatment modality.1 The patient had clinical T4 (stage T4), N0 (stage 0 regional lymph nodes), MX (metastases cannot be evaluated) with a pathologic stage of ypT0N0 (complete pathological response). Due to the patients initial clinical stage, post mastectomy radiation therapy was indicated. Past Medical History: CS has a history of high blood pressure, diabetes, gastric ulcers, chronic arthritis, and reflux disease. She also has occasional migraine headaches. Social History: The patient is married with one child. She has a high school education and currently works for a university. She has no history of using alcohol or tobacco. The family history includes her mother with a history of cancer but she did not specify the type.

Medications: CS uses the following medications: Atenolol, Celexa, Dicyclomine, Gabapentin, Nabumentone, Prochlorperazine Maleate, Reglan, and Vytorin. Diagnostic Imaging: Ultrasound guided fine needle aspiration biopsy was performed on the left intramammary lymph node in October 2012. The results were negative for malignancy. No other diagnostic imaging techniques were used in this case. Radiation Oncologist Recommendations: The radiation oncologist discussed with CS the options, risks, and benefits of post mastectomy radiation therapy. For instance, post mastectomy radiation therapy reduces locoregional recurrence and improves survival of patients with breast cancer.1,2 He also discussed with her conventionally fractionated versus hypofractionated techniques. Alternative methods of irradiation for breast cancer, such as hypofractionated therapy, have been developed to abbreviate treatment times, enhance convenience, and/or decrease exposure to the normal tissues.3 The radiation oncologist offered to refer the patient somewhere closer to home, but she wanted to have her treatment at the current facility. Because of her long commute, CS benefited from a short hypofractionated course for treatment. The Plan (Prescription): The patient had a locally advanced breast cancer with a mastectomy. She had radiographic workup and biopsy prior to neoadjuvant chemotherapy, which revealed no evidence of lymph node involvement with the inflammatory carcinoma of the breast. She had a complete pathologic response after neoadjuvant chemotherapy and mastectomy. Even after mastectomy and systemic therapy, disease may remain in the chest wall and/or regional lymph nodes. This residual disease is not only a risk of morbid locoregional recurrence, but also as an important reservoir from which distant metastases may be seeded or reseeded after the initial elimination of distant disease.4 Due to these risks, they planned to treat her chest wall using an opposed tangential technique in a combination of 6 and 10 megavoltage (MV) photons. The radiation oncologist prescribed hypofractionated chest wall radiation therapy to a total dose of 4050 cGy in 15 fractions followed by an additional boost to the mastectomy scar of 900 cGy in 3 fractions using en-face electrons to the maximum dose (dmax). Patient Setup / Immobilization: In April 2013, CS underwent a computed tomography (CT) simulation scan. She was placed head first 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 her right arm was positioned akimbo. The patient had a sponge under her knees for support. The radiation oncologist marked the superior, inferior, medial, and lateral regions of the left chest wall. The radiation therapist outlined the mastectomy scar with radioopaque wire for treatment planning purposes. 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 mastectomy scar was contoured by using the radioopaque wires from CT simulation. The radiation oncologist reviewed the OR and the case was ready for treatment planning. Beam Isocenter / Arrangement: The radiation oncologist placed the isocenter in the superior left chest wall on the TPS, which was located in the superior portion of the patients left chest wall. The medial and lateral conventional tangential photon beams of the chest wall plan utilized gantry angles of 305 degrees and 125 degrees respectively. The electron boost plan for the mastectomy scar had a gantry angle of 28 degrees. Treatment Planning: The radiation oncologist outlined the dose prescription and objectives for the chest wall plan (Figure 2). The objective was to reduce radiation toxicity to the heart and left lung while maintaining the prescription dose evenly throughout the chest wall. The prescription dose for the conventional tangential fields was prescribed to a calculation point placed by the medical dosimetrist at a depth of 7.8 cm within the medial tangent field and 11.8 cm within the lateral tangent field. The medical dosimetrist placed the calculation point near the mid-plane depth of the medial and lateral tangential beams and the center of the superior and inferior extents of the left chest wall (Figure 3). The multi-leaf collimators (MLCs) were used to block dose to critical structures, such as the heart. The modern radiotherapy techniques can improve local control and avoid cardiac morbidity.5 Both unequally weighted tangential beams were assigned to the calculation point and computed to deliver the prescription dose. Mixed beam energies of 6 MV and 10 MV, MLCs, and the field-in-field technique were used to improve dose homogeneity in the chest wall (Figures 5 and 6). The field-in-field technique uses portals treated through the same gantry angle to reduce high dose regions.6 The medical dosimetrist accomplished this by converting the 110% isodose level to a structure in the TPS. Next, the

medical dosimetrist looked in the beams eye view of the field-in-field and adjusted the MLC to cover the 110% structure. Once calculated, all of the fields were appropriately weighted. The medical dosimetrist then converted the 107% isodose level to a structure to increase dose homogeneity and lower the maximum dose region. The hot spot was 107.5%. Once adequate prescription dose coverage was achieved to the left chest wall, the medical dosimetrist reviewed the OR doses, the isodose lines, and the dose volume histogram (DVH) (Figure 10). The DVH for the chest wall plan reflected doses of 3282.5 centigray (cGy) in the heart, 29.7 cGy in the spinal cord, 3963.8 cGy in the left lung, and 32.1 cGy in the right lung. Mean doses include 174.9 cGy in the heart, 7.4 cGy in the spinal cord, 540.1 cGy in the left lung and 5.4 cGy in the right lung. The plan of the left chest wall achieved adequate prescription coverage and a homogeneous dose distribution throughout the left chest wall. For the mastectomy scar, electrons would deliver dose to the scar and limit the dose to adjacent tissue.6 The medical dosimetrist used 9 mega-electron volts with a 1 cm bolus at 110 cm source to skin distance (SSD). A block was created in the TPS that was 2 cm around the scar. The medical dosimetrist set the gantry at 28 degrees with the collimator at 25 degrees. A 25x25 cm field size was large enough to cover the entire mastectomy scar. A calculation point was placed at 2.1 cm, the dmax of 9 MeV. The hot spot was 103.2%. The DVH for the boost plan reflected doses of 228.9 centigray (cGy) in the heart, 3.5 cGy in the spinal cord, 250.5 cGy in the left lung, and 5.3 cGy in the right lung. Mean doses include 8.1 cGy in the heart, 1.7 cGy in the spinal cord, 6.6 cGy in the left lung and 2.3 cGy in the right lung. The medical dosimetrist observed the 95% isodose line and confirmed that the boost plan achieved adequate prescription coverage in the scar. Quality Assurance/Physics Check: The monitor units (MU) were reviewed then a second check was completed with MUCheck, a quality assurance (QA) computer program (Figure 17). The MUs were within 5% tolerance and passed. The plan treatment plan was reviewed by a medical physicist for a final check before treatment began. Diodes and weekly physics chart checks were employed for QA. Conclusion: The chest wall plan presented the medical dosimetrist with several challenges. One challenge was determining the desirable gantry angles to provide adequate coverage, while sparing critical structures without compromising the target. The medical dosimetrist used

conformal blocking to protect the heart and lung from the primary beams. In addition, the hot spot area presented another problem for the medical dosimetrist. Mixed energy beams helped provide homogeneous dose in the chest wall plan. This case study was another opportunity for the medical dosimetrist to become more experienced with treatment planning for chest wall irradiation.

Figures

Figure 1. CT simulation setup demonstrating the patients placement. The patient was (A) head first in the supine position on a tilt board immobilization device, head turned to the right, and a sponge under her knees for support. The radiation oncologist marked the (B) superior, inferior, medial, and (C) lateral regions.

Figure 2. Left chest wall plan summary.

Figure 3. Left chest wall plan in the beams eye view for the left medial tangent field. The pink structure is the heart, the light green structure is the left lung, and the dark green structure is the right lung.

Figure 4. Left chest wall plan in the beams eye view for the left lateral tangent field. The pink structure is the heart, the light green structure is the left lung, the dark green structure is the right lung, and the yellow structure is the spinal cord.

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Figure 5. Left chest wall plan in the beams eye view for the left medial tangent field with the field in field technique. The pink structure is the heart, the light green structure is the left lung, the dark green structure is the right lung, and the yellow structure is the spinal cord.

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Figure 6. Left chest wall plan in the beams eye view for the left lateral tangent field with the field in field technique. The pink structure is the heart, the light green structure is the left lung, the dark green structure is the right lung, and the yellow structure is the spinal cord.

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Figure 7. Left chest wall plan in transverse view. The green isodose line represents the 100% prescription line.

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Figure 8. Left chest wall plan in frontal view.

Figure 9. Left chest wall plan in sagittal view.

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Figure 10. Left chest wall plan DVH.

Figure 11. Boost plan summary.

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Figure 12. Boost field in the beams eye view.

Figure 13. Boost plan transverse view. The treatment consisted of 9 MeV electrons to cover the mastectomy scar.

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Figure 14. Boost plan frontal view.

Figure 15. Boost plan sagittal view.

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Figure 16. Boost plan DVH view.

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Figure 17. QA for chest wall plan.

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References 1. Wright JL, Takita C, Reis IM, et al. Predictors of locoregional outcome in patients receiving neoadjuvant therapy and postmastectomy radiation. Cancer. 2013;119(1):16-25. doi:10.1002/cncr.27717. 2. Gebski V, Lagleva M, Keech A, Simes J, Langlands AO. Survival effects of postmastectomy adjuvant radiation therapy using biologically equivalent doses: a clinical perspective. J Natl Cancer Inst. 2006;98(1):26-38. doi:10.1093/jnci/djj002. 3. Yang JT, Ho AY. Radiation therapy in the management of breast. Surg Clin N Am. 2013;93(2):455-471. doi:10.1016/j.suc.2013.01.002. 4. Jagsi R, Pierce L. Postmastectomy radiation therapy for patients with locally advanced breast cancer. Semin Radiat Oncol. 2009;19(4):236-243. doi:10.1016/j.semradonc.2009.05.009. 5. Dewar JA. Postmastectomy radiotherapy. Clin Oncol. 2006;18(3):185-190. doi:10.1016/j.clon.2005.11.006. 6. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.