1

Megan Whitley September Case Study September 26, 2013 Right Breast Radiotherapy with Electronic Compensators History of Present Illness: EN is a 55 year old white female who, upon routine examination, was found to have a 1.2 centimeter (cm) mass in her lateral right breast. Diagnostic mammogram and ultrasound were used to confirm a suspicious appearing mass and a biopsy revealed grade 2 infiltrating ductal carcinoma (IDC) which was strongly estrogen and progesterone receptor positive, ER and PR positive. A magnetic resonance imaging (MRI) scan was recommended and performed, confirming the previous findings. EN underwent a lumpectomy and sentinel lymph node biopsy where the final pathology determined a 1.3 cm, grade 1, IFDC with associated ductal carcinoma in situ (DCIS). Her margins tested negative, there was no lymphoascular invasion, and the one sentinel node was negative for malignancy. Past medical History: The patient has a history of hypertension, gastroesophageal reflux, and Lyme disease. She has a surgical history that includes the previously mentioned breast surgery, a hysterectomy in 2001, prior laparoscopies, a benign tumor removal from her left tibia, and arthroscopy of her left knee. EN is gravida 2 and para 2 and was 36 at the time of her first pregnancy. She underwent fertility treatments for 9 months. At age 40 she went through surgical menopause fur to endometriosis. Social History: EN works part-time in market research and is married with 2 teenage children. She consumes approximately 2 alcoholic beverages per week and is a nonsmoker. ENs sister was diagnosed with breast cancer at the age of 49 (stage 1, grade 3, ER PR negative), and her mother had precancerous breast (potentially DCIS) at age 79. Medications: EN is on Triamterene, losartan, Nexium, and Lunesta. She has allergies to both Zithromax and sulfa drugs. Radiation Oncologist Recommendations: Upon meeting with the radiation oncologist (RO), EN and her husband were apprised of the potential treatment options available. The RO discussed the rationale for whole breast radiation. She also entailed various fractionation schemes including conventionally fractionated and hypofractionated treatments. EN asked multiple questions and they were answered to her satisfaction. Both the acute and delayed side effects were discussed. Based on this conversation, the diagnostic imaging, the pathology, and

the ROs previous experience, a hypofractionated treatment regimen was decided upon with an initial 16 fractions, followed by a 4 fraction boost. The radiation oncologist recommended EN for adjuvant radiation therapy following breast conservation surgery. Three different treatment regimens were discussed. The first was whole breast irradiation with a boost either in standard fractionation or hypofractionation. Also discussed was the potential for a trial/protocol study. Side effects of radiation for all of these options were discussed, and a final decision was reached by EN, her husband, and the RO for the hypofractionated 4256 centigray (cGy) dosing at 266 cGy per day for 16 fractions, followed by a 4 fraction boost. Patient Setup/Immobilization: Patient EN was scanned in the supine position, using a wing board, Vac-Lok, head rest, and knee wedge for immobilization. Radiopaque markers were placed on the patient prior to scanning to aid in localization of breast tissue. For planning purposes, 3 fiducial markers represented laser placement and 6 radiopaque markers were used to outline breast tissue on the inferior, superior, medial, and lateral aspects, nipple and lumpectomy scar. A GE LightSpeed CT scanner was used for treatment planning simulation and 2.5 millimeter (mm) slices were obtained. After the scan was complete, the radiation oncologist set the isocenter, the table was shifted, and the treatment isocenter was marked on the patient. Pictures were taken of the markers and fiducials to assist in accurate patient setup during treatment. The pictures were then transferred to the picture archiving and communication system (PACS) software and the computed tomography (CT) images were transferred to the Eclipse treatment planning software (TPS). Anatomical Contouring: The Eclipse TPS, version 10.0 was used for target delineation. A CT scan was obtained with the patient in the previously mentioned treatment position. After the patient was imported into Eclipse, contouring was done of the lungs, as well as a cumulative lung structure representing the total lung tissue. Other contouring included the heart, spinal cord, carina, liver, body, scar wire plus the medial, lateral, superior, and inferior field delineating wires, and the thyroid gland. The radiopaque marks used to indicate regions of interest have a higher atomic number than human tissue. This provided visualization on the scan, outlining the regions of interest. Lastly, the radiation oncologist contoured the clinical target volume (CTV). The CTV consists of the lumpectomy cavity and the clips that remain post operatively which designate the extent of the tumor cavity. The medical dosimterist expanded the CTV by 1 cm, labeling it CTV + 1. Both the CTV and the expansion for Patient EN are represented in Figure

1. A plan was generated focusing the prescribed dose on both the expansion and the CTV for the patient. Beam Isocenter/Arrangement: ENs prescription held the challenge of delivering 4256 cGy in 16 fractions to the CTV and was complicated by the nearness of lung tissue and healthy breast tissue, to gross disease. A Varian Trilogy was chosen as the patients treatment machine and a tangential beam arrangement was prescribed. The Trilogy provides both 6 megavoltage (MV) and 18MV beam energies. The medial beam and isocenter were placed by the physician. The first step was to oppose the medial, producing the lateral tangent beam. Treatment Planning: Using the Eclipse 10.0 treatment planning system, the medical dosimetrist began designing ENs breast treatments. With both of the beams created, a noncoplanar technique was used to provide non-divergent posterior borders decreasing the radiation received in the lung and heart. Deep penetration towards the chest wall was required to fully cover the CTV and CTV + 1 (Figure 1). The maximum separation (S(max)) of the patient was 23.2 cm, established the need for mixed energies, 6 MV and 18MV, to achieve proper dose distribution. Both the separation and the dose distribution can be seen in Figure 1. The initial beams were duplicated for a total of 4 beams (beam report in Figure 2). The final weighting for the plan was 70% of the dose from the 6 MV fields and 30% of the dose from 18 MV fields, with those weights equally divided between each energies beams. To increase the depth of the dose a calculation point was placed posteriorly to the central axis, as shown in the axial view in Figure 3. After a location for the calculation point was determined, the point was assigned to the prescription in order to deliver 100% of the dose to this point, rather than the isocenter. Electronic Compensators (ECs) were used to decrease the hot spot in the plan while maintaining optimal coverage. Irregular surface compensators use dynamic multileaf collimators (dMLCs) to modify the fluence of an irregular surface.1 Unfortunately, although ECs provide a more conformal dose coverage, it should understood that they are less efficient when the impact of respiratory breast motion and setup errors are taken into consideration. 2 The overall hot spot for this plan was 106.8% at the completion of planning. The RO was very pleased with this plan for achieving all of the prescribed goals, thus approving it. These doses were registered on the DVH and reported to the physician (Figure 4). Quality Assurance/Physics Check: After the plan was approved by the RO, a second check was done in RadCalc to verify the calculations. All 4 of the beams in the second check require a

differentiation of less that 2% to pass. ENs plan passed the second check (Figure 5). At the facility, when ECs are used, physics has to perform a quality assurance (QA) test to verify the accuracy of the plan. Once the plan was approved and ready for treatment, the final step was to generate and perform a trial fraction, making sure that the information accurately transferred to the record and verify software, and that the plan would behave in the manner in which it was intended. The trial fraction was done on the treatment machinery, a Varian Trilogy IX, and verified by the physics quality assurance tool, a Delta4 phantom. The fluence that registered within the Delta4 was compared to the approved treatment plan fluence. The Delta4 functions from a gamma analysis. The absolute dose evaluation and gamma analysis of the fluence were performed and compared to the measured dose delivered against the calculated phantom plan. For the plan to pass QA, 95% of all the points tested within the phantom must have a 3% deviation from the predetermined dose. This plan passed QA. Conclusion: When planning using electronic compensators, there are several hurdles to be faced. The first is learning the strategy to build and design the ECs. Implementing the ECs into the treatment plan is more difficult than it seems, and a misstep in any direction in the process renders flaws within the treatment plan. The medical dosimetrist came into these issues with this plan, leading to multiple attempts to correctly add the ECs. Complications were also found determining if the case was suitable for mixed beam energies. This facility has a standard that if the separation measurement is higher than 20 cm, the plan could potentially include mixed energies. The reasoning for this is that with increased separation, deeper penetration will be required to provide full coverage of the prescribed dose. Furthermore, issues can arise when establishing the proper weighting. This is highly impacted by the placement of the lumpectomy cavity. If the cavity is more laterally positioned, then more of the weight will be required from the lateral beam, and vice versa with a medially located cavity. All of these hurdles were included in the treatment planning process for EN. And with all learning, practice makes perfect, so the more these issues are encountered, the more easily they will be overcome.

Figures

Figure 1. The CTV, or cavity (red), and the expansion, or CTV + 1 (blue).

Figure 2. Beam report providing information on the number of beams within the plan, the measurements for setup purposes, and any other valuable information the therapists or physicists may need when checking the plan.

Figure 3. Illustration of the placement of the calculation point which helps to provide a more conformal dose distribution.

Figure 4. DVH used to illustrate doses received by both the targets and the organs at risk.

Figure 5. Documentation, provided by RadCalc, verifies the secondary calculation check passed QA.

10

References 1. Emmens DJ, James HV. Irregular surface compensation for radiotherapy of the breast: correlating depth of the compensation surface with breast size and resultant dose distribution. Br J Radiol. 2010;83(986):159-165. doi: 10.1259/bjr/65264916. 2. Furaya T, Satoru S, Chie K, et al. The dosimetric impact of respiratory breast movement and daily setup error on tangential whole breast irradiation using conventional wedge, field-in-field and irregular surface compensator techniques. J Radiat Res. 2012:1-9. doi: 10.1093/jrr/rrs064.