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Dustin Melancon September Case Study September 27, 2013 3D CRT for Invasive Ductal Carcinoma of the Left Breast History of Present Illness: Patient PR is a 67-year-old female who felt a mass in her left breast in April 2012. The mass gradually progressed until it was picked up on a routine mammogram in January 2013. She underwent an ultrasound guided core biopsy in February 2013. The lesion was measured to be 2.3 centimeters (cm). The disease was diagnosed as poorly differentiated grade 3 invasive carcinoma, estrogen receptor (ER) negative, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) negative. Metastatic carcinoma was identified in 3 of 4 lymph nodes. She also had some overlying inflammatory changes. Triple-negative inflammatory breast cancer has poor overall survival and high locoregional relapse.1 Multi-modality therapy is the standard of care for this patient because of the initial clinical stage of inflammatory breast cancer.2 Past Medical History: PR has a history of arthritis and left hip replacement in 2010. 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. Her family history includes her sister with breast cancer. Medications: PR uses the following medications: Simvastatin, Gemfibrozil, Prochlorperazine, and Zofran. Diagnostic Imaging: PR received a whole body bone scan in February 2013. She was administered 17.2 millicuries (mCi) of Technetium-99m (Tc-99m) methylene diphosphonate. Static scintigraphic images of the skeleton were obtained in the anterior and posterior projections. Additional lateral views of the skull and upper extremities were also obtained. There was no obvious evidence of osseous metastatic disease. She also had ultrasound guided port placement and ultrasound guided left breast biopsy in the upper-outer quadrant in February 2013. Radiation Oncologist Recommendations: The radiation oncologist discussed with PR the options, risks, and benefits of post mastectomy radiation therapy for locally advanced inflammatory breast cancer. For instance, post mastectomy radiation therapy reduces locoregional recurrence and improves survival of patients with breast cancer.3,4 He

recommended irradiation of the chest wall, regional lymphatics of the supraclavicular fossa and axilla, and an electron boost to the mastectomy scar. He recommended seeing her postoperatively after several rounds of chemotherapy in June 2013. The Plan (Prescription): PR was planned for treatment of the left chest wall and regional lymph nodes of the supraclavicular fossa and axilla using a 3-field monoisocentric technique with complex multi-leaf collimation for blocking and 2 tangential portals aligned to a supraclavicular field. Beam splitting techniques were used to align the fields in a perfectly matched fashion. The patient received a total dose of 50.4 Gray (Gy) in 28 fractions to this region followed by an additional 10 Gy en face electron boost to the mastectomy scar. 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. 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, spinal cord, and the heart. The radiation oncologist reviewed the ORs and the case was ready for treatment planning. Beam Isocenter / Arrangement: The radiation therapist scheduled the patient during simulation on the Varian TrueBeam linear accelerator. After scanning the patient, 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. In the TPS, the medical dosimetrist selected the beam arrangement for treatment. The medial and lateral tangential 6 megavoltage (MV) and 10 MV photon beams of the chest wall plan utilized gantry angles of 310 degrees and 130 degrees respectively. The supraclavicular field featured a gantry angle of 345 degrees to decrease dose to the spinal cord. The electron boost field had a gantry angle of 30 degrees and a collimator rotation of 10 degrees.

Treatment Planning: The patient was planned using the Varian Eclipse TPS for a Varian TrueBeam linear accelerator. A 3-field monoisocentric technique was used for field matching between the tangential fields and a supraclavicular field. Three separate plans included the tangential fields, supraclavicular field, and electron boost. The mixed energy tangential fields for the chest wall featured the field-in-field technique and provided better homogeneity and less dose to critical structures. 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 11.5 cm within the medial tangent field and 8.0 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. These 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 photon 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 hot spot was 110.0%. Next, the medical dosimetrist created a plan for the supraclavicular field. This field used 6 MV with a right anterior oblique angle to decrease dose to the spinal cord (Figure 12). The MLCs were also used to decrease dose to the spinal cord and humeral head. The medical dosimetrist placed the calculation point at a depth of 3.0 cm. The hot spot in the supraclavicular plan was 109.4%. The medical dosimetrist then created an additional boost plan. This plan contained a 9 mega-electron volt (MeV) field at a distance of 105 cm with a 1 cm bolus. This field was shaped using an electron block with a 2 cm margin around the surgical scar (Figure 19). The medical dosimetrist calculated the electron boost to a depth of 2.1 cm. The hot spot was 104.0%. Once adequate dose coverage was achieved to the left chest wall and supraclavicular area, the medical dosimetrist reviewed the OR doses, the isodose lines, and the dose volume histogram (DVH) in the composite plan (Figure 17). The OR on the composite plan DVH had maximum doses of 3998.6 centigray (cGy) in the heart, 146.6 cGy in the spinal cord, 5127.0 cGy in the left lung, and 164.2 cGy in the right lung. Mean doses include 292.4 cGy in the heart, 44.0

cGy in the spinal cord, 1250.5 cGy in the left lung and 23.1 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. Quality Assurance/Physics Check: The monitor units (MU) were reviewed and a second check was completed with MUCheck, a quality assurance (QA) computer program. The MUs were within 5% tolerance and passed. In the final check before treatment, the medical physicist reviewed and approved the treatment plan. 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. Another challenge was to spare critical structures and not compromise the target. The medical dosimetrist used MLCs to protect the heart and lung from the primary beams. In addition, the hot spot presented another problem for the medical dosimetrist. Mixed energy beams helped lower the hot spot with a more even dose distribution 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 head first in the supine position on the CT simulation couch on a tilt board immobilization device. The patients head was turned to the right and supported with a tilt board headrest (A). 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 borders (B) of the left chest wall.

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.

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.

Figure 11. Supraclavicular plan summary.

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Figure 12. Supraclavicular field in the beams eye view.

Figure 13. Supraclavicular field in the transverse view.

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Figure 14. Supraclavicular field in the frontal view.

Figure 15. Supraclavicular field in the sagittal view.

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Figure 16. Supraclavicular plan DVH.

Figure 17. Composite plan DVH.

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Figure 18. Boost plan summary.

Figure 19. Boost field in the beams eye view.

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Figure 20. Boost plan transverse view.

Figure 21. Boost plan frontal view.

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Figure 22. Boost plan sagittal view. References 1. Li J, Gonzalez-Angulo AM, Allen PK, et al. Triple-negative subtype predicts poor overall survival and high locoregional relapse in inflammatory breast cancer. Oncologist. 2012;16(12):1675-1683. doi:10.1634/theoncologist.2011-0196. 2. Rehman S, Reddy CA, Tendulkar RD. Modern outcomes of inflammatory breast cancer. Int J Radiat Oncol Biol Phys. 2012;84(4):619-624. doi:10.1016/j.ijrobp.2012.01.030. 3. 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. 4. 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. 5. Dewar JA. Postmastectomy radiotherapy. Clin Oncol. 2006;18(3):185-190. doi:10.1016/j.clon.2005.11.006.