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Dustin Melancon October Case Study October 24, 2013 3D CRT for Invasive Ductal Carcinoma of the Left Breast History of Present Illness: Patient NC is a 68 year-old female who presented with metastatic disease. In March 2013, she was seen by a gynecologist for evaluation of 2 pimples located around her nipple. At that time they were thought to be due to infection and she was treated with antibiotics. Unfortunately, the patient developed worsening erythema, warmth, breast swelling and hardening over the next 3 weeks. A punch biopsy of the skin was performed in April 2013. It revealed a grade 3 invasive ductal carcinoma involving the deep and superficial dermis of the skin with no ulceration present. It was estrogen receptor (ER) positive, progesterone receptor (PR) positive, and human epidermal growth factor receptor 2 (HER2) negative. Fine needle aspiration of ipsilateral axillary lymph node was consistent with metastatic disease. Pathology revealed 2 foci of disease. There was a 4.5 x 3 x 2 cm lesion in the upper outer quadrant and a 3 x 2.5 x 2 cm lesion in the lower inner quadrant. Both were consistent with grade 3 invasive ductal carcinoma. The patient was taken for left sided modified radical mastectomy with lymph node dissection in July 2013. Of the 20 lymph nodes sampled, 12 were positive for metastatic disease with evidence of extranodal extension. Past Medical History: NC has a history of hypertension, peptic ulcer disease, and depression. Social History: The patient drinks 2-3 alcoholic drinks a week. She has a masters degree in counseling, education, and psychology. Her family history includes her mother with breast cancer. Medications: NC uses the following medications: Ambien, Effexor, Gabapentin, Lipitor, Lisinopril, and Metformin. Diagnostic Imaging: NC had a positron emission tomography (PET) computed tomography (CT) scan in April 2013 which showed uptake in multiple left axillary lymph nodes, uptake in the left breast, and suspicious uptake in her retroperitoneal lymph nodes. The patient was subsequently initiated on palliative chemotherapy. Subsequent PET/CT scans revealed post

treatment changes and improvement of her left axillary lymphadenopathy. She had a PET scan in June 2013 that revealed stable disease. Radiation Oncologist Recommendations: The radiation oncologist discussed that the patient needed adjuvant radiation therapy to decrease her risk of local recurrence. The radiation oncologist discussed with NC the options, risks, and benefits of post mastectomy radiation therapy for locally advanced left sided breast cancer. For instance, post mastectomy radiation therapy reduces locoregional recurrence and improves survival of patients with breast cancer.1,2 The patient understood and agreed to the assessment and treatment plan. The Plan (Prescription): The patient lives a distance from the cancer center and wanted to be treated with a hypofractionated approach. The team planned to treat the patients left chest wall and regional lymph nodes of the supraclavicular fossa and axilla using a 3-field monoisocentric technique with high energy photons to a total dose of 4,050 cGy in 15 fractions. Beam splitting techniques and multileaf collimation was requested to match multiple fields and block critical structures. Following this, the radiation oncologist prescribed an electron boost to the mastectomy scar to 900 cGy with bolus and an electron block. Patient Setup / Immobilization: In September 2013, NC underwent a CT 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 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 298 degrees and 118 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 degrees and a collimator rotation of degrees. Treatment Planning: A 3-field monoisocentric technique with beam splitting techniques was used for field matching between the tangential fields and a supraclavicular field. Three separate plans were used for the tangential field, supraclavicular field, and the electron boost. The mixed energy tangential fields for the chest wall featured the field-in-field technique and allowed for better homogeneity and less dose to critical structures. The radiation oncologist outlined the dose prescription 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 8.2 cm within the medial tangent field and 10.5 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.3 Both unequally weighted tangential beams were assigned to the calculation point and computed to deliver the prescription dose. Mixed photon beam energies of 6 megavolts (MV) and 18 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 108.8%. 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 104.8%. Once adequate prescription dose coverage was achieved to the left chest wall and supraclavicular area, the medical dosimetrist reviewed the OR doses, the isodose lines (Figures 13-16), and the dose volume histogram (DVH) in the composite plan (Figure 17). The OR on the composite plan DVH had maximum doses of 1794.3 centigray (cGy) in the heart, 120.6 cGy in the spinal cord, 3967.4 cGy in the left lung, and 109.4 cGy in the right lung. Mean doses include 139.3 cGy in the heart, 38.8 cGy in the spinal cord, 771.8 cGy in the left lung and 16.6 cGy in the right lung. Next, the medical dosimetrist created the electron boost plan. This plan contained a 9 mega-electron volt (MeV) field at a distance of

110 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 103.2%. The field featured a 15 x 15 cm electron cone with an electron block. The gantry and collimator angles were set at 35 degrees with 0 degree couch rotation Quality Assurance/Physics Check: The MUs were reviewed and a second check was completed with MUCheck (Figures 17, 23). 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 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. The light green contoured structure is the left lung, the dark green structure is the right lung, the pink structure is the heart, and the yellow structure is the spinal cord.

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. The green isodose line represents the 100% prescription dose.

Figure 8. Left chest wall plan in frontal view. The green isodose line represents the 100% prescription dose.

Figure 9. Left chest wall plan in sagittal view. The green isodose line represents the 100% prescription dose.

Figure 10. Left chest wall plan DVH.

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Figure 11. Supraclavicular plan summary.

Figure 12. Supraclavicular field in the beams eye view.

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Figure 13. Supraclavicular field in the transverse view. The green isodose line represents the 100% prescription dose.

Figure 14. Supraclavicular field in the frontal view. The green isodose line represents the 100% prescription dose.

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Figure 15. Supraclavicular field in the sagittal view. The green isodose line represents the 100% prescription dose.

Figure 16. Supraclavicular plan DVH.

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Figure 17. Composite plan DVH.

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Figure 18. Chest wall MU calculation.

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Figure 19. Electron boost in the beams eye view.

Figure 20. Electron boost in the transverse view.

Figure 21. Electron boost in the frontal view.

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Figure 22. Electron boost in the sagittal view.

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Figure 23. Boost plan MU calculation.

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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. Dewar JA. Postmastectomy radiotherapy. Clin Oncol. 2006;18(3):185-190. doi:10.1016/j.clon.2005.11.006.