1

Improved Reproducibility and Dosimetry of Prone Breast Irradiation Using Styrofoam

Blocks: A Case Study
Author: Derek Smith, B.S.
Abstract:
Introduction: Styrofoam blocks are often used with prone breast irradiation for the purposes of
improved reproducibility and dose homogeneity. he purpose of this case study was to evaluate
the reproducibility and dose homogeneity of female breast patients with and without the use of
styrofoam blocks during prone breast irradiation.
Case Description: !hen treating a malignant neoplasm of the female breast, the prone setup
techni"ue is often used for large pendulous breasts which in turn spares dose to the ipsilateral
lung and heart. ypically, the problem with this techni"ue is reproducibility and dose
homogeneity and conformity. his case study demonstrated two patient cases: patient 1
represented a patient that was simulated with and without a styrofoam block but planned and
treated with the styrofoam block techni"ue due to improved dose homogeneity when planning#
patient $ represented a patient that was simulated and treated with the same prone styrofoam
block techni"ue. %atient 1 represented a smaller breast tissue volume to evaluate if the styrofoam
block helped improve dose homogeneity and conformity in both a small &patient $' and a large
&patient 1' breast tissue volume.
Conclusion: (ach plan evaluated dose constraints, homogeneity, and whole breast dose
coverage. !hile the homogeneity inde) and "uality of coverage did not vary with the block, the
conformity inde) improved with the styrofoam setup techni"ue. Although planning and setup
included a few more steps, the overall reproducibility and dose uniformity seemed to improve
when utili*ing the styrofoam block setup techni"ue.
ey!ords: %rone, styrofoam block, +omogeneity, ,eproducibility
Introduction
,adiotherapy after breast-conserving surgery reduces the risk of locoregional recurrences
and improves overall survival when appropriate prone and supine techni"ues are utili*ed.
1
%rone
breast setup has become a popular treatment techni"ue for patients with large pendulous breasts.
$
he biggest advantage of the prone setup is the chance for better dose homogeneity and a lower
dose to the heart and the ipsilateral lung in both left and right breast treatments.
$
,esearch by
.ak et al
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indicated that the supine techni"ue with large breast volumes yielded acute and late-
effect skin to)icities. his is attributed to the dose inhomogeneity and increased separation
distance that was often associated with large breasted women in the supine position.
0
he prone
breast setup has been proven superior to decrease to)icity of post-lumpectomy whole-breast
irradiation.
$
here are current articles available to assist in the improvement concerning a more
comfortable, efficient, and reproducible immobili*ation for prone setup. According to 1ymberis
et al,
0
the prone setup is not only a helpful setup for large breasted women, but it has also
reduced the mean ipsilateral lung dose in all the patients as well as reducing the mean heart dose
to 234 of left breast patients in their study.
Although the prone setup is beneficial, there has also been substantial reproducibility
problems.
5
he most common difficulties with prone breast setups include inade"uate target
coverage, incorrect positioning of the patient, potential issues with e)cessive sinking and rolling
toward the opening of the breast board, and respiratory motion.
5
An important component of
ensuring treatment accuracy to avoid these common problems is verifying the patient position
before treatment delivery. he techni"ue discussed in this case study involves the use of
styrofoam blocks to improve prone breast setup reproducibility and dose homogeneity.
Dose homogeneity is an important aspect to improve the comfort of the patient after
radiotherapy. Breast pain after breast-conserving radiotherapy is not unusual. he risks for this
pain after treatment includes younger age, preoperative breast pain, boost irradiation, and
dosimetric inhomogeneity. .ak et al
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reported that long term breast pain was evident in patients
who received post lumpectomy whole breast irradiatioin 61754 and 61174 of the prescribed
dose. 8rom this observation it was concluded that minimi*ation of dosimetric inhomogeneity
should be prioriti*ed. he styrofoam block could be a helpful tool in the planning and treatment
process to reduce dose inhomogeneity and increase planning target volume &%9' conformity.
Case Description
Patient Selection & Set up
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he patients in this case study were female and diagnosed with left sided breast cancer.
(ach patient re"uired a course of post lumpectomy radiation therapy to the left breast making
them suitable candidates for prone-setup whole breast irradiation.
(ach patient was placed in the prone position on a :ivco ;ew +ori*on %rone Breast
board for simulation. A flat hori*ontal rather than rolled patient position ensures reproducibility
as well as aids in the avoidance of the ipsilateral lung and heart within the treatment volume. o
also avoid the contralateral breast, right breast in these cases, the patient and radiation therapist
worked to pull the contralateral breast laterally out of the treatment field. <nce the patient is
lying comfortably, arms above head, and head turned to the contralateral breast, the patient is :
scanned with the affected left breast rela)ed in air or touching the treatment table. 8or this case
study the patients were also simulated with a styrofoam block or blocks resting below the breast
to achieve greater reproducibility and dose homogeneity &8igure 1'. <nce in position, the breast
is marked with setup reference marks and the patient=s breast tissue is bordered with inferior,
superior, medial and lateral markers &8igure $'.
<nce the patient is in the optimal treatment position, tattoo=s are marked on a plane
posterior to the rib cage to avoid discrepancies that result from breathing or breast organ motion
&8igure /'. attoo=s are also marked in reference to the inferior to superior lasers to ensure the
patient is not rotated to the left or right &8igure 0'. he styrofoam blocks become very useful in
the process of reproducibility. he resting breast circumference, and lateral laser pro>ections are
marked as a setup reference on the styrofoam blocks &8igure 5'. A ruler is also placed on the
table to mark the inferior and superior borders of the breast board opening that has an inde) on
both the ruler and styrofoam block &8igure ?'. 8or e)ample, if the patient=s lateral tattoos and
laser alignments lie at ? inches on the inde) ruler then this ensures that the breast is centered
correctly in all directions. he utili*ation of the styrofoam blocks are a helpful tool in
reproducibility and give the large pendulous breasts a more cylindrical shape for improved dose
homogeneity.
Target Delineation
he 9arian (clipse v.11 treatment planning system was used along with the %hillips
Brilliance Big Bore : scanner for the delineation of the lumpectomy and left breast tissue
0
e)cluding the chest wall. <rgans at risk &<,' for each case were the ipsilateral lung, heart, spinal
cord, esophagus and contralateral breast. 8or evaluation purposes, the radiation oncologist
contoured the entire left breast e)cluding the chest wall and a %9 structure was created by
cropping the left breast contour 7.5cm within the e)ternal contour surface.
Treatment Planning
8or both patient 1 and $, the data was transferred to the 9arian (clipse v.11 treatment
planning system &%S'. he medical dosimetrist imported the : images. he medical
dosimetrist set up ? .9 lateral and medial fields with coordinates set to the medial, lateral,
inferior, and superior wires &8igure $'. he radiation oncologist contoured the lumpectomy site
in reference to the scar wire and the seroma seen in the : dataset. he medical dosimetrist
contoured <, which included the spinal cord, esophagus, heart, right lung, and left lung. he
radiation oncologist reviewed and approved the <, contours.
wo-field left breast tangential planning can become somewhat of an art for medical
dosimetrists. here has been much research on different techni"ues, but patient anatomy varies
leading to different gantry angles, field in field techni"ues, beam weighting, and wedges being
used.
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%atient 1 had a prescribed dose of 57.0 @y for $2 fractions to the whole breast with a boost
to the lumpectomy site of 1$.7 @y for ? fractions. A /D breast tangential techni"ue was used to
obtain an optimal plan &8igure 2'. %atient 1 was treated with a styrofoam block setup techni"ue,
but simulated with and without the styrofoam block. he radiation oncologist recommended that
the heart receive no more than a mean dose of 5 @y and9$5 A54. he contralateral breast was
given a constraint of 9/.72 A54. he ipsilateral lung was also given a constraint of 95 A$54 and
9$7A174. hese constraints are standard dosimetry goals for whole breast irradiation with a
boost. 8or %atient 1, the gantry angle for the medial field was set at 35.?B and the collimator
remained at 127B. he lateral field gantry angle was set at $05.$B and the collimator also
remained at 127B. he photon beam energy for both fields was set at ?.9 with a dose rate at 077
.CDmin &8igure E'.
%atient $ was also treated with styrofoam blocks below the breast to a prescribed dose of
57.0 @y for $2 fractions to the whole breast with a boost to the lumpectomy site of 17.7 @y for 5
fractions. raditional /D breast tangentials were used to treat the entire left breast with the same
5
<, constraints for patient 1. he gantry angle for the medial field was set at 35.5B and the
collimator was turned to 12$B. he lateral field gantry angle was set at $0E.EB and the collimator
was rotated to 132.7B. he photon beam energy for both fields was set at ?.9 with a dose rate at
077 .CDmin.
%atient 1 had : datasets available that represented the breast with styrofoam and
without. he approved and prescribed patient plan included the styrofoam blocks. !hen
planning the medical dosimetrist struggled to lower the ma)imum dose near the inner "uadrant
of the left breast. o mitigate this problem, the medical dosimetrist placed a 15B right wedge on
the lateral beam. here were two field-in-field beams placed from the initial lateral beam and one
field-in-field placed from the medial beam. Fn total there were three static ?.9 beams and three
?.9 field-in-field beams to obtain an acceptable coverage and global dose ma). he beam
weight was ad>usted fairly higher in percentage to the medial beam for a minimum dose of
177.$4 and a global dose ma) of 17E.24 of the prescribed dose.
%atient $ had : datasets available that represented the breast with and without
styrofoam. !hen planning the dosimetrist worked to lower the ma)imum dose near the outer
"uadrant of the left breast. o mitigate this problem, the medical dosimetrist placed a 15B left
wedge on the lateral beam. here was a total of two static ?.9 beams. he beam weighting was
ad>usted to obtain an acceptable minimum coverage and ma)imum dose respectively of 17E.24
and E2.54 of the prescribed dose.
Plan Analysis and Evaluation
Fn both cases the medical dosimetrist was planning with the greatest dose homogeneity in
mind. 8or patient 1, the medical dosimetrist had difficulty lowering the global dose ma)imum.
he use of three static ?.9 beams and three ? .9 field-in-field beams as well as a 15B right
wedge and a /7B right wedge placed on both lateral beams lowered the global dose ma)imum to
17E.24. he medical dosimetris had less difficulties when planning patient $. Simply planning
with a 15B left wedge on the lateral beam lowered the global dose ma)imum to 17E.24. 8or the
purpose of this case study, there were two separate plans created on each patient dataset. he two
plans had the same gantry angles, collimator angles, and field si*es described previously. hese
evaluation plans had dose distributions related only to the tangential fields with no dose
?
modifying techni"ues to obtain a more consistent dose homogeneity and conformity inde)
comparison between a setup with and without the styrofoam block. he only significant
controlled variable from patient 1 to patient $ was that patient 1 had a larger overall left breast
tissue volume. his variable was helpful in identifying if the use of a styrofoam block would be
useful in the treatment of both smaller and larger breasts &8igure 3'.
o determine if the use of the styrofoam block improved homogeneity, coverage, and
conformity three factors were evaluated. Dose homogeneity was evaluated using the ,<@
homogeneity inde) calculated via the ratio of the ma)imum isodose &F.AG' in the target and
reference isodose &,F'. Dose conformity was measured with the ,<@ conformity inde) defined
as the ratio of the reference isodose volume &9,F', or the tissue volume that receives 1774 of the
prescribed dose, and the %9. Dose coverage was calculated using the ,<@ "uality of coverage
e"uation which is a ratio of the minimum isodose surrounding the target &F.F;' and the reference
isodose values &,F'. A homogeneity inde) less than or e"ual to $ is complying with ,<@
protocol. A conformity inde) of 1 is considered ideal dose conformation while anything below
indicates that the target volume is only partially irradiated and a conformity inde) greater than 1
indicates that the irradiated volume is greater than the target volume. ,<@ "uality of coverage
is considered to comply with protocol if the E74 isodose covers all of the %9 thus anything
between E74 and 1774 covering all of the %9 is considered a higher "uality of coverage
&able 1'.
%atient 1, with a larger %9 volume, had a high /D ma)imum dose of ?7./2 @y with the
styrofoam block as compared to without the block at 5?.13 @y. 8rom this higher /D ma)imum,
the setup with the styrofoam block had a slight decrease in dose homogeneity at 1.1E rather than
1.11 for the plan without the styrofoam block. +owever, it was apparent that the conformity
inde) increased from 7.$5 to 7.E12 when using the styrofoam block. his increase in conformity
was most likely related to the more cylindrical shape of the breast with the block resting below it
&8igure 3'
%atient $ did not have a comparable drastic change in shape as patient 1, but able $
indicated that the use of the styrofoam block increased homogeneity, conformity, while the
"uality of coverage remained the same with the conformity inde) increasing from 7.?22 to 7.30?.
A noticeable difference between patient 1 and patient $ was the variation of hotspots when using
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the styrofoam block. %atient 1 had a higher hotspot when using the block and a lower hotspot
without the block at ?7./2 @y and 5?.1$ @y respectively. %atient $ had a lower hotspot with the
block and a higher hotspot without the block at 5?.55 @y and ?7.7/ @y respectively. his can be
attributed to the higher breast tissue volume for patient 1.
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he most drastic improvement was the
conformity inde) for both patients when using the styrofoam block. Due to a greater
reproducibility with the styrofoam blocks and an improved dose conformity both patients were
planned and treated with the styrofoam block below the treated breast tissue. Although patient $
initially had a higher hotspot, the physician determined treating patient $ with the block would
likely result in a higher reproducibility and further planning would lower the hotspot to an
acceptable dose.
Conclusion
he styrofoam block was used for both patient treatment plans for the sake of improved
reproducibility and an improved dose conformity. According to Halpana et al,
3
adding a breast
tissue inde) and circumference indicator helps improve reproducibility. he prone breast setup
with a styrofoam block below the treated breast that adds an inde) for the breast circumference
and an anterior reference to the setup isocenter can improve reproducibility overall. 8or the
purposes of this case study, the styrofoam block=s role in dose homogeneity, conformity, and
"uality of coverage was evaluated in further detail with the e"uations in table $.
%atient 1 and $ were evaluated by comparing simple /D breast tangential techni"ues
without the use of wedges, field-in-field techni"ue, or beam weight ad>ustments to compare dose
differentiations simply without or without the use of a styrofoam block. he plans used for
treatment were discussed however to demonstrate the planning techni"ues that are typically used
when planning with a styrofoam block to further increase dose homogeneity, conformity, and
"uality of coverage.
%atient 1 showed no change in "uality of coverage, and a slight decrease in homogeneity.
%atient $ also had no change in "uality of coverage and a slight increase in homogeneity. he
most evident change when using the block was the improved conformity inde). %atient 1
increased from 7.$57 to 7.E12 and patient $ from 7.?22 to 7.30? with the block. ,esearch shows
an increased dose conformity can help reduce long term breast pain.
/
2
he prone techni"ue has already concluded an improvement in dose to)icity to the heart
and ipsilateral lung but +uppert et al
5
also mentions that the prone techni"ue can produce
reproducibility difficulties. Any contact with the breast to the treatment couch can compromise
the prone treatment techni"ue reproducibility and utili*ing a block can help in reducing these
issues by providing a breast tissue inde) while possibly providing improvements in whole breast
irradiation dosimetry.
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his techni"ue proved beneficial to the dose conformity for both patients
in this case study. Due to a limitation of only two patients being simulated with and without the
block for the purpose of this case study, it cannot be confidentially concluded that the use of a
styrofoam block is more beneficial than not using a block for all patients. 8urther research
evaluating the styrofoam block=s role in an improvement in dose coverage and reproducibility
could be useful to understand if a styrofoam block with the prone techni"ue is an ideal
immobili*ation and dosimetry enhancement.
E
References
"# Shafi" I, Delaney @, Barton .. An evidence-based estimation of local control and
survival benefit of radiotherapy for breast cancer. Rad.Onc. $773#20&1':11-13.
http:DDd).doi.orgD17.171?D>.radonc.$773.7/.77?
$# Stegman 1D, Beal H%, +unt .A, 8ornier .;, .c:ormick B. 1ong-term clinical
outcomes of whole breast irradiation delivered in the prone position. Int J Radiat Oncol
Biol Pys $773#?E&1':3/-21. http:DDd).doi.orgD17.171?D>.i>robp.$77?.11.750
%# .ak HS, :hen J, :atalano %I, et al. Dosimetric inhomogeneity predicts for long-term
breast pain after breast-conserving therapy. Int J Radiat Oncol Biol Pys $710#2E&1':1-E.
http:DDd).doi.orgD17.171?D>.i>robp.$710.75.7$1
&# 1ymberis S:, de!yngaert IH, %arahar %, et al. %rospective assessment of optimal
individual position &prone versus supine' for breast radiotherapy: volumetric and
dosimetric correlation in 177 patients. Int J Radiat Oncol Biol Pys. $71$#20&0'.
http:DDd).doi.orgD17.171?D>.i>robp.$71$.71.707
'# +uppert ;, Io*sef @, De!yngaert H, 8ormenti S. he role of a prone setup in breast
radiation therapy. !ront Oncol. $711#/1&1'. http:DDd).doi.orgD17.//2EDfonc.$711.777/1
(# Hirby A., (vans %., +elyer SI, et al. A randomi*ed trial of supine versus prone set-up
errors and respiratory motion. Rad Onc. $711#177&$':$$1-$$?.
http:DDd).doi.orgD17.171?D>.radonc.$717.11.775
)# Barret-1ennard .I, hurston S.. :omparing immobili*ation methods for the tangential
treatment of large pendulous breasts. Te Radiograper. $772#55&$':3-1/.
http:DDwww.minnis>ournals.com.auDarticlesD,adiographer4$7Aug
4$7724$7Barrett1ennard.pdf. %ublished December $772. Accessed Iuly 1, $710.

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*igures
*igure ". %atient 1 &left' and patient $ &right' setup with styrofoam block
11
*igure $# Breast tissue border markers for patient $ &,ed: medial, Dark @reen: lateral, 1ight
green: superior, yellow: inferior'
1$
*igure %# %atient $ demonstrating later rib cage tattoos &arrow'.
1/
*igure &# %atient $ demonstrating posterior setup tattoo and levelingDstraightening tegaderm
marks.
10
*igure '# %atient 1 breast tissue resting on styrofoam block with breast tissue outlines &arrow'.
15
*igure (# %atient 1 setup alignment marks on styrofoam blocks and ruler inde) &arrows'.
1?
*igure )# Difference in breast tissue shape with and without the styrofoam block respectively
from left to right and breast tissue si*e variation from patient 1 &upper images' to patient $ &lower
images'.
13
*igure +# %atient 1 treatment plan beam configuration and dose distribution &@reenK E54
isodose line and yellowK 1774 isodose line'.
12
*igure ,# %atient $ treatment plan beam configuration and dose distribution. &greenK E54
isodose line and yellow K1774 isodose line'.
1E
-ables
-able ": (valuation ratiosDe"uations and parameters
Dose Improvement
.valuated
Ratio/e0uation R-12 parameters
+omogeneity inde) F.AGD,F L$ complies
:onformity inde) 9,FD%9 K1:ideal coverage
A1:irradiated volumeM %9
Nuality of coverage F.F;D,F E74 isodose covers of %9
$7
-able $: (valuation details and results.
Patient "
3I CI 4ual#
Cov#
I5A6
72y8
RI
(Gy)
VRI
(cc)
PTV
(cc)
IMIN
(Gy)
9it: block 1.19 0.91
8
0.96 60.377 50.4 1380 1502.3 48.8
!/o block 1.11 0.25 0.96 56.167 50.4 375.7 1502.3 48.8
Patient $
9it: block 1.12
2
0.74
6
0.98 56.548 50.4 470.6 630.8 49.6
!/o block 1.19
1
0.68
8
0.98 60.024 50.4 434.5 630.8 49.6