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Yasmin Ahmed
Clinical Practicum I
April 19, 2015
Prone Breast Case Study
History of Present Illness: Patient FP is a 70-year-old female who did not undergo routine
screening mammography. Last fall, she had an asthma exacerbation and went to see her primary
care physician who detected a nodule in the right breast. She underwent a mammogram in
August of 2014 that showed indeterminate calcifications in her right upper outer quadrant and
scattered nodularity in her left breast with asymmetry and adjacent calcifications in the central
breast. An ultrasound showed no evidence of malignancy. She underwent a biopsy of the right
breast in September of 2014, which showed columnar cell changes and hyperplasia. She then
underwent a biopsy of the left breast lesion in September of 2014 of the area in her upper/central
left breast showing moderately differentiated infiltrating ductal carcinoma. There were two foci
of 1 mm each. There was no lymphovascular invasion. The tumor was estrogen receptor (ER)
positive, progesterone receptor (PR) positive, and human epidermal growth factor receptor-2
(HER-2) negative. About 48% of breast cancers arise in the upper outer quadrant.1 Also, patients
with ER/PR positive tumors generally have an improved outcome than if the tumor is ER/PR
negative.1 There was associated ductal carcinoma in situ (DCIS) of intermediate nuclear grade.
She underwent MRI of the bilateral breasts in late September 2014 which showed a 2.7 cm linear
enhancement in the left breast at the 11-12 oclock position. There was an intermediate nodule at
the 7-9 oclock position and a biopsy was recommended again. She had a biopsy of the left-sided
lesion in October 2014 with only columnar cell hyperplasia seen. She then underwent an
excisional biopsy of the right breast lesion in September 2014 and the pathology showed only
proliferative changes. On the same day, she underwent a lumpectomy of the left breast lesion
with pathology showing a 1.2 cm grade 2 infiltrating ductal carcinoma. The margins were 5 mm
away from the tumor. The five-year survival rate for patients that have lesions > 0.5 cm is 82%.1
There was also intermediate grade DCIS associated with infiltrating ductal carcinoma. There was
no lymphovascular invasion seen. Two sentinel lymph nodes were negative for tumor. The
patient had a genetic Oncotype Dx test done which returned a score of 31, hence chemotherapy
was recommended. She received four cycles of Taxotere and Cyclophosphamide (TC) and

completed this in March of 2015. FP stated that she has been recovering slowly from the
chemotherapy. She currently has fatigue and numbness/tingling in her fingers and toes.
Past Medical History: The patient has hyperlipidemia and asthma. Any other medical and
surgical history is listed above. The patient has no known allergies to food or medications.
Social History: FP stated that she has always been a housewife. Her husband passed away two
years ago and so she lives alone. She is a smoker who smokes six cigarettes a day and has been
doing so for the past 40 years. She denied drinking alcohol and denied any history of drug abuse.
She also stated that her mother died from some sort of pelvic cancer and her brother had
lymphoma in his 40s.
Medications: FP uses the following medications: Lipitor and Advair.
Diagnostic Imaging: FP underwent a mammogram in August of 2014 that showed indeterminate
calcifications in her right upper outer quadrant and scattered nodularity in her left breast with
asymmetry and adjacent calcifications in the central breast. An ultrasound showed no evidence of
malignancy. She underwent MRI of the bilateral breasts in late September 2014, which showed a
2.7cm linear enhancement in the left breast at the 11-12 oclock position. There was an
intermediate nodule at the 7-9 oclock position.
Radiation Oncologist Recommendations: After reviewing FPs past medical and surgical
history, as well as pathology reports, the oncologist discussed options for local management
including mastectomy versus breast observation. FP was a suitable candidate for breast
observation which included radiation therapy to the left breast. Radiotherapeutic options include
standard fractionation for five weeks versus hypofractionation for three weeks. The pros and
cons of these approaches were discussed in detail with FP. The rationale for treatment as well as
the possible risks and benefits were discussed with the patient in detail. The possible acute and
long-term side effects were also reviewed. The patient was given an opportunity to ask questions
which were answered to her satisfaction. FP was encouraged to contact the oncologist or resident
with any further questions or concerns. A final decision was made to treat the patient prone with
a dose of 4240 cGy to the left breast using hypofractionation.
The Plan (prescription): The oncologists treatment recommendation for FP was a 3D
conformal plan to the left breast in the prone position, since the breast was large and pendulous.
The prone position also substantially reduces heart and lung dose as opposed to treatment in the
supine position. The breast plan consisted of two tangential fields (a medial and lateral). All

fields used were photon coplanar beams. The prescription for the left breast was 4240 cGy at 265
cGy per fraction for 16 fractions daily.
Patient Setup/Immobilization: In April of 2014, FP underwent a CT-simulation in the radiation
medicine department. She was placed prone on the simulation couch on a prone breast board.
FPs arms were both extended above her head. FPs head was turned in the opposite direction to
the right (Figure 1). The radiation therapist placed BBs on the posterior and lateral aspects of the
patient (Figures 2 and 3).
Anatomical Contouring: After completion of the CT-simulation, the images were transferred to
Velocity (Varian Medical Systems, Palo, Alto California) for contouring. All ORs were drawn by
the importing physicist. This included the heart, right lung, and left lung. The radiation
oncologist then reviewed these contours and added contours for the inferior, superior, medial,
and lateral borders of the breast. These borders were used for planning of the tangents for the left
breast. The left breast planning target volume (PTV) was later defined by the dosimetrist as the
95% isodose line. All contours were approved in daily rounds and the CT data set was then sent
to the Pinnacle 9.6 treatment planning system (TPS).
Beam Isocenter/Arrangement: For this plan, I placed the beams at the marked isocenter
(Figure 4). For the breast, two tangential beams were utilized. The reason for using tangential
fields is to maximize dose to the affected area, while minimizing dose to other structures such as
the heart and lung.1 The two tangential beams had gantry angles of 106 and 286. Each beam
was assigned an energy of 6 megavoltage (MV) photons. The field was set by me for each beam
according to the oncologists drawn borders for the breast. A block to both beams was not needed
since this was a prone breast and the lung is out of the way (Figures 5 and 6). The collimator was
set to 270 for both beams.
Treatment Planning: FPs plan was completed on the Pinnacle TPS, version 9.6. The radiation
oncologist entered all planning directives in Mosaiq for the medical dosimetrist to refer to. The
prescription outlined a treatment technique of 3D conformal for the left breast. The left breast
was prescribed to 265 cGy x 16 = 4240 cGy. While all beams were set to the marked isocenter, a
separate calculation point was needed to distribute the dose properly (Figure 7). The prescription
in the TPS was set to deliver point dose to the breast calculation point. Once the plan was
complete, a breast PTV was created from the 95% isodose line. The oncologists target goals for
the breast plan were entered into Mosaiq for reference. These goals were as follows:

Heart (Left sided treatment): V20Gy 5%; V10Gy 35%

Heart Mean Dose: 400cGy
Lung (ipsilateral): V20Gy 15%; V10Gy 40%; V5Gy 55%
Lung (contralateral):V5Gy 15%
PTV Breast: max dose 107%
Once the plan was complete, a normalization of 100% was sufficient enough to achieve desired
coverage. I then reviewed the ORs for the plan in the dose volume histogram (DVH) and all
outlined constraints were being met. Since it was a prone breast, all the ORs were well below the
outlined objectives. The mean dose to the heart was 137 cGy, the maximum dose to the left lung
was 1870 cGy, and the maximum dose to the right lung was 38 cGy. The maximum dose in the
breast volume was a point dose of 4454 cGy. This is a maximum hot spot of about 5%.
The oncologist did a final review of the plan and dose volume histogram (DVH) and was happy
with the overall plan (Figures 8 and 9). The plan was then locked and approved by the
supervising dosimetrist and oncologist.
Quality Assurance/Physics Check: Once the plan was complete, a monitor unit (MU) check
was performed. This was done by exporting the entire plan to PTW Diamond MU verification
software. Our facility requires all MU checks to be within 5% error between the TPS and
Diamond software for each field. All of the fields were within this range. In addition to this
second check with Diamond, the plan was reviewed by a physicist for approval.
Conclusion: This case was a bit challenging for me to plan at first, since I am used to planning
supine breasts. However, as the dosimetrist coached me, I found the prone breast plan to be
easier to plan than a supine breast. After I initially placed the beams for the plan, the dosimetrist
evaluated it and suggested I modify the angle a bit to avoid the prone breast board cushion a bit
more (Figure 10). She said that scatter from the beam passing through the cushion sometimes
causes irritation to the patients skin in that area. This was something I had not even thought of. I
am now aware that in the future I should decrease the contrast and see where the prone breast
cushion is and how the beam is going past it. After modifying the fields I calculated the plan. It
was very hot. I then had to construct control points that act similar to what intensity modulation
radiation therapy (IMRT) does, by using the leaves in order to reduce the excess hot spots by
setting the beams to step and shoot. This part was a bit tricky because I had to tweak each control
point several times and adjust the weighting to achieve a decent dose distribution. If you add too

much weight to a control point it can have the opposite effect of what you are trying to achieve,
so one must always look at the images while adjusting to see what is happening. This was a great
plan to work on. However, the dosimetrist stated that even though this type of plan is somewhat
easier to plan, it can be very difficult for the therapists to set up on a daily basis when the patient
is in the prone position for a breast.

References
1. Washington C, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis,
Missouri: Mosby Elsevier; 2010.

Figure 1: Patient position on breast board during CT-simulation.

Figure 2: Posterior view of BB placement during CT-simulation.

Figure 3: Lateral view of BB placement during CT-simulation.

Figure 4: Marked isocenter placement in axial, sagittal, and coronal views.

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Figure 5: Jaw setting for medial tangential beam with gantry of 106.

Figure 6: Jaw setting for lateral tangential beam with gantry of 286.

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Figure 7: Calculation point for left breast in axial, sagittal, and coronal views.

Figure 8: Isodose lines for left breast. The red is the 100% line (4240 cGy) and the blue is the
95% line (4028 cGy).

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Figure 9: Oncologist approved DVH for planning volume and ORs.

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Figure 10: Picture of beams avoiding the prone breast cushion.