1 Nick Piotrowski Dos 731 Research Methods July 2, 2013 Right Breast Carcinoma History of Present Illness: GK is a 52 year

old female with infiltrating ductal carcinoma. She had a prophylactic left simple mastectomy, and right modified radical mastectomy, as well as a right axillary sentinel lymph node dissection with frozen section. The poorly differentiated carcinoma also included the nipple and vascular space invasion in the nipple. The tumor spanned 4.5 centimeters (cm) at its greatest dimension. It was also noted that 9 of the 20 lymph nodes were positive for potential metastatic disease. She also had a reconstruction of the right breast. Past Medical History: As the patient has not had much prior medical history, the cancer diagnosis was not tolerated well. She received a colonoscopy 30 years ago that revealed a small polyp. She also suffers from severe migraines, as well as frequent anxiety. Besides anything related to her present disease, her only other surgery was a cesarean section in 1995. Social History: GK is currently married with one daughter. Her daughter is currently disease free, but did have thyroid cancer at the age of 17. She also had another family member with disease as her father had previous skin cancer. She denies any use of tobacco and occasionally consumes alcohol. Medications: She is currently taking Ambien, Florinol, Vitamin B, Tylenol #3, Compazine, and Biotin. She also has reported allergies to Neomycin, Keflex, and Neosporin. Diagnostic Imaging: In May 2012 a yearly mammogram was performed revealing no disease. In November 2012, another mammogram was performed due to a palpable mass, revealing a lesion on the scan. That same day an ultrasound of the right breast was performed to confirm a 2.8 cm lesion, 3 cm superior the nipple and another mass 4 cm inferior and laterally from the nipple. This led to an ultrasound guided core biopsy that revealed an infiltrating ductal carcinoma. In December of 2012 a magnetic resonance image (MRI) of both breasts was completed to reveal the lesions that were initially discovered. Later that day, a chest x-ray (CXR) was performed that confirmed no extension into the lungs. Two weeks later GK went in for a computed tomography (CT) scan of the chest, abdomen, and pelvis that demonstrated no

2 metastatic disease. Finally, the following day GK finished with a bone scan that reported no osseous metastasis. Radiation Oncologist Recommendations: A modified radical mastectomy was to be performed on the right breast, and a simple mastectomy to be completed on the left breast for precaution. The surgery would be followed by post-operative radiation therapy to the right chest wall of 50.4 Gray (Gy) in 28 fractions. Adjuvant chemotherapy may also be beneficial for radiosensitivity. The Plan (prescription): In order to bring coverage to the surface without causing her too much irritation, this plan was given two separate prescriptions. One of the prescriptions was taken to 27 Gy in 15 fractions with a 0.5 cm bolus on. The other prescription was 23.4 Gy in 13 fractions without the bolus. With the fields being exactly the same, the plan summation created a dose of 50.4 Gy in 28 fractions. Both plans consisted of four beams, with 2 being the same lateral fields and 2 being identical medial fields. The only difference in the beams was the energy. Patient Setup/Immobilization: For the treatment planning CT, GK was placed in the supine position with both arms raised above her head. A custom Vac-Loc was created on the breast board to support her head and help immobilize the upper body of the patient. Radio-opaque markers were placed on the clinical borders of the fields on all sides, as well as on the mastectomy scar. The isocenter was set in the simulation by the physician, and marked on the skin with BBs. Anatomical Contouring: Similar to most breast cases, there were four major organs that required contouring. The heart, liver, lungs and spinal cord were all contoured, as well as the radio-opaque wires, and the scatter caused by the breast implants. The scatter would have created pockets with the density of air, which were contoured and forced to the density of soft tissue.1 Beam Isocenter/Arrangement: During the CT simulation, there was an initial thought of a supraclavicular field. This idea led the physician to place the isocenter near the supraclavicular region with the intent of a half beam block. After learning the treatment would be tangents only, the shifts required were 7 cm right, 14 cm superior, and 1 cm posterior. To get the best possible coverage, 4 tangential beams were used for each plan. Two of the beams had a gantry rotation of 57 degrees with no collimator or couch rotations. The other two beams were placed at 237 degrees, again with no collimator or couch rotations. These angles had to be directly opposed as it was planned to be half beam blocked. The only difference of the 2 beams with same

3 arrangement, was one had a 6 megavoltage (MV) energy and the other had an 18 MV energy. The beams were weighted 1:1:2:2, medial and lateral 6 MV tangents, and medial and lateral 18 MV tangents. The actual field sizes increased to maximum because two of the dimensions were half beam blocks. The widths of the fields were 13.9 cm so the fields would not split when using electronic compensation. The lengths of the fields were at the maximum jaw position of 20 cm with the superior border at 0. Fortunately these dimensions still gave plenty of flash anteriorly and coverage inferior the chest wall. Treatment planning: Using the treatment planning system Eclipse 10.0, this plan was created and initially calculated. The first time this plan was being developed, the goal was to receive 95% coverage around the entire breast while keeping the dose to the right lung as low as possible. After a fair amount of work, the initial constraints were met with a hot spot region of dose of 6.8%. Upon looking at the plan, the physician lowered the lung dose constraint to 20% of the volume to 20 Gy, and demanded 98% isodose coverage around the chest wall. The physician also modified the lung blocks that were set by another physician to minimize some unnecessary lung exposure. With all of the immediate changes it was easier to delete most of the plan and start over with the initial angles versus editing the initial plan. All field sizes, beam and collimator angles, and weighting remained the same as they still provided good dose distribution. The irregular surface compensators and multileaf collimators (MLCs) were added as needed for the fields. A 2 cm skin flash was added to the fluence and the portion where there was lung blocking was deleted (Figure 1). For better coverage of the chest wall, the reference point was placed deeper into the breast. The dose volume histogram (DVH) revealed 20% of the lung received 15 Gy (Figure 2). The initial calculation resulted in a hot spot of 116%, but after eliminating most of the dose, the plan summation hot spot was decreased to 10.0%. While it was substantially hotter than the initial plan, the 98% isodose line perfectly conformed to the entire breast and was therefore approved (Figure 3). Quality Assurance (QA)/Physics Check: Before printing, the monitor units that were calculated by Eclipse 10.0 were double checked using RadCalc. Once the numbers were found to be within the 2% tolerance, the plan was sent to the medical physicist for quality assurance (QA) of the fluence. After approval, it was double checked and approved by both the physicist, as well as the attending physician.

4 Conclusion: After the initial confusion of including the supraclavicular field, this plan resulted in a standard tangential chest wall plan. Usually choosing the beam angles is one of the more challenging portions of the treatment planning process, but in this case it was relatively easy. The most challenging piece of this plan was to have the persistence needed to finish this plan. Initial plans that the physicist thought would get approved were denied by the physician which can be disheartening. The most difficult part of this treatment plan was to complete the plan while working against the clock. It is one of the most important qualities a medical dosimetrist needs to have as this is not a rare case. The physicians request certain criteria for a reason, and it is the medical dosimetrists job to meet these standards within the allotted time. One thing to learn from this case is that no matter how much work is assigned, with some extra effort, it will all get finished.

5 Figures

Figure 1: Fluence of the right breast with a 2 cm flash and deleted lung dose.

Figure 2: Dose volume histogram of the right lung, liver, and heart.

Figure 3: Dose distribution for right breast.

7 References 1. McGonigal M. The trauma professionals blog. Region Traumas Pro. 2013. Available at: http://regionstraumapro.com/post/16349545265. Accessed July 2, 2013.