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Nick Piotrowski Comprehensive Case Study August 10, 2013 Irregular Surface Compensation Technique for Right Breast Carcinomas Abstract: Introduction: The goal of this study was to evaluate the use of irregular surface compensators when planning right breast carcinomas. Many literature studies also refer to this technique as using electronic tissue compensation (ETC). Case Description: Using three separate patient plans, an evaluation of tangential irregular surface compensation was performed. Patient 1 presented with an infiltrating ductal carcinoma in which she was treated to the chest wall after having a right modified radical mastectomy and the implantation of expanders. Patient 2 was an example of a non-metastatic right breast carcinoma that treated an intact breast after a prior lumpectomy. Patient 3 represented another right breast carcinoma in which a right modified lumpectomy was performed and expanders were implanted. Conclusion: Each of these plans was evaluated by determining their ability to meet the constraints by using the dose volume histogram (DVH). The isodose lines were also identified to determine the amount of 98% prescription dose coverage. By using multileaf collimators (MLC) the dose fluence can be modified to conform to an irregular surface.1 ETC has the potential to become the standard of treatment for breast irradiation if it continues to produce positive results. Key Words: Irregular surface compensation, Tangential field technique, conventional wedge pair technique Introduction Prior to the days of irregular surface compensators, physical wedges were often used in breast cancer planning. As the field has progressed, physical wedges have become a less common

2 technique. In its place was the more efficient enhanced dynamic wedge (EDW). While the technique itself did not change much, the advancement made the treatments easier on the radiation therapists. From there the field in field technique became another standard of treatment, as it sufficiently decreased dose regions while maintaining coverage to the volume of interest. With the invention of irregular surface compensation, the effectiveness of these initial treatments is being tested. Numerous studies have been completed comparing the dose coverage, global maximums, and dose to the critical structures. While the technology used to improve coverage and decrease regions of excess dose has changed, the concept of tangential fields has not. Each of these 3 cases was treated with a mixed energy tangential technique with ETCs on the 6 megavoltage (MV) fields. The results were analyzed by their ability to cover the tumor volume, decrease dose to the critical structures, and keep the global maximum as low as possible. By modulating the MLCs, the dose fluence can be conformed to an irregular surface. A depth of penetration is initially set based on the thickness of the patients breast. This penetration value sets the depth of the irregular surface and the region for the dose optimization. While optimization does take place, the field by field calculations categorize it as forward planning as opposed to the inverse planning of intensity modulated radiation therapy (IMRT). This treatment technique has proven to be effective in breast irradiation and its future looks promising. Methods and Materials Patient Selection All three of these cases presented with, were planned, and treated within a 2 month period of time. Each case used a tangential technique consisting of mixed energies with ETCs on the 6 MV fields. Patient 1 was a 52 year old female with infiltrating ductal carcinoma. The patient underwent a right modified radical mastectomy prior to receiving radiation therapy. Using the technique described above, irregular surface compensation allowed for sufficient dose coverage to the chest wall. Patient 2 was a 41 year old female with a tumor extension 1, no lymph node extension, and no metastatic disease (T1C N0 M0) right breast carcinoma. After receiving a right lumpectomy the patient received a course of radiation therapy to the entire intact breast, which included the

3 cavity. The irregular surface compensators allowed for the decrease in hot spot as well as sufficient coverage around the intact breast. Patient 3 was a 49 year old female with a stage T1b N0 M0 disease of the right breast. After having a right lumpectomy, she received radiation therapy treatment to the breast, including the surgically implanted expander. Similar to patient 1 the irregular surface compensation allowed for the dose coverage to be pushed deeper into the breast near the chest wall. Patient Set-up During the treatment planning computed tomography (CT) scan, each patient was immobilized and set-up the same way. The patients were placed in the supine position with both arms raised above their heads. For immobilization, a custom vac-lock was formed around their heads and arms and placed on a wing board. In order to keep their mandibles out of the fields, their heads were turned to the left as the right breast was being treated. Radio-opaque markers were placed on the clinical borders of the fields on all sides, as well as on the surgical scars. The isocenter was not set in the simulation by the physician, but BBs were placed on the skin to assist with patient set-up. Target Delineation As they were treated at the same site only months apart, the treatment planning system Eclipse 10.0 was used for each of the patient plans. While each patient had a magnetic resonance image (MRI), only the treatment planning CT was used for target delineation. Each plan took into concern the right lung, liver, heart, and contralateral breast. Besides these contours, the physician additionally contoured the lumpectomy cavity for Patient 2. Treatment Planning The goal for each of these treatment plans was to get 98% dose coverage to the breast, or chest wall for patient 1. The prescriptions of these plans varied as the different surgeries changed the disease extent. Patient 1 received a total of 50.4 Gray (Gy) in 28 fractions (fxs), while patient 2 and 3 received a total of 52.56 Gy in 20 fxs, 4 of the fxs being a boost.

4 Patient 1 proved to be the most difficult of the 3 cases as the physician changed her mind multiple times throughout the treatment planning process. At completion, there was a requirement of 98% dose coverage to the chest wall while keeping 10% of the heart volume under 25 Gy, and 20% of the right lung under 20 Gy. Patient 2 was a more standard plan with the objective being to cover the entire intact breast with 98% of the prescription dose, and reach 100% of the dose to the entire cavity while keeping the organs at risk under the physician constraints. In this case these constraints consisted of keeping 10% of the heart under 25 Gy, and 30% of the right lung under 20 Gy. While not as difficult as patient 1, the results of the plans were relatively similar. The goal was once again to receive 98% coverage to the chest wall and cavity, while keeping 10% of the heart under 25 Gy and less than 30% of the right lung to receive 20 Gy. Although it was not imperative, the physician also wanted to try and keep the right lung mean dose under 20 Gy. In each of these cases there was a separate but equally important use for the irregular surface compensators. In patient 1 it was necessary for dose to be added to the chest wall without pushing it into the right lung. In patient 2 and 3, it was the ability of the irregular surface compensators to decrease regions of excess dose and lower the global maximum. It also helped to keep dose away from the skin surface and spare the irritation for the patient. Plan Analysis & Evaluation Irregular surface compensation has become an integral part of radiation therapy treatment planning, but each case must be evaluated to determine its true effectiveness in meeting dose constraints and providing better patient care. Although it was not easy, Patient 1 eventually met all of the dose constraints that were given. As seen in Figure 1, the dose to the heart only allowed 10% of the volume to receive 2 Gy, and the right lung had 20% of the volume reach 7 Gy. More importantly in this case, the chest wall was entirely covered by 98% of the prescription dose (Figure 2). The use of the mixed 18MV and 6MV energy, as well as the irregular surface compensators, allowed the dose to be pushed closer to the chest wall. Using a 0.5 centimeter (cm) bolus, and the ability to decrease dose regions, also helped keep the lung dose at a minimum.

5 Patient 2 also met the constraints that were provided as 10% of the heart received 0.64 Gy, 30% of the lung received 3.4 Gy, and 100% of the cavity received the full prescription dose (Figures 3 and 4). Similar to patient 1, this case required a mixed energy technique to force dose away from the skin surface. With the patient having an intact breast, it was difficult to keep the global maximum low while maintaining dose to the cavity. The irregular surface compensators allowed for the decrease of these excess dose regions and resulted in a global maximum of 105.5%. Similar to patient 1 and 2, patient 3 also met the necessary physician constraints. The heart volume of 10% only received a dose of 4.3 Gy while 20 Gy to the right lung was given to 17.9% with a mean dose of 9.1 Gy (Figure 5). Once again thanks to the ability of the ETC, 99% of the dose was able to cover both the chest wall as well as the cavity (Figure 6). It also contributed to the lowering of the global maximum to 107.5%. After looking at the data in Table 1, it is apparent that the irregular surface compensators will do an above average job. Besides meeting the constraints for each case, it was able to keep the global maximum relatively low. While the chest wall case for patient 1 could have been improved, the physician preferred to have a higher global maximum and better coverage. To ensure that the monitor units were correct, RadCalc was used as a verification system. Once the numbers were within the 2% tolerance, the medical physicist completed the quality assurance (QA) of the irregular surface compensation. Results and Discussion After working on these 3 cases there are a variety of positive and negative conclusions that can be drawn about ETC. The first thing that was apparent about this technique was its ability to eliminate excess dose from the medial and lateral aspects of the breast. At the institution these treatment plans were created, the transmission penetration depth (TPD) varied depending on the size of the patients breast. For patient 2 and 3, the more intact breast required a TPD of 40%, whereas the chest wall for patient 1 required the standard TPD of 50%. In a study completed by Emmens,1 it was found ideal to use a TPD of 40% for patients with a separation greater than 24 cm and 50% with a patient separation less than 24cm. This technique has allowed the dose distribution to be pushed closer to the skin surface and decrease the overall volume of excess

6 dose region. In a similar study performed by Aref et al,2 a comparison between irregular surface compensation and conventional wedge technique revealed a dramatic decrease of the global maximum as well as volume of 105% and 110% dose. Another more recent study completed by Su et al3 also supported these findings in a comparison of ETC and conventional wedge techniques. While the findings of this study showed no improvement in planning target volume (PTV) coverage, it did reveal a decrease in hotspot regions.3 Of course there are going to be some drawbacks in most technologies, and ETC is no different. As the dose fluence within the breast was measured for these three plans, points that were separated by millimeters (mm) had varying doses. This variation could lead to problems if the patient is not set-up correctly for treatment each day. In 2012 a study completed by Furuya et al4 compared the effects of respiratory breast movement and set-up error in field-in-field, conventional wedge and ETC techniques. It was found that ETC had the most dramatic dosimetric impact as the dose fluence was not necessarily in line with what was planned.4 Fortunately there are ways to minimize these errors when using irregular surface compensation. The skin flash tool was used on these plans to add an extra margin of dose anteriorly to the breast. This technique helped to reduce the possibility of underdosing the breast due to set-up error and respiratory movement. In a study completed by Yada et al5 the skin flash tool did decrease the percentage of error from respiratory motion, but did not completely eliminate it. By analyzing these studies as well as the data found in these cases it is clear why ETC has become a more popular treatment technique, and hopefully it continues to improve.

7 Figures

Right Lung

Heart

Figure 1: Patient 1 evaluation of DVH right lung and heart.

Figure 2: Patient 1 dose distribution showing coverage of 98% to the chest wall.

Figure 3: Patient 2 evaluation of DVH of heart, right lung, cavity, and cavity plus 1 cm margin.

Figure 4: Patient 2 dose distribution with 100% coverage to the cavity.

Figure 5: Patient 3 evaluation of DVH of heart, right lung, cavity, and cavity plus 1 cm margin.

Figure 6: Patient 3 dose distribution with 99% coverage to expander and chest wall

10 Tables Table 1: Dose coverage and analysis results for 3 cases. Case Treatment Description Patient 1 Chest wall/expander (mastectomy) Prescription Dose Coverage 50.4 Gy (28 fxs) 98% dose to entire chest wall Critical Structures Heart 10% volume received 2 Gy Rt lung 20% volume received 7 Gy Patient 2 Intact breast (lumpectomy) 52.56 Gy (20 fxs) 100% of cavity received 100% dose Heart 10% volume received 0.64 Gy Rt lung 30% volume received 3.4 Gy Patient 3 Chest wall/expander (lumpectomy) 52.56 Gy (20 fxs) 99% dose to chest wall and cavity Heart 10% volume received 4.3 Gy Rt lung 20 Gy to 17.9% volume and mean 9.1 Gy Global Max 110% 105.5% 107.5%

11 References 1. Emmens DJ, James HV. Irregular surface compensation for radiotherapy of the breast: correlating depth of the compensation surface with breast size and resultant dose distribution. The British Journal of Radiology. 2010;83:159-165. 2. Aref A, Thornton D, Youssef E, et al. Dosimetric improvements following 3D planning of tangential breast irradiation. Int J Radiat Oncol Biol Phys. 2000;48(5):15691574. 3. Su M, Ayzenberg V, Li W. Dosimetric parameter comparison of the electronic tissue compensator technique with the conventional physical wedge technique for the whole breast treatment. Medical Physics. 2008;35(6):2837. 4. Furuya T, Sugimoto S, Kurokawa C, et al. The dosimetric impact of respiratory breast movement and daily setup error on tangential whole breast irradiation using conventional wedge, field-in-field, and irregular surface compensator techniques. Journal of Radiation Research. 2012;10:1-9. 5. Yada R, Hayashi N, Nozue M, et al. SU-E-T-767: Improvement of dose conformity and homogeneity of the dose distribution on irregular-surface-compensator based breast irradiation. The International Journal of Medical Physics Research and Practice. 2011;38(6):3667.