1

Irregular Surface Compensation Technique for Right Breast Carcinomas : A Case Study Authors: Nick Piotrowski and Nishele Lenards Abstract: Introduction: The goal of this study was to evaluate the use of irregular surface compensators in radiation therapy treatment planning for patients with right breast carcinoma. Many 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. All three patients presented with non-metastatic, right breast carcinoma and received a right lumpectomy. The surgery kept the breast intact and allowed for the use of tangential radiation therapy. Conclusion: Each plan 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 The ETC technique improved coverage and homogeneity in the breast when compared with standard wedge or field in field techniques.2 If there are consistently ongoing improvements, this could become an optimal choice for future treatments. Key Words: Electronic tissue compensation, Breast cancer, Wedge pair Introduction As technology in this field changes, so does the standard of treatment. Before the use of irregular surface compensators, physical wedges were commonly used in breast cancer radiation treatment planning. Physical wedges were heavy, time consuming, and limited in wedge angles therefore bringing about the enhanced dynamic wedge (EDW). While the technique itself did not change much, the advancement made the treatment delivery easier for the radiation therapists. The field in field technique became another standard of treatment as it significantly decreased dose regions while maintaining coverage to the volume of interest. Like any new technology, the invention of irregular surface compensators has challenged the standards of

2 treatment. To determine which of these treatments is most effective, it was necessary to complete a direct comparison. Numerous studies have been completed comparing the dose coverage, global maximum dose, and dose to the critical structures. As this new technology has been used to improve coverage and decrease excess dose regions, the tangential beam arrangement has not changed. Each of these 3 cases was treated with a mixed energy tangential technique with ETC on the 6 megavoltage (MV) fields. As beneficial as the ETC technique is, a larger breast will occasionally require a mixed energy technique. Lief et al,3 concluded that a breast separation larger than 24 cm showed dramatic improvement when a higher energy was mixed with the standard 6MV tangents. In order to compare and analyze the results, the tumor volume coverage, dose to critical structures, and global maximum doses were recorded. These impressive results are achieved by modulating the MLCs, as the dose fluence is conformed to an irregular surface. These cases require a depth of penetration to be set based on the thickness of the patient breast. This penetration value helps the computer recognize 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). Methods and Materials Patient Selection All 3 patients were treated with the same technique of tangential beams consisting of mixed energies with electronic tissue compensation on the 6 MV fields. They all presented with a T1C N0 M0 right breast carcinoma and underwent a right lumpectomy prior to receiving a course of radiation therapy to the entire intact breast. The irregular surface compensators allowed for the decrease in hot spot, sufficient coverage around the intact breast, and minimized the skin reaction. Patient Set-up All 3 patients were placed in the supine head first position with both arms raised above their heads. For immobilization, a custom vac-lock was created around their heads and arms placed on a wing board. In order to keep the mandible out of the treatment field, the head was turned to

3 the left. Radio-opaque markers were placed on all clinical borders as well as on the surgical scar. 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 The Eclipse 10.0 treatment planning system and computed tomography (CT) was used to delineate anatomical and target contours for treatment planning. The right lung, liver, heart, and contralateral breast were all contoured by the medical dosimetrist. In addition, the physician also contoured the lumpectomy cavity on each patient, which was the primary target for the boost plan. Treatment Planning The goal for each treatment plan was to achieve 98% dose coverage to the intact breast. Each patient received the same dose prescription of 52.56 Gy in 20 fxs, 4 of these fxs being a boost. The goal was to deliver 98% of the prescription dose to the entire breast with 100% of the dose to the lumpectomy cavity while keeping the organs at risk within the specified physician dose constraints. The constraints included keeping 10% of the heart under 25 Gy and 30% of the right lung under 20 Gy. Using ETC for each plan helped keep the constraints within tolerance and help manage the excess dose Aref et al,2 provided a comparison between irregular surface compensation and conventional wedge technique that revealed the use of irregular surface compensators dramatically decreased the global maximum as well as the volume of 105% and 110% dose. Another similar comparison study by Su et al4 also supported the conclusion that ETC will decrease regions of excess dose better than a wedge technique. While coverage was sufficient for every plan, it would have been well covered using a wedge technique as well.4,5 Each of the patient cases required the use of ETC but was utilized differently in each case. For patient 2, the physician instructed the medical dosimetrist to decrease skin dose that may cause reactions. For patients 1 and 3 the ETC was used to decrease regions of excess dose in the breast and increase the overall homogeneity. In addition, the physician wanted patient 3 to have dose reach the skin while still keeping the hot spot to a minimum. Being a larger breasted patient, with a separation of 26 centimeters (cm) made this more difficult. Each case had this same issue,

4 issuing the use of a mixed energy treatment. In addition to using the 6MV energy, 18MV energy beams with identical angles and MLCs were used. With the higher energy pulling dose away from the skin, the transmission penetration depth (TPD) became more important. For each patient, the intact breast required a TPD of 40%, whereas a standard chest wall patient would have required a 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 centimeters (cm) and 50% for a patient separation less than 24 cm. This technique has allowed the dose distribution to be closer to the skin surface and decrease the overall volume of excess dose region.1 In order to reduce the chance for error, each plan used the skin flash tool was used to add 2 cm to the anterior portion of the breast. This technique helped to reduce the possibility of underdosing the breast due to set-up error and respiratory movement. Even with this prevention ETC still requires an exact set up and treatment. Dose fluence that is measured within the breast, only separated by millimeters (mm) have varying doses. While dose in an ETC plan is mostly homogenous, these small variations could lead to problems if the patient is not set-up correctly for treatment each day. Furuya et al6 compared the effects of respiratory breast movement and set-up error in field-in-field, conventional wedge and ETC techniques. The conclusions were the highest impact occurred with the ETC plans as the dose fluence treated did not necessarily match what was planned.6 As this could be a major issue, it is important medical dosimetrists do what they can to minimize these possible misses. Yada et al7 determined and the effectiveness of the skin flash tool and concluded that while the skin flash tool did decrease the percentage of error caused by patient motion, it did not completely eliminate it.

Plan Analysis & Evaluation After evaluating each plan, every patient case met the criteria provided by the physician. For patient 1, 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 1 and 2). As this patient had a large separation, a mixed energy technique and ETC were used to decrease skin dose. It is difficult to keep the global maximum low while maintaining dose to the cavity for patients with an intact

5 breast. The irregular surface compensators allowed for the decrease of these excess dose regions and achieved a global maximum of 105.5%. The treatment plan for patient 2 revealed 10% of the heart volume received only 1 Gy and 30% of the right lung received 3.6 Gy (Figure 3). Both of these results were well within the constraints while not losing coverage to the lumpectomy cavity and intact breast (Figure 4). The irregular surface compensators in this case helped keep the maximum dose under 106.6% and minimize dose to the surface, while sparing the patient from a possible skin reaction. For patient 3 the constraints were met with 10% of the heart receiving 0.67 Gy and 30% of the right lung receiving 3.4 Gy (Figure 5). The treatment plan revealed 100% of the prescription covered the lumpectomy cavity and 98% homogenously covered the intact breast (Figure 6). While this case could have been treated with a wedge or field in field technique, a global maximum dose of 106.1% would have been less likely. Electronic tissue compensation played an integral part in creating dose homogeneity, decreasing excess dose regions, and assuring dose to the cavity. It is reasonable to conclude that irregular surface compensators are effective for radiation treatment of the breast. While the current standards of treatment are also efficient, this new technology has provided another excellent treatment technique. Conclusion After reviewing the 3 cases there were various positive conclusions that could be drawn about ETC. The most notable of these benefits was the ability of ETC to eliminate excess dose from the medial and lateral portions of the breast. As mentioned previously, in studies by Aref et al,2 and Emmens,1 the global maximum dose and overall volume of excess dose both saw improvement with the use of ETC. As far as coverage of the planning target volume (PTV), there was no difference between the ETC, and wedge pair technique.4,5 There are also drawbacks of ETC with the set up needing to be precise. As mentioned previously it is for this reason that a 2 cm flash is included and immobilization devices are in place. While irregular surface compensation has shown improvements in treatment planning, each patient needs to be evaluated individually. There are many cases in which ETC is needed to increase or decrease

6 dose regions or minimize global maximum dose, but there are also cases where the current standard is still beneficial. As technology pushes forward it is important that studies continue to compare treatment standards with new advances. In this case, doing a direct comparison of wedge, field in field, and ETC techniques may be a beneficial study. There may also be the possibility that these techniques will one day be compared to rapid arc, or proton therapy results.

7 Figures

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

Figure 2. Patient 1 dose distribution with 105.5% global maximum dose.

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 106.6% global maximum dose.

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

Figure 6. Patient 4 dose distribution with 106.1% global maximum dose.

10 Tables Table 1. Dose coverage and analysis results for 3 cases.

Case Treatment Description Prescription

Patient 1 Intact breast (lumpectomy) 52.56 Gy (20 fxs)

Patient 2 Intact breast (lumpectomy) 52.56 Gy (20 fxs) 98% of cavity received 100% of dose

Patient 3 Intact breast (lumpectomy) 52.56 By (20 fxs) 100% of cavity received 98% of dose

Dose Coverage

100% of cavity received 100% dose

Critical Structures

Heart volume 10% received 0.64 Gy Rt lung volume 30% received 3.4 Gy

Heart volume 10% received 1Gy Rt lung volume 30% received 3.6 Gy

Heart volume 10% received 0.67 Gy Rt lung volume 30% received 3.4 Gy 106.1%

Global Max

105.5%

106.6%

11 References 1. Emmens DJ and James HV. Irregular surface compensation for radiotherapy of the breast: correlating depth of the compensation surface with breast size and resultant dose distribution. BJR. 2010;83(986):159-165. doi:10.1259/bjr/65264916 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. Lief EP, Hunt MA, Hong LX, et al. Radiation therapy of large intact breasts using a beam spoiler or photons with mixed energies. Med Dosim. 2007;32(4):246-253. doi:10.1016/j.meddos.2007.02.002 4. 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. Med Phys. 2008;35(6):2837-2838. doi:10.1118/1.2962237 5. Fujita H, Kuwahata N, Hattori H, et al. Improvement of dose distribution with irregular surface compensator in whole breast radiotherapy. Med Phys. 2013;38(3):115-119. doi:10.4103/0971-6203.116361 6. 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. JRR. 2013;54(1):157165. doi:10.1093/jrr/rrs064 7. 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. Med Phys. 2011;38(6):3667-3668. doi:10.1118/1.3612731