1

Lee Culp
October Case Study
October 2, 2014

Right Breast Irradiation with Supraclavicular and Posterior Axillary Boost Fields
History of Present Illness: Patient KS is a 69 year old female who presented in the emergency
room in February 2014 with a palpable mass in her right breast near the nipple. She had a
mammogram and ultrasound (US) that showed a spiculated mass that was given a BI-RADS
category of 5. Also, there were two axillary lymph nodes, each measuring 9mm. KS underwent a
stereotactic core needle biopsy, demonstrating an infiltrating ductal carcinoma; AJCC Stage IIIC
(T2N3aM0). The tumor was 100% ER positive, PR 95% positive, and HER2/neu negative.
Following, she had a total body bone scan which found no evidence of metastatic spread.
However, there was an increased uptake around the lower SI joints, bilaterally, likely from
sacroiliitis. Also, there was an increased uptake in the right breast and two axillary lymph nodes.
Patient KS denied any breast dimpling, pain, nipple discharge, or skin changes prior to finding
the palpable mass. Breast cancer is the most frequently diagnosed cancer and the leading cause
of cancer death in women, accounting worldwide for 23% of total new cancer cases and 14% of
total cancer deaths in 2008. The past decades have seen advances in the diagnosis and treatment
of breast cancer, associated with a decrease of mortality rate. Among treatments, adjuvant
radiotherapy has shown to improve local control and overall survival, with a 70% proportional
reduction of the risk of recurrence and a 9%12% proportional reduction of the risk of death.1

Past Medical History: KS has a past medical history of the above mentioned breast cancer,
along with cataract surgery, depression, and pain in her hips bilaterally. In addition, KS reported
an allergy to anything with metal, though no known drug allergies.
Social History: KS is retired, although she worked for several years in a factory, doing factory
work. She is divorced with three children. The patient denied any IV drug use, however has
smoked cigarettes one pack a day for over 50 years. She drinks two glasses of wine daily. The
patient reported that her mother had passed away from metastatic breast cancer at age 59, her
father passed away at age 84 of COPD, a twin sister has a history of lymphoma and passed away
at age 31. Another sister passed away at age 60. A brother is alive at age 82 with a history of
prostate cancer.
Medications: KS uses the following medications: Tylenol, acid reflux medication, Xanax, and
ibuprofen.
Diagnostic Imaging: At time of presentation in the emergency room in February 2104, KS,
underwent a US on her right breast to which no prior studies were available for comparison. This
study revealed evidence of an irregular spiculated mass at the 6 o'clock position 2 cm from the
nipple measuring 2.5 x 2.5 x 1.9 cm. In addition, there were two axillary lymph nodes, each
measuring 9 mm. In March of 2014 patient KS had a chest X-ray which demonstrated that her
heart was normal in size, shape, and position, as well as no evidence of infiltration of the heart
by the disease. Again in March 2014, KS has a PET scan followed by CT, and MRI scans the
next day. The PET scan determined that there was no evidence for distant metastases, however it
was noted that there was increased FDG accumulation in the right breast, as well as two axillary
lymph nodes corresponding to previous US study. The CT scan of the chest found a slightly

spiculated mass measuring 2.1 x 1.9 cm in the anterior aspect of the inner lower quadrant of the
right breast. Again, this finding corresponds to site reflected from the US. The MRI obtained
axial images of the bilateral breasts utilizing multiple pulse sequences. Examination of the right
breast revealed evidence of a large mass involving the right periareolar region with architectural
distortion. The examination of the left breast revealed evidence of normal morphology of the left
breast without any evidence of abnormal enhancing lesion. There is no evidence of chest wall
invasion on either side, nor is there evidence of involvement of the axillary lymph nodes on the
left side.
Radiation Oncologist Recommendations: The radiation oncologist recommended KS to
undergo radiation therapy to the whole right breast after lumpectomy as a part of breast
conservation therapy. In specific, the radiation oncologist planned on utilizing three fields to
treat KS whole breast and nodes: Tangentials, Supraclavicular (SupClav), with a Posterior
Axillary Boost. (PAB). More than half of breast cancers are associated with axillary nodal
involvement. Post-operative radiation therapy (XRT) is a crucial part of locoregional treatment
in axillary nodal involvement breast cancer owing to a 15-years risk reduction of locoregional
recurrence of 70% and to a 5.4% risk reduction of specific mortality.2 The treatment fields are set
up so that tangential fields cover the entire breast with 2 cm flash, and a 2 cm inferior/superior
margin around the breast tissue, not to cross the midline. The SupClav field is a single field with
a 15o gantry angle coming from the opposite side of the patient. KS was treated on her right side,
so the gantry was a Left Anterior oblique (LAO) with a 15o angle. The medical dosimetrist then
drew in the SupClav field utilizing the MLC leaves, blocking out the head of the humerus, and
cord/esophagus. The PAB field had the gantry at 180o, and again the dosimetrist drew in the
MLC blocking the head of the humerus, lungs, and clavicle.

The Plan (prescription): The radiation oncologists plan was to use four beams in the tangential
beam: two 6 MV and two 16 MV, as well as one 16 MV beam for the SupClav field, and one 6
MV beam in the PAB field due to the disease spread to the axillary nodes. The prescription dose
was 5040 cGy at 180 cGy per fraction for 28 fractions to the Right Breast and SupClav fields,
with a prescribed dose of 766.2 cGy at 27.4 cGy per fraction to the PAB field (total dose of 5040
cGy).
Patient Setup/Immobilization: KS underwent a computer tomography (CT) simulation scan for
radiation therapy treatment planning in September 2014. The patient was placed in the supine
position on the CT simulation couch upon a Civco Breast Board with Vac Loc. KS had both of
her arms positioned above her head, and her head placed on a Civco B headrest, turned to the
left. A triangle sponge was placed under the knees for support (Figure 1). The isocenter
coordinates were marked on her skin with BB's, as well as a Central Axis, inferior, and medial
edge marker placed by the radiation oncologist. The patient was scanned with 3.0 mm axial
spacing.
Anatomical Contouring: The CT data set was transferred into the Varian Eclipse 11.0.30
radiation treatment planning system (TPS). The medical dosimetrist contoured organs at risk
(OR) which included the spinal canal, heart, right and left lungs, total lung, esophagus and
ipsilateral (right side) ribs. The carina was also contoured to assist in patient setup for the
therapists.
Beam Isocenter/Arrangement: The radiation therapist placed an AP isocenter during the
simulation procedure. From here, the images were received on the TPS, and the medical
dosimetrist marked the placed AP isocenter at 100 cm SSD, and 0, 0, 0 for x, y, z co-ordinates.

This plan is monoisocentric, so will incorporate half beam blocking in each of the fields. For the
tangetial field the medial beams utilized a gantry angle of 50o, while the lateral beams had a
gantry angle of 226o. There were a total of four beams; a medial 6MV, a medial 16 MV, a lateral
6MV, and a lateral 16 MV; each weighting 0.321, 0.311, 0.184, 0.184 respectively. The
SupClav field had a gantry rotation of 15o, and a weighting of 1.000, while the PAB field had a
gantry rotation of 180o and a weighting of 1.000 as well. The medical dosimetrist determined
field sizes of each beam in relation to the treatment objectives to meet the goals of the desired
dose distribution throughout the whole right breast.
Treatment Planning: The radiation oncologist outlined the desired dose prescription and
objectives for whole breast with SupClav and PAB treatment plan. The intention was to irradiate
the whole right breast, with SupClav and PAB, with an appropriate energy without destroying
surrounding normal tissue and ORs. This type of planning is Monoisocentric, where there is only
one technical isocenter, however there are three fields. To account for this, each field in this type
of setup and treatment has its own calculation point, as well as each field has a half beam block.
For the tangential field, a calculation point was placed by the Medical Dosimetrist (rt brst calc)
which was set for mid-breast in all dimensions. This rt brst calc point is used to give an accurate
dose reflection for this specific field, and is used to tell the computer where to normalize to. For
the tangential fields, the borders were a marked medial edge, marked inferior edge, and 2 cm of
flash. The superior edge stopped at where the therapist placed the Central Axis during the
simulation. A half beam block was used here, for the superior edge. The dosimetrist made this
plan so that the SSD at the technical isocenter is 100 cm. The patient received a total of 180 cGy
per day with 67 cGy delivered by the medial 6 MV, 60 cGy delivered by the medial 16 MV, 45
cGy delivered by the lateral 6 MV, and 42 cGy delivered by the lateral 16 MV for 28 fractions

(Figures 2-5).

For the SupClav field, the medical dosimetrist rotated the gantry 15o for an LAO. The isocenter
is the same as the breast field, again making this a monoisocentric treatment, and a half beam
block utilized on the inferior edge (matching the superior edge of the tangential field). The
superior edge is set at a hair above the clavicle, medial edge is at the spinal cord, and the lateral
border includes the humeral head. No wedge was used in this field. The medical dosimetrist then
drew in MLC blocking, which the radiation oncologist did not need to edit. MLC's are to block
along the spinal cord, and block most of the humeral head leaving a silver out into the field.
Another calculation point was added to this field (SC Calc), and placed at a depth of 3cm, within
a node. This is where the SupCalc plan was to normalize to (Figures 6-9). Ideally, a 6 MV beam
is used to utilize the dmax of the beam to the nodes, however if the total dose in the Plan Sum is
too hot, a 16 MV beam will be used, which was the case here. The patient received a total of 180
cGy delivered by the LAO 16 MV beam for 28 fractions.
The PAB field was a duplicate of the SupClav field, however the MLCs were changed, and the
gantry was rotated to 180o. The Lateral edge was where the rib and clavicle intersected, but the
rest of the edges matched the SupClav field. The MLCs were drawn by the medical dosimetrist
so that they split the clavicle, split the lung which accounted for breathing, and blocked the head
of the humerus just like in the SupClav field (Figure 10). A new calc point (Rt PAB Calc) was
used in the PAB field, this point is placed at a depth of midplane within the patient. Again, this
was the point where the beam was normalized to. However, calculating the PAB dose is a bit
more complicated because it involves scatter from the previous two fields, which must be
accounted for. To do this, the medical dosimetrist had to go back to the tangential and Supclav

fields, and find the scatter dose to the Rt PAB Calc point. Once those numbers were obtained
(125.7 cGy from the tangential, and 4841.1 cGy from the SupClav), they were subtracted from
the daily dose (180 cGy), and placed within the PAB Dose Prescription field in Eclipse. This
then gives a lower daily dose from the PAB field, again accounting for the scatter from the other
two fields (Figures 11-13). KS received 27.4 cGy delivered by the PAB beam (6 MV) for 28
fractions, however a total dose of 5040 cGy (including the scatter). PAB fields are used in this
type of treatment because the more lateral Level I/II axilla nodes have a much deeper location,
the dose anticipated to this region is less. Therefore, a PAB field was used to supplement dose to
a point located at a midplane depth within this region.3
A Plan Sum was then created incorporating all three fields, to get an overall sense of the plan; it
summarizes the three fields to give the dosimetrist a better idea of where the dose is going
(Figures 14-16). The total dose of all three plans in the Plan Sum should not exceed 6000 cGy,
due to the start of deterioration of the Brachial Plexus at 6000 cGy. The brachial plexus is a
network of nerve bundles that originate from the cervical and upper thoracic spinal cord and is
intimately responsible for the cutaneous and muscular innervation of the chest, shoulder, and
upper extremity. It is believed that when the brachial plexus is irradiated to doses greater than
6000 cGy, a significantly higher proportion of patients develop neuropathic symptoms,
suggesting a threshold effect. 4 The Plan Sum was over 6000 cGy in this case, so energy of the
SupClav beam was changed from 6MV to 16 MV to lower the overall dose to 5688.
Quality Assurance/Physics Check: The monitor units (MU) were reviewed and a second check
was completed with a Quality Assurance (QA) computer program RadCalc. The monitor units
for the tangential portion of the plan were within tolerance: medial 6 MV-3.0%, medial 16 Mv -

1.7%, Lateral 6 MV 0%, Lateral 16MV 0% differential. The planned MUs (total) were at 214,
while the actual delivered MUs were 211. The monitor units for the SupClav portion of the plan
were within tolerance: -1.7% differential. The planned MUs were at 180, while the actual
delivered MUs were 177. The monitor units for the PAB portion of the plan were within
tolerance: -2.8% differential. The planned MUs were at 36, while the actual delivered MUs were
35. All the designed fields in the treatment plan were reviewed by a junior medical physicist for
a final check before treatment began.
Conclusion: Overall, the whole breast with Supraclavicular and PAB Fields treatment plan for a
whole breast is a complex treatment design for a medical dosimetrist. Many steps are involved,
including many minor details that must be remembered in each field. If one of these fine details
is missing, the whole plan is effectively invalid because the dosage will be incorrect. The reason
for the three fields is for adequate coverage of the affected lymph nodes. While this plan is very
complicated and time consuming, it is an excellent plan to be able to demonstrate ability for a
medical dosimetrist, as well as maintaining the desired goal for the patient. These types of plans
are not used in most clinics because their setups are quiet difficult. I have been told this is one of
the most complex plans a medical dosimetrist can perform, second only to head and neck IMRT.
Oftentimes, this type of modality can be combined with a Chest Wall, replacing the Breast field.
Treatment for KS is expected to be delievered efficiently, and with no constraints. All of her OR
are within their constraints as demonstrated by the DVH (Figure 17), so the plan has no concern
of serious side effects. Once the 5040 cGy have been delivered to the patient, she will receive an
electron boost of 1000 cGy to the right breast scar - with an energy that has yet to be determined.

References
1. Van Parijs H, Miedema G, Vinh-Hung V, et al. Short course radiotherapy with
simultaneous integrated boost for stage I-II breast cancer, early toxicities of a
randomized clinical trial. 2012:80(7). http://dx.doi/10.1186/1748-717X-7-80
2. Belaid A, Kanoun S, Kallel A, et al. Breast cancer with axillary lymph node
involvement. Cancer/Radiothrapie. 2010;14(1):S136-S146.
http://dx.doi/10.1016/S1278-3218(10)70017-2
3. Wang X, Yu TK, Salehpour M, et al. Breast cancer regional radiation fields for
supraclavicular and axillary lymph node treatment: Is a posterior axillary boost field
technique optimal? Int J Radiat Oncol Biol Phys. 2009;74:86-91.
http://dx.doi/10.1016/j.ijrobp.2008.07.016
4. Chen A, Hall W, Li J, et al. Brachial-Plexus neuropathy after high-dose radiation
therapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2012;84(1):165-169.
http://dx.doi/10.1016/j.ijrobp.2011.11.019

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Figures

Figure 1: Patient KS position on a Civco Breast Board with Vac Loc with her head placed on a
"B" headrest, turned to the left from CT simulation.

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Figure 2: Tangential Right Medial Field - Half Beam Block.

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Figure 3: Tangential Right Breast Isodose placement in the sagittal view showing Rt Brst
Calc Point as well as scatter to Rt PAB Calc point..

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Figure 4: Tangential Right Breast Isodose placement in the transverse view showing Rt Brst
Calc Point as well as scatter to Rt PAB Calc point.

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Figure 5: Tangential Right Breast Isodose placement in the transverse view showing Rt Brst
Calc Point & scatter to Rt PAB Calc point.

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Figure 6: Rt SupClav - Half Beam Block.

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Figure 7: SupClav Right Breast Isodose placement in the transverse view showing Rt SC
Calc Point & scatter to Rt PAB Calc point

Figure 8: SupClav Right Breast Isodose placement in the frontal view showing Rt SC
Calc Point & scatter to Rt PAB Calc point

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Figure 9: SupClav Right Breast Isodose placement in the sagittal view showing Rt SC
Calc Point & scatter to Rt PAB Calc point

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Figure 10: Rt PAB - Half Beam Block.

Figure 11: PAB Right Breast Isodose placement in the transverse view showing Rt PAB
Calc Point

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Figure 12: PAB Right Breast Isodose placement in the frontal view showing Rt PAB
Calc Point

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Figure 13: PAB Right Breast Isodose placement in the sagittal view showing Rt PAB
Calc Point

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Figure 14: Plan Sum Right Breast Isodose placement in the transverse view showing Rt Brst
Calc Point, Rt SC Calc Point & scatter to Rt PAB Calc point

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Figure 15: Plan Sum Right Breast Isodose placement in the frontal view showing Rt Brst
Calc Point, Rt SC Calc Point & scatter to Rt PAB Calc point

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Figure 16: Plan Sum Right Breast Isodose placement in the sagittal view showing Rt Brst
Calc Point, Rt SC Calc Point & scatter to Rt PAB Calc point

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Figure 17: Plan Sum Right Breast Dose Volume Histogram (DVH).