Treating Breast Cancer in a Reproducible Prone Position

Ashley Coffey
July 23, 2014

Breast cancer is one of the most common and deadly forms of cancer a woman can have.
With modern medicine, breast cancer can be treated with radiation to destroy the tumor and any
cancerous cells remaining in the breast. One risk factor with breast irradiation is dose to critical
structures in the treatment area, such as lungs, heart, and the unaffected breast. The TD 5/5 doses
to one third of the heart and lung are 60 Gray and 45 Gray respectively. Although it varies
patient to patient, the average dose for whole breast radiation falls around 50 Gray. Significant
dose to both of these structures can cause damage and possibly a secondary cancer. Patient
positioning for treatment can help reduce the dose to these structures; both supine and prone
positioning are used depending on the patient. Supine has been the most common positioning of
choice but prone positioning is starting to receive attention for reducing dose to the lungs and
heart since the breast hangs away from these structures. Many studies have focused on the
decrease of dose in the heart and lungs with prone positioning but the logistics and
reproducibility have been skimmed over in these
studies. The reproducibility and standard deviation
in necessary shifts has given prone position a
negative view in terms of modern treatment; a
solution must be found in order to treat breast
cancer with the least negative long-term affects.
Even with the increased difficulty of
positioning, prone positioning for breast irradiation
is the better option for reducing dose to critical structures such as the lungs and contralateral
breast. A more reproducible setup can be achieved in order to have a higher accuracy rate in

setup. This can be accomplished by using a combination of immobilization devices. The best
option for a reproducible prone set up includes a prone breast board with readable board scale at
the base, a ten degree medial sloped contralateral breast platform to create a prone-lateral
setup, a breast holder to reposition the untreated breast up and away from the field (see picture
by Veldeman et all, 2010), and a strip of aquaplast across the mid back to ensure the same body
rotation. Although it sounds excessive, it is more important to have a reliable setup to optimize
each radiation treatment. The importance of the sloped platform is to roll the treated breast away
from the lungs and mediastinum, which will create a better position for true tangent angles. This
will reduce hotspots in the top and bottom of the breast and create a more even dose distribution.
Aquaplast will help to ensure the roll from the platform will be the same for each treatment,
causing not only a better treatment setup but also a quicker setup time. The use of all these
devices will ensure the setup error will be minimized and the treatment times can be quicker as
well. There could be the view that too many immobilization devices are used in this concept but
when the studies all point to a worse setup error based on large shifts, there is not enough
immobilization being used currently and something needs to change. The simple addiction of an
aquaplast strip to ensure the same roll each treatment can be easily added and utilized daily.
In the study by Veldeman and others in Belgium, a prone- lateral positioning technique
was used with a fifteen degree lateral wedge under the unilateral breast and lower body to move
the treated breast laterally away from the body; a unilateral breast holder to move the untreated
breast away from the field. This interesting technique proved to be affective in avoiding dose to
the contralateral breast and developing gantry angles that would not intersect the table. Eighteen
patients were simulated in both supine and prone positioning to compare dose volumes but
sixteen were treated in prone position. Each successfully received fifty gray in twenty-five
fractions with a daily cone beam to analyze the daily positioning to the original CT image used
for planning. The doses for both supine and prone position were compared and in the heart, lung,
and breast comparison, prone proved to be the clear choice in setup (Veldeman et al, 2010). The
use of the wedge moves the breast to a more lateral position instead of directly under the heart
and lungs. Although this allows better treatment angles, the reproducibility comes into question
when the whole body is rotated. As it is already difficult to get the patient laying flat in prone
position, replicating the body rotation and getting the breast into the position needed for
treatment would be an even more challenging task. However, when comparing the random setup

error in this particular setup to other studies, the numbers fall within the trend, if not better then
some studies with 4.2 mm laterally, 2.6 mm longitudinally, 3.2 mm vertically (Veldman et al,
2010).
A study by Varga and others in Hungary developed both supine and prone treatment
plans for sixty-one patients and twenty treated in supine and the remaining forty-one treated in
prone. For supine, an aquaplast mold was formed from the chin, neck, and down the abdomen,
leaving the treated breast exposed. Prone positioning included a prone breast board with a
semicircular aperture for the treated breast. Portal images were taking three times a week to
ensure proper setup. When analyzing supine and prone position doses, the prone was better in
decreasing dose to the lung and the treated breast received a higher average PTV. In
repositioning, the random setup error was 2.58 mm and 3.48 mm for supine and prone,
respectively (Varga at al, 2009). Seeing that the difference is less than one millimeter, prone
positioning accuracy ultimately is not significantly different than supine. The benefits seem to
outweigh the uncertainty of setup difficulty in prone position.
The study by Veldeman and others in Belgium analyzed ten patients with alternating
daily treatments between supine and prone with a cone bream image used to accurately set up.
Intensity-modulated radiation therapy with daily cone beam adjustments was utilized in both
positions to a total of fifty gray in twenty-five fractions. A prone-lateral approach was taken with
the used of a an unnamed angle. A surgical clip was placed in the breast by the isocenter in nine
of the ten patients and was used as the most reliable source of alignment for each treatment.
Respisens magnetic sensors were also placed on each patients isocenter and on the thorax in the
same vertical axis to monitor the movement of the breast due to normal breathing (Veldeman et
al, 2012). Based off the magnetic sensors, the dose to the treated breast, contralateral breast, and
heart did not carry any significant difference in supine over prone positioning. However, the
ipsilateral lung did receive less dose in prone positioning. Overall, prone positioning was slightly
worse in setup error. On average, the lateral, longitudinal, and vertical prone position random
error was 1.17 mm, 1.35 mm, and 2.09 mm larger then supine, respectively. In terms of
breathing, the sensors were able to detect an average movement of 0.93 mm for supine and 0.77
mm in prone; this is attributed to the chest wall resting directly against the breast board
(Veldeman et al, 2012). The study continues to discuss the reproducibility of the body roll in
prone set up and the lack of study done on this topic; an inadequate roll would cause the

contralateral breast to be in the treatment field. What this study lacks is the use of immobilization
to the contralateral breast and a secure way to ensure the same roll is used daily. It was noted that
although prone required larger shifts and more time to treat that is was the better choice for
breast treatments if tolerable by the patient. The angle of the wedge used to prompt the patient
roll in prone position was also not stated which could play a large factor in reproducibility.
One study collected data from many other studies and compared the immobilization
techniques used for breast irradiation. The advantages of prone over supine were the more
homogenous dose to the treated breast based off of the narrowing of the breast due to gravity.
Organs, more specifically the lungs, near the treated fields receive less dose and movement of
the lung is limited due to the chest wall resting directly against the breast board, not allowing
much leeway in respiration. While most of the studies analyzed in lung movement where
millimeters larger for supine, Probst and associates question the clinical significance. The
disadvantages listed were the lack of dose to the chest wall in cases of the original tumor being
more posterior in the breast, the lack of node treatment, and rib pain due to positioning (Probst et
al, 2014). All of these seem to be arbitrary problems compared to the difficulty of the actual
positioning of the prone setup. A common piece of information found in many studies is that the
patients involved where good candidates for prone radiation due to tumor location and lack of
lymph node involvement. The one study that points to rib pain states that it is only found in less
than 5% of the studied individuals. While they gathered many studies to compare data, the
authors of this article seemed to throw all the facts together and lacked any true conclusions even
when trends were found amongst them. No questions seemed to be answered throughout the
entire journal article; this collaboration seemed to present opposing facts at points and failed to
tie together real results.
In the study Kirby and associates, sixty-five women were simulated in both supine and
prone position and hundreds dosimetry plans were generated. The supine position was a
standard position and prone was with a board with aperture and wedge for the contralateral
breast. Plans included mainly opposing laterals with 100% to the isodose with MLC use to block
cardiac dose. The dose to the target volume, lung, and heart were analyzed in both positions
based off of possible plans; cardiac dose did not differ in prone or supine position unlike what
other studies state. Cardiac dose only proved to be better in larger breasted woman positioned in
prone. Prone also resulted to be deliver less dose to the ipsilateral lung than a supine position

(Kirby et al, 2010). One major conclusion found was that the dose to heart and lung depend on
the size of the breast; prone is better for larger breasted women due to the pull of gravity on the
breast away from these structures. Since smaller breasts sit close to the chest wall and in prone
the heart falls anterior, the use of supine in small-breasted woman is not idea for cardiac dose.
However, the study openly lacks analysis in tumor bed location, heart size, and chest wall size.
Kirby et al also states that the use of IMRT on a left breast treatment should result in zero dose to
the heart regardless of position, which is not a plausible or supported by facts.
Stegman and colleagues developed a study in which the long-term clinical outcomes of
prone breast irradiation were observed. Over twelve years, two hundred and forty-five women
were treated with conformal beams to the standard fifty grey in normal fractionation. A prone
lateral approach was also used to rotate the treated breast away from the medial center of the
body with wedges used in the daily treatments. Only weekly port films were used to check
alignment and the shifts were not typically made unless completely out of tolerance; this is a
huge error in treatment due to the known reputation that prone setup positioning is less reliable
than supine. The five-year average clinical survival was 93% and contralateral breast tumor
occurrence was at 2% (Stegman at al, 2007). The results prone positioning had was comparable
to supine results which are said to be excellent. Limitations in this study could be found in supine
analysis and setup error. Supine five year outcomes were not discussed at all in the methods and
results section but heavily compared to prone outcomes in the discussion. The statistical data for
supine was never revealed let alone if the number of patients and timeframe is even comparable
to the prone analysis they provided. It was also stated that prone setup was reproducible but the
lack of explanation in setup and daily imaging would make this statement insignificant.
Using the techniques mentioned, an experiment can be performed with appropriate
candidates; non-nodal involved breast cancer and the patient being tolerable to lay in the prone
position is ideal for the study. A ten degree wedge sloping to the medial side on the contralateral
side of the prone breast board, a breast holder for the contralateral breast to move it up and away
from the treatment field, and a strip of aquaplast across the lower back are all used to ensure a
clear treatment field and secure positioning (see picture for example of breast board with
contralateral wedge by Bionix). To start, simulate as many patients that fit the criteria in both
supine and prone position with the use of the stated immobilization devices. After developing
dosimetric plans for each setup, a prone-lateral treatment should provide the most benefit to the

treated breast and surrounding normal tissue. The treatments can then be scheduled and the daily
setup timed and cone beam shifts analyzed. It is hypothesized that with the use of the body tilt
and aquaplast strip that this should not take as long as it would without and the shifts should be
on the minimal side of the spectrum. To ensure the aquaplast is of reasonable use in this position,
setup and cone beam should be performed with alternating the use of the aquaplast every other
day. The time used to set up and shifts should be recorded and evaluated to ensure the setup for
prone position is comparable to the numbers found in recent studies of supine setup errors. These
supine numbers are found to be within millimeters of each other in multiple studies, providing a
reliable comparison.
If the experiment provides the results expected based on the hypothesis, the setup error
data for prone will be comparable to supine statistics found in pervious studies. Compared to the
prone setup error range from about 4 millimeters up to 7 millimeters found in the mentioned
studies, a goal of less then 4 millimeters for the prone setup errors using the above technique
would be considered successful and ideal. These results would decrease setup time and
ultimately time the patient is required to lie on the table, increase the accuracy of planned
treatment and doses delivered, and decrease any long-term effects from treatment. With
immobilization of the body roll of each patient using aquaplast, the setup should be stable and
consistent day to day. If the hypothesis is incorrect, the only affect it would have would be in the
stability and setup time. The current method in practice is not an intolerable or absurd method as
it is; the problem found is in the large shifts made after imaging, which is the result of a more
difficult setup compared to supine position. The experiment aims to reduce time on setup and
make the process of setting up prone position more efficient. While there are some slight effects
on doses, such as hot spots and lung dose, the success of this immobilization technique would
not cause any significant changes in those aspects. Any possible changes would be minor and
almost negligible; many studies have shown different prone setup positions with similar dose and
long-term affects. Overall, the use of the contralateral breast wedge with breast holder and
aquaplast strip across back should create a reliable and more efficient setup when it comes to
treating patients with breast cancer in the prone position.

References
Bionix Radiation Therapy (2013). Operating Instructions for the BONIX Prone Breast Treatment
System-Product#: RT-6025. http://www.bionixrt.com/RT_Pages/RTinstructions/RT6025.pdf
Kirby, A. M., Evans, P. M., Donovan, E. M., Convery, H. M., Haviland, J. S., & Yarnold, J. R.
(2010). Prone versus supine positioning for whole and partial-breast radiotherapy: A
comparison of non-target tissue dosimetry. Radiotherapy and Oncology, 96(2), 178-184.
doi:http://dx.doi.org/10.1016/j.radonc.2010.05.014
Probst, H., Bragg, C., Dodwell, D., Green, D.,Hart, J.,. (2014). A systematic review of methods
to immobilise breast tissue during adjuvant breast irradiation. Radiography, 20(1), 70-81.
Stegman, L. D., Beal, K. P., Hunt, M. A., Fornier, M. N., & McCormick, B. (2007). Long-term
clinical outcomes of whole-breast irradiation delivered in the prone position. International
Journal of Radiation Oncology*Biology*Physics, 68(1), 73-81.
doi:http://dx.doi.org/10.1016/j.ijrobp.2006.11.054
Varga, Z., Hideghty, K., Mez, T., Nikolnyi, A., Thurz, L., & Kahn, Z. (2009). Individual
positioning: A comparative study of adjuvant breast radiotherapy in the prone versus supine
position. International Journal of Radiation Oncology*Biology*Physics, 75(1), 94-100.
doi:http://dx.doi.org/10.1016/j.ijrobp.2008.10.045
Veldeman, L., De Gersem, W., Speleers, B., Truyens, B., Van Greveling, A., Van den Broecke,
R., & De Neve, W. (2012). Alternated prone and supine whole-breast irradiation using
IMRT: Setup precision, respiratory movement and treatment time. International Journal of
Radiation Oncology*Biology*Physics, 82(5), 2055-2064.
doi:http://dx.doi.org.proxy.lib.ohio-state.edu/10.1016/j.ijrobp.2010.10.070
Veldeman, L., Speleers, B., Bakker, M., Jacobs, F., Coghe, M., De Gersem, W., . . . De Neve, W.
(2010). Preliminary results on setup precision of prone-lateral patient positioning for whole

breast irradiation. International Journal of Radiation Oncology*Biology*Physics, 78(1),

111-118. doi:http://dx.doi.org.proxy.lib.ohio-state.edu/10.1016/j.ijrobp.2009.07.1749