Karen Krueger

February Case Study

February 25, 2015
Rapid Arc Treatment of the Left Chestwall and Supra Clavicular
History of Present Illness: Patient CU is a 47 year old female who first noticed swelling/mass
in the left axilla in September of 2013. She brought this to the attention of her primary care
physician and was found to have some swollen cervical lymph nodes as well. This was thought
to be secondary to an infection. CU also had a bilateral screening mammogram on October 8,
2013. The mammogram showed an abnormality in the anterior third of the superior outer
quadrant of the left breast with a focal asymmetry. Further evaluation was recommended with
spot compression views. Unfortunately, CU was lost to follow-up and she claims that her work
schedule would not allow her to obtain a mammogram for further follow-up. In the meantime,
the areas of swelling resolved on their own. In April of 2014, CU discovered a palpable area of
concern in the left breast. The patient brought this to the attention of her primary care physician
and was referred to a breast surgeon. A Tru-Cut biopsy of the area of concern was performed on
May 5, 2014. The pathology from the biopsy showed invasive ductal carcinoma, grade 2.
Estrogen receptors (ER) and progesterone receptors (PR) were positive. HER-2/neu was
negative. Samples of tumor tissue should be analyzed to determine the level of expression of
estrogen, progesterone, and HER-2/neu receptors on the cells.1 Estrogen and progesterone
positive cancer cells receive signals from the estrogen and progesterone that promote their
growth.2 Patients who are ER/PR positive are more likely to respond well to hormonal therapy
and generally have a better outcome than patients with receptor-negative tumors.1 In addition, the
HER-2/neu expression has been associated with a poor outcome.
There were foci suspicious for lymphovascular invasion. After a consultation with the breast
surgeon, CU expressed interest in a breast conservation lumpectomy. She was also referred to a
radiation oncologist who ordered a mammogram. The patient received a lumpectomy on June 2,
2014 with the greatest tumor dimension reported as 2.6cm. The margins were negative but less
than 1mm laterally. At the time of the lumpectomy, CU was found to have 4/4 sentinel lymph
nodes positive for disease and 4/19 nodes positive in completion dissection for a total of 8/23
total lymph nodes positive. CU was clinically negative for metastasis (M0). Postoperatively,

pathology from the lumpectomy confirmed the Tru-Cut biopsy results. CU was diagnosed with
T2 pN2a M0 Invasive ductal carcinoma of the left breast.
The staging system used for patient CU is the American Joint Committee on Cancer Staging
System1, 2 It is the staging system that is most commonly used in the United States. According to
the American Joint Committee on Cancer Staging System: T2-Tumor > 20mm but < 50mm in
greatest dimension, pN2a- Metastases in four to nine axillary lymph nodes; or in clinically
detected internal mammary lymph nodes (at least one tumor deposit > 2.0mm), and M0- No
clinical or radiographic evidence of distant metastases (no pathologic M0; use clinical M to
complete stage group).
Upon further evaluation from a multi-disciplinary tumor board, it was recommended that CU
receive chemotherapy followed by radiation therapy and then 5 years of hormone blockade
treatment. The patient received 2 cycles of chemotherapy. CU received a dose every other week
for 8 doses initially, Adriamycin and Cytoxan for 4 cycles, and then Taxol for an additional 4
cycles. After laboratory tests were reviewed by the medical oncologist and discussed with the
CU, she began a second cycle of chemotherapy. The patient completed chemotherapy on October
20, 2014. On October 29, 2014 CU met with the radiation oncologist for a treatment
consultation. The radiation oncologist recommended adjuvant whole breast and regional nodal
irradiation and discussed the radiation therapy treatment delivery process including acute and
late side effects. CU was not ready for a treatment planning simulation at that point because she
was scheduled to see her surgeon the following day in order to discuss persistent/recurrent left
breast seromas which have required drain placement. Due to the extensive disease revealed by
the lumpectomy pathology and full lymph node dissection, CU underwent a completion and
prophylactic contralateral mastectomy on November 16, 2014. The pathology following the
mastectomy showed that all of the tissue removed was benign. CU saw the radiation oncologist
again on December 11, 2014. The patient was struggling with postoperative seroma/edema and
redundant skin and had a follow-up appointment scheduled with her surgeon to discuss these
issues. CU was scheduled to return to the radiation oncologist in three weeks. The patient also
had an ultrasound of the left axilla December 11, 2014. The ultrasound was recommended by the
radiation oncologist for evaluation of a small palpable abnormality in the left axilla. The
abnormality was determined to be a benign cyst. The patient had a MRI of the brain December
19, 2014 and the results were unremarkable showing no metastatic disease. CU returned to the

radiation oncology department on February 3, 2015 and after speaking with the radiation
oncologist, decided to proceed with the radiation therapy treatments.
Past Medical History: CU has a past medical history of diverticulitis, hypertension, and sleep
apnea. The patient has a surgical history that includes appendectomy, back surgery,
cholecystectomy, knee arthroscopy, and gastric bypass. The patient received gastric bypass in
2012 and lost 170 pounds. The dates of the other surgeries were not given. The patient reported
an allergy to Cipro, Codeine, Erythromycin, Levaquin, PCN and Sulfa.
Social History: CU is married. The patient has a history of smoking, but no longer smokes. CU
reported that her father is deceased and had a medical history of lung cancer. The patient also
reported that her maternal grandfather is deceased and had a medical history that included
congestive heart failure and breast cancer. CU stated that her mothers sister had a medical
history of breast cancer. The patient also stated that her fathers sister had a medical history of
breast cancer. In addition, CU reported that her maternal grandmother had a medical history of
leukemia.
Medications: CU reported using the following medications: Cyclophosphamide, DOXOrubicin
HCL, Dexamethasone Sodium Phosphate, Fosaprepitant Dimeglumine, Ondansetron HCL,
Pegfilgrastim, Sodium Chloride, Imitrex, Nortiptyline HCL, Promethazine HCL, TraMADol
HCL, and Zofran ODT.
Diagnostic Imaging: The patient underwent a routine bilateral screening mammogram on
October 8, 2013 that revealed a suspicious lesion in the anterior third of the superior outer
quadrant of the left breast. A Tru-Cut biopsy of the suspicious lesion was performed on May 5,
2014. The pathology from this biopsy revealed an Invasive Ductal Carcinoma that was ER and
PR positive. Consequently, the patient underwent an s/p lumpectomy on June 2, 2014. The
greatest dimension of the tumor from the lumpectomy site was reported to be 2.6cm. The
margins were negative, but less than 1mm laterally. CU was found to have 8/23 total lymph
nodes positive, including 4/4 sentinel lymph nodes. The pathology from the tumor lumpectomy
confirmed the diagnosis of Invasive Ductal Carcinoma of the left breast. CU had a computed
tomography (CT) scan of the neck, chest, and abdomen on June 24, 2014, for evaluation of
metastatic disease. The CT images showed no evidence of soft tissue or bony metastases. The
patient had an ultrasound of the left axilla on December 11, 2014 in order to evaluate a palpable
abnormality in the left axilla. The abnormality was determined to be a benign cyst. CU

underwent a MRI of the brain on December 19, 2014 in order to be evaluated for metastatic
disease. The results of the MRI were unremarkable, showing no metastatic disease.
Radiation Oncologist Recommendations: After reviewing the patients surgical history and
pathologic reports, the radiation oncologist performed a physical exam of the patient. CU was
found to be alert and oriented, under no acute distress, and the mastectomy scars were healing
well. The patient had no visible masses or palpable concerns in the chest wall. The radiation
oncologist recommended chest wall and regional nodal irradiation based on her original
pathology results. He recommended a 3D tangential plan matched with a supraclavicular plan.
The Plan (prescription): The radiation oncologists recommendation was to treat the chestwall
with a tangential plan matched with a supraclavicular plan to treat the area of the lymph node
dissection. The initial prescription was for the patient to receive 5000cGy at 200cGy per day for
a total of 25 fractions for the tangents and opposing supraclavicular fields. The tangential fields
were to have bolus placed every other day. In addition, an electron boost to the mastectomy scar
was prescribed for 1000cGy at 200cGy per day for a total of 5 fractions. The prescribed
composite dose to the left chestwall was 6000cGy. However, it was determined early in the
treatment planning process that the dose to the heart and lungs was too high with tangential fields
to the chestwall and would be much too high when the supraclavicular fields were added. This
was due to the barrel shaped chest wall of the patient. The radiation oncologist then revised his
prescription to 5000cGy at 200cGy per day for a total of 25 fractions with 1cm bolus to the total
PTV volume by rapid arc treatment, prescribed to the PTV volume.
Patient Setup/Immobilization: CU underwent a computed tomography (CT) simulation scan
for treatment planning on February 11, 2015. The patient was placed in the supine position on an
inclined wingboard/ breastboard on headrest B. Both of the patients arms were extended
above her head and she was holding an indexed handle bar. Her arms were relaxed against the
wingboard. An indexed hip stop was placed at C. This is done to insure that the patient is in
the correct position for each treatment. A knee sponge was placed for support. CUs feet were
banded together for further immobilization. The radiation oncologist outlined the treatment area
of the breast by placing CT-spot lines on the superior, inferior, medial, and lateral borders of the
breast. The isocenter was marked at the tangent and supraclavicular matchline with CT-spot
pellets. The breast mastectomy scar was also outlined with a CT-spot line. An aquaplast bolus
was created and left on the patient during CT simulation(Figures 1-7).

Anatomical Contouring: After the treatment planning simulation on the CT simulator, the
images were sent to the Eclipse treatment planning system (TPS). The certified medical
dosimetrist (CMD) imported the images into Eclipse, named the CT data set, inserted a new plan,
and inserted a structure set from template before closing out of the patient so that the radiation
oncologist could contour the planning target volume (PTV). The radiation oncologist contoured
the chestwall PTV and supraclavicular PTV. After the radiation oncologist contoured the PTVs,
the CMD contoured the organs at risk (OR). The ORs for the treatment of the left chestwall of
this patient included the heart, spinal cord, bowel, and the right and left lungs as well as the total
lung volume. For this plan, optimization structures were also created. These structures include:
lung-PTV (remove lung extending inside PTV), heart-PTV (remove heart extending inside PTV),
and a 1cm ring structure was created around the PTV to help with dose conformity (Figure 8).
Beam Isocenter/Arrangement: The CMD received a written directive from the radiation
oncologist with the intended prescription and technique. At my clinical site, 4-field breasts are
generally planned and treated mono-isocentrically. The CMD placed the isocenter on the
matchline so that the multi-leaf collimation (MLC) leaves could cover the isocenter, and not
cover the PTV. The amount of lung that would be treated was also taken into consideration when
placing the isocenter. The radiation oncologist preferred for a depth of no more than 3cm of lung
to be treated. The goal of the CMD was to treat a depth of no more than 2cm of the patients
ipsilateral lung. The lung volume was also taken into consideration when choosing the gantry
angles of the tangential fields. The goal of the CMD was to find gantry angles that allowed
coverage of the PTV, with no more than 2cm of lung in the treatment field. Unfortunately, due to
the barrel shape of the patients chestwall, when angles were chosen for optimal PTV coverage
approximately 5cm of the ipsilateral lung and 4cm of the heart was in the tangential fields
(Figure 9). It was clear from viewing the dose volume histogram (DVH) that the dose to the lung
and heart was outside of the tolerance (Figure 10). The CMD reviewed the plan with the
radiation oncologist and suggested a rapid arc treatment plan. Volumetric modulated arc therapy
(VMAT) is a rotational intensity modulated radiation therapy (IMRT) delivery technique.3 The
dose distribution of VMAT plans has been proven to be comparable to the dose distribution of
fixed-beam IMRT. The radiation oncologist agreed to the rapid arc treatment plan and updated
the prescription accordingly. It was then determined by the CMD that CU would be treated on
the Varian Trilogy with a 6MV VMAT rapid arc plan (Figure 11). Isocenter placement is different

for rapid arc plans. The isocenter doesnt have to be placed on the matchline and is instead
placed approximately mid-volume. The isocenter for rapid arc should not be placed superficially
and was therefore moved medially in the lung. Moving the isocenter medial and less superficial
decreases the effect of beam divergence on the plan and allows for a more conformal treatment
plan (Whittington A, oral communication, February 2015). Because cone beam computed
tomography (CBCT) was the imaging modality choice of the doctor, the table constraints for
CBCT had to be considered. The CMD went to the treatment room in order to determine the
table vertical tolerance for the CBCT. It was determined that the table vertical should be under
126.2. When placing the isocenter, the CMD ensured that the table vertical met the required
constraints by measuring the distance from the isocenter to the table top. The CMD decided to
treat CUs chestwall and supraclavicular fields with two partial arcs. After setting the isocenter,
the CMD determined the arc angles required for optimal coverage of the PTV (Figure 12). The
arc angles for a partial arc treatment should be at least 210 to 220 apart for optimum coverage
of the PTV (Whittington A, oral communication, February 2015). The rotation of the arc should
also extend slightly beyond the PTV in order to ensure adequate PTV coverage. The rotation of
the first arc was set to begin at 240 and end at 30. The rotation of the second arc was therefore
30 to 240. In order to create a more conformal plan with rapid arc, it is necessary to make sure
that different collimator angles are used for each arc. This is done to ensure that the transmission
radiation coming through the MLC leaves is different for each arc. At my clinical site, the
collimator is turned 30 degrees less than 180 for the first arc and 30 greater than 180 for the
second arc. The collimator was set to 150 for the first arc and 210 for the second arc. After the
collimator rotation and gantry angles were set for the first arc, the CMD set the field size. The
field size along the y-axis was pulled out to completely cover the PTV with a .5cm margin. In
order to set the field size along the x-axis, the dosimetrist used the play setting in Eclipse to
review the PTV coverage as the arc rotates around the patient. The field size was adjusted so that
all of the PTV received coverage at some time during the arcs rotation. The field size along the
x-axis was kept below 18cm in order to minimize transmission radiation through the MLC leaves
(Figure 13). The MLC leaves are not long enough to block transmission radiation for fields
longer than 18cm with rapid arch treatment planning. After setting the field size for the first arc,
the CMD created a new field for the second arc. The gantry and collimator angles were manually

entered. The field size along the y-axis was kept the same size as it was for the first arc. The
CMD then used the play function in Eclipse to review the coverage as the second arc rotated
around the patient and adjusted the field size along the x-axis as previously done for the first arc.
Treatment Planning: The patient was planned for treatment on the Varian Trilogy with a 6MV
rapid arc plan. During the isocenter placement and beam arrangement, the arc angles, collimator
angles, and field size were entered into Eclipse version 11 treatment planning system. Before
treatment optimization, the prescription was entered into Eclipse. The prescription dose was
prescribed to the PTV volume. The CMD then began the optimization process. At this point the
priorities and upper and lower constraints were set. Initially, the CMD only gave priority to the
lower constraints (Figure 14). The optimization level was then paused in the first phase in order
to allow the treatment planning algorithm to provide coverage to the PTV (Figure 15). Once the
desired coverage was achieved, the CMD gave priority to the upper constraints (Figure 16). The
coverage to the PTV decreased as the optimization took the upper constraints into consideration
(Figure 17). The CMD kept the first phase paused until the objectives were nearly met and then
unpaused the first phase and allowed VMAT optimization (Figure 18). Once optimization was
complete, the plan was evaluated. This was done by viewing the DVH to check the PTV
coverage and ensure that the dose constraints were met and scrolling through the images to view
the dose distribution. The CMD used the following dose constraints: Heart-V25 < 10%,
Ipsilateral lung- V25 < 20%, and Contralateral Lung- V5 < 10%. During this time, the CMD
normalized to the 90% isodose line in order to get optimal coverage of the PTV and continued to
evaluate the plan. After normalization, the initial plan had a hotspot of 118% in the PTV. In order
to decrease the hotspot, the CMD copied and pasted the plan. He then created a new optimization
structure for the second plan and named it PTV OPT. The CMD converted the isodose level of
114% to a structure. He then went to the new structure that he created and cropped the PTV from
the hotspot. The CMD went back to the optimization and put an upper constraint for 0% to be
above 5150cGy and a lower constraint for 100% to receive 5000cGy. The CMD then set the PTV
OPT structure to a high priority. He continued the previous optimization. Once the VMAT
optimization was complete, the plan was again evaluated by the CMD. It was determined that the
plan met all of the OR objectives and provided optimal coverage of the PTV. (Figure 19) The
DVH showed that the V25 of the heart was 5%, the V20 of the ipsilateral lung was 23.7%, and
the V5 of the contralateral lung was 67.69% (Figure 20). Although the dose to the contralateral

lung was high, the dose to the ipsilateral lung and the heart was within the tolerance constraints.
This could not be achieved with the 3D-XRT plan. The plan was reviewed and approved by the
radiation oncologist.
Quality Assurance/Physics Check: The monitor units (MUs) for the plan were double checked
with the RadCalc program. The accepted tolerance between the TPS MUs and the RadCalc MUs
is 5% for each field at my clinical facility and this plan fell within this tolerance. A second check
was completed with a quality assurance (QA) plan on the linear accelerator. At my clinical
facility, the physicist uses the Map Check 2 diode array system to perform QA for rapid arc
plans. The tolerance for each field when comparing the Map Check 2 results to the TPS plan is
3%. The QA for this plan was within tolerance. The completed rapid arc VMAT plan was
reviewed by the physicist for a second check before treatment began.
Conclusion: Post-mastectomy radiotherapy (PMRT) treatment planning is challenging because
the target volume covers a large, superficial area that is thin and convex in shape.3 Adding to the
degree of difficulty is the fact that the target volume is immediately adjacent to the lung, heart,
and contralateral breast. Treatment planning for a barrel shaped chestwall proved to be a
dosimetric challenge. The dosimetrist began treatment planning by setting up tangential fields for
the chestwall. It was clear early in the planning process that a 3D conformal technique would
include a lot of the left lung and heart in the treatment fields, exceeding the tolerance constraints
for both the left lung and the heart. Sometimes you have to deviate from the norm to create the
best plan for the patient. Once it was decided to proceed with rapid arc treatment planning of the
chestwall, the physicist researched treatment of the chestwall with rapid arc and found that rapid
arc plans for the chestwall yield acceptable quality with superior ipsilateral tissue sparing
compared to the 3D conformal technique.4 The rapid arc treatment plan to the chestwall allowed
for the patient to be treated without exceeding the ipsilateral lung tolerance constraints. I am new
to treatment planning, but through this case study, I have a better understanding of VMAT
treatment planning. I learned techniques for creating an optimal plan such as pausing the
optimization during the first phase and only giving priority to the lower constraints until the
desired coverage is nearly met, and then increasing the upper constraint priorities. In addition, I
learned that you can create structures that are only used for optimization, including structures
created from the isodose levels. The optimization structures help with plan conformity as well as
reducing hotspots. I also learned that there is not always a perfect plan. Although the CMD

was able to get the ipsilateral lung dose within the constraint tolerance, the dose to the
contralateral lung was much higher than preferred. The CMD spent a lot of time on this treatment
plan. However, when the patient came for her first treatment, it was determined that the aquaplast
bolus did not conform to the patient as it should due to loose skin from the gastric bypass and
instead left a large air gap between the bolus and the skin. The radiation oncologist decided that
it was in the best interest of the patient to re-do the simulation and treatment planning process.
CU was discouraged when hearing this news. The patient said that she really didnt want to
undergo radiation therapy. After a discussion with the radiation oncologist, CU and the radiation
oncologist agreed on a half-beam treatment to the supraclavicular area. At this time, the
supraclavicular treatment has not been planned. It was determined that the patient would undergo
radiation to the chestwall should she have a recurrence in that area. This was the first rapid arch
treatment plan for the chestwall performed at my facility. Though the plan was not used for
treatment of the patient, the radiation oncologist is open to this technique and modality in the
future for other patients with barrel shaped chestwalls. Although the CMD spent a lot of time
on a treatment plan that will not be used, in the end only the best interest of the patient matters.

References

1. Uschold GM, Zhang H. Breast Cancer. In: Washington CM, Leaver D, eds. Principles
and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010: 866894.
2. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed.
Philadelphia, PA: Lippincott, Williams, and Wilkins; 2011.
3. Nichols GP, Fontenot JD, Gibbons JP, Sanders ME. Evaluation of volumetric modulated
arc therapy for postmastectomy treatment. Radiat Oncol J. 2014;9(66):1-8.
doi:10.1186/1748-717X-9-66
4. Subramaniam S, Thirumalaiswamy S, Srinivas C, et al. Chest wall radiotherapy with
volumetric modulated arcs and the potential role of flattening filter free photon beams.
Strahlenther Onkol. 2012;188(6):484-490. doi: 10.1007/s00066-012-0075-6

Figures

Figure 1. Patient position on a Med-Tec, Inc. breast board with a wingboard attached during CT
simulation.

Figure 2. Lateral view of CT-simulation set-up, showing radio-opaque CT-spot pellet used to
mark the isocenter laterally and CT-spot lines used to mark the lateral border, superior border,
inferior border, and mastectomy scar.

Figure 3. Anterior view of CT-simulation set-up, showing both CT-spot pellets used to mark the
isocenter and the CT-spot lines used to mark the medial border, superior border, inferior border,
and mastectomy scar.

Figure 4. Patient position and markers during CT simulation.

Figure 5. Lateral view of the patient in position for CT simulation with aquaplast bolus in place.

Figure 6. Anterior view of the patient in position for CT simulation with the aquaplast bolus in
place.

Figure 7. Patient hand position during CT simulation.

Figure 8. Screenshot of the PTV (red) and an optimization structure (pink).

Figure 9. Amount of lung and heart in the tangent fields. Lung = 4.69cm and Heart = 3.56cm

Figure 10. DVH showing the dose to the lungs and heart with the tangent fields compared to the
dose with rapid arc.

Figure 11. Varian Trilogy radiation therapy treatment machine.

Figure 12. Isocenter placement and the two arcs used for treatment planning.

Figure 13. Field size adjusted to cover tumor volume while keeping the field size along the xaxis 18cm

Figure 14. Initial optimization.

Figure 15. Optimization paused during first phase of planning to allow dose coverage to the
PTV.

Figure 16. PTV coverage is met during optimization with the first phase paused. Notice in the
top right corner, the PTV (red) reaches the triangle that indicates optimal PTV coverage.

Figure 17. The upper constraints were added during optimization. The PTV (red) lost coverage
as the algorithm took the upper constraints into consideration. Notice in the top right corner the
red line doesnt quite reach the triangle that indicates optimal PTV coverage.

Figure 18. Upper constraints are added and the optimization phase 1 is unpaused.

Figure 19. Colorwash of the dose coverage to the PTV.

Figure 20. DVH of the rapid arc plan.