1

Dustin Melancon Semester Case Study November 23, 2013 3D CRT for Invasive Ductal Carcinoma of the Left Breast Abstract: Introduction: This study aims to evaluate post-mastectomy radiation therapy !M"T# usin$ three-dimensional con%ormal radiation therapy 3D-C"T# &ith the %ield-in-%ield '('# techni)ue %or invasive ductal carcinoma o% the le%t breast* This treatment techni)ue has been sho&n in literature to reduce dose to or$ans at ris+ ,"#, such as the heart, and assists in deliverin$ an even dose distribution to the tar$et* (n addition, studies reveal that alon$ &ith systemic therapy, !M"T &ith modern techni)ues can reduce side e%%ects, increase local control, and improve survival*1-Case Description: (nvasive ductal carcinoma in post-mastectomy patients &ho &ere treated &ith chemotherapy then %ollo&ed by !M"T* The . cases include the %ollo&in$/ !atient 1 represents a le%t chest &all case usin$ tan$ential photon beams, a supraclavicular %ield, and an electron boost0 !atient 2 represents the le%t chest &all treated &ith tan$ential photon beams and a supraclavicular %ield0 !atient 3 represents a le%t chest &all case treated &ith tan$ential photon beams and an electron boost* !atients - and . represent le%t chest &all cases &ith tan$ential photon beams, a supraclavicular %ield, and an electron boost* 1ll %ive 3D-C"T cases %eatured mi2ed ener$y beams &ith the '(' techni)ue* Conclusion: 1ll plans &ere evaluated %or ho& &ell dose ob3ectives and constraints &ere met usin$ 3D-C"T* !lans &ere evaluated individually %or doses to critical structures based on dose volume histo$ram D45# and the dose distribution throu$hout the tar$et* 6sin$ 3D-C"T in !M"T cases has been sho&n in literature to spare critical structures and improve dose homo$eneity* Key ords/ !ost-mastectomy radiation therapy !M"T#, three-dimensional con%ormal radiation

therapy 3D-C"T#, %ield-in-%ield '('# techni)ue*

Introduction ,lder !M"T techni)ues established better local control, but they also had an e2cessive ris+ o% cardiovascular death* More recent studies sho& that modern radiotherapy techni)ues can improve local control and avoid cardiac morbidity, re$ardless o% tumor si7e, number o% positive nodes, or histopatholo$ic $rade*1,2 1 8ritish Columbia randomi7ed trial &ith 20 years o% %ollo&up %ound that post-mastectomy patients &ho had chemotherapy and irradiation o% all re$ional lymph nodes and the chest &all areas had si$ni%icantly reduced rates o% breast cancer recurrence, compared &ith post-mastectomy chemotherapy alone*3 The trial also sho&ed a reduction in overall mortality* 1s in other solid tumors such as lun$, esopha$eal, and rectal cancers, chemotherapy alone cannot al&ays eliminate all residual disease* The microscopic disease may be resistant or become resistant to chemotherapy* 1d3uvant !M"T can be delivered to optimi7e outcome*The 3D-C"T techni)ue is commonly used %or !M"T, &hich uses tan$ential radiation %ields to treat the chest &all* The physician may pre%er the tan$ential %ields to %eature a combination o% lo& and hi$h ener$y photon beams %or better dose homo$eneity* The lo& ener$y beams allo& %or ade)uate dose near the s+in sur%ace &hile hi$her ener$y beams can achieve $reater depth* !atients &ithout a2illary lymphatic involvement are sometimes treated usin$ only tan$ential %ields to the chest &all* The a2illa and supraclavicular re$ions may be treated based on pro$nostic ris+ %actors, such as involvement o% - or more positive nodes* 1n electron boost is usually delivered to the e2cision site because local tumor recurrence is most %re)uently observed near the site o% the tumor bed*3 !atients &ith reconstructive breast sur$ery at my %acility do not receive boost %ields* 1 standard course o% !M"T consists o% .0 to .0*- 9ray 9y# delivered in 2. to 2: %ractions %2#, %ollo&ed by a 10 to 1: 9y boost to the tumor bed* 1 typical course o% 3D-C"T %or any o% the . cases presented mi$ht %ollo& a standard %ractionation o% 1*;-2*0 9y<%2 delivered daily in . to = &ee+s*3 Several alternative methods o% radiation delivery have been developed to shorten the number o% treatments* >ach techni)ue and %ractionation scheme should be individuali7ed to the patient?s anatomy, tumor characteristics, and institutional resources* 5ypo%ractionation is de%ined as, @The delivery o% lar$er-than-standard doses o% radiation over a shorter period o% time*A.

5ypo%ractionation &as ori$inally considered in the 1B:0s, but &as associated &ith a hi$h rate o% late complications* 1s technolo$y advanced, hypo%ractionated treatments re$ained popularity in the 6nited States* The hypo%ractionated treatment commonly used in the 6nited States has 1: treatments &ith a hi$her dose per day and is re%erred to as @Canadian %ractionationA* Cith a median %ollo&-up o% 12 years, studies have sho&n there &as no si$ni%icant di%%erence in local recurrence bet&een standard %ractionation and hypo%ractionation*. The cases presented &ill demonstrate both standard %ractionation and hypo%ractionation re$imens* (n the case o% hypo%ractionated therapy, there are clinical, lo$istical, and economic %actors that may be considered in the rationale %or this therapy* !otential e%%ects o% !M"T include s+in reactions, lymphedema, brachial ple2opathy, radiation pneumonitis, rib %ractures, cardiac to2icity, radiation-induced secondary neoplasms, and poor cosmetic results*.,: The data su$$ested that the incidence o% many o% these to2icities &ill be lo&er &hen modern radiotherapy techni)ues are used0 there%ore, the cases discussed have been planned and treated usin$ modern techni)ues* The remainder o% this study &ill %ocus on deliverin$ a homo$enous dose to the tar$et &hile minimi7in$ dose to critical structures* Danish trials have sho&n that !M"T &ith modern techni)ues did not increase the ris+ o% ischemic heart disease-related morbidity or mortality*3 Several studies have sho&n bene%its o% the '(' techni)ue %or improvin$ tar$et con%ormity and reducin$ dose to ," durin$ tan$ential irradiation*=,; The '(' techni)ue also demonstrated '(' techni)ue had superior results to most cases usin$ dynamic or physical &ed$es*; "esults such as these provide evidence that modern treatment techni)ues, such as the '(' techni)ue, allo& us to provide patients the bene%its o% !M"T &ithout to2icity to ,"* >ven &ith these improvements, it?s important that these doses are properly documented in the treatment plannin$ system*B The . cases presented &ere planned &ith a '(' techni)ue usin$ a multi-%ractionated approach to !M"T* !lans &ere evaluated individually based on cumulative dose volume histo$ram D45#, 100D o% prescription dose covera$e, prescription dose, and ma2imum and mean doses to ,"*

!ethods and !aterials Patient Selection The patients selected &ere cases o% invasive ductal carcinoma o% the le%t breast &ho presented to the %acility as candidates %or !M"T* >ach treatment demonstrated use o% the '(' techni)ue* !atient 1, a :. year-old male, is a case that demonstrated that !M"T in men is treated &ith the same approach as &omen* The patient had standard %ractionation as &ell as an electron boost to the mastectomy scar* 1 3-%ield monoisocentric techni)ue &ith beam splittin$ techni)ues &as used %or %ield matchin$ bet&een the tan$ential %ields and a supraclavicular %ield* Three separate plans &ere used %or the tan$ential %ields, supraclavicular %ield, and electron boost* The mi2ed ener$y tan$ential %ields %eatured the '(' techni)ue and allo&ed %or better homo$eneity and less dose to critical structures* !atient 2, a -; year-old %emale, had reconstructive breast sur$ery &ith a tissue e2pander and implant* 6sin$ standard %ield arran$ements, one study demonstrated that ade)uate dose to the reconstructed breast &as %easible in &omen &ho had immediate reconstruction a%ter mastectomy, re$ardless o% the reconstruction type or laterality o% the treatment plan* The results su$$ested that clinically acceptable doses to the heart and lun$s could be achieved in most patients*2 The patient?s plan &as desi$ned usin$ a 3-%ield monoisocentric techni)ue &ith beam splittin$ techni)ues %or matchin$ %ields* This case represented standard %ractionation scheme usin$ mi2ed ener$y tan$ential %ields &ith the '(' techni)ue and a supraclavicular %ield* !atient 2 did not have an electron boost because she had reconstructive sur$ery* !atient 3, a :0 year-old %emale, under&ent hypo%ractionated therapy* The radiation oncolo$ist o%%ered to re%er the patient some&here closer to home, but she &anted to have treatment at the current %acility* 8ecause o% the lon$ commute, the patient bene%ited %rom a short hypo%ractionated course %or !M"T* The treatment consisted o% mi2ed ener$y tan$ential %ields &ith the '(' techni)ue to the chest &all and an electron boost to the mastectomy scar* The radiation oncolo$ist elected to not treat the supraclavicular area because the patient did not have a2illary lymphatic involvement* !atient -, a := year-old %emale, had a standard course o% !M"T that consisted o% mi2ed ener$y

tan$ential %ields &ith the '(' techni)ue to the chest &all and an electron boost to the mastectomy scar* !atient ., a :; year-old %emale, under&ent hypo%ractionated therapy because o% her lon$ commute to the cancer %acility* Three separate plans &ere used %or the tan$ential %ields, supraclavicular %ield, and electron boost* The mi2ed ener$y tan$ential %ields %eatured the '(' techni)ue and allo&ed %or better homo$eneity and less dose to critical structures* Patient Set-up 1ll patients under&ent a computed tomo$raphy CT# scan head %irst in the supine position on a tilt board immobili7ation device* >ach patient &as placed in the supine position on a head support &ith the head turned to the ri$ht and supported &ith a tilt board headrest* The le%t upper arm &as e2tended and positioned above their head &hile their ri$ht arm &as positioned a+imbo* >ach patient had a spon$e under the +nees %or support* The radiation oncolo$ist mar+ed the superior, in%erior, medial, and lateral re$ions o% the le%t chest &all &ith radioopa)ue mar+ers* The radiation therapist outlined the mastectomy scar %or patients 1, 3, -, and . &ith radioopa)ue &ire to assist the medical dosimetrist durin$ treatment plannin$* Target Delineation The 4arian >clipse Treatment !lannin$ System T!S#, version 10*0 &as used %or all tar$et delineation* 1 CT scan &as obtained in all cases &ith each patient in the described treatment position* The radiation oncolo$ist placed the isocenter based on the desired treatment re$imen* The radioopa)ue mar+ers sho&ed up on the T!S and helped the medical dosimetrist determine the tar$et* 1ny !M"T techni)ue re)uires irradiation o% the entire mastectomy %lap, includin$ the entire mastectomy scar, sur$ical clips, and drain sites*2 The %ields %or each patient e2tended %rom the sternum to at least the mid-a2illary line* (t &as important to provide ade)uate covera$e in the in%erior border* This border &as placed about 2 centimeter cm# caudal to the previous location o% the in%ramammary sulcus* The superior border o% the chest &all %ields abutted the supraclavicular %ield* To avoid e2cessive dose at the %ield 3unction, the radiation oncolo$ist pre%erred usin$ a monoisocentric techni)ue to create a non-diver$ent ed$e* (n order to create a

non-diver$ent %ield ed$e, asymmetric-3a&s beam-split the tan$ential and supraclavicular %ields alon$ the central-a2is plane* Critical normal structures near the treatment area included the spinal cord, le%t lun$, ri$ht lun$, and heart* (n patients 1, 3, -, and . the medical dosimetrist used the radioopa)ue &ire that outlined the mastectomy scar to plan the electron boost plan* 1 1 cm bolus &as added in the T!S %or the electron boost plan* The medical dosimetrist added a 2 cm mar$in in all directions o% the sur$ical scar* Treatment Planning The dose prescription and +ey plannin$ parameters are presented %or each respective case in Tables 1-3* The plans &ere $enerated usin$ %or&ard plannin$* 1ll tan$ential %ields to the chest &all %eatured mi2ed ener$y photon beams &ith the '(' techni)ue* The '(' techni)ue can attenuate radiation in small areas o% the %ield &ith customi7ation o% the MECs* 5i$h dose areas are common &ith : me$avolta$e M4# beams in lar$e separation si7es* Chen there is a substantial amount o% tissue in the %ield, a mi2ture o% hi$her-ener$y beams can be used to reduce the areas o% hi$her dose* The lo&er ener$y remains in the tan$ential %ields to treat the super%icial areas o% the breast*. 1ll plans &ere optimi7ed &ith hetero$eneity corrections on* The $oals &ere to achieve con%ormal tar$et covera$e and preserve as much normal tissue as possible* 'or !atient 1, the challen$e o% deliverin$ a prescription dose o% .0 9y in 2. %2 to the tan$ential %ields &as complicated by the close pro2imity o% the heart and le%t lun$* The ob3ectives included/ ma2imum spinal cord dose less than -. 9y, mean heart dose less than 2 9y, and the le%t lun$ dose to be as lo& as reasonably achievable* The prescription dose %or the conventional tan$ential %ields &as prescribed to a calculation point placed by the medical dosimetrist at a depth o% 12*1 cm &ithin the le%t breast tissue* The medical dosimetrist placed the calculation point near the mid-plane depth o% the medial and lateral tan$ential beams, in the center o% the superior and in%erior e2tents o% the le%t breast volume, and appro2imately 1*. cm %rom the le%t chest &all* ,pen tan$ential %ields o% : M4 and 1; M4 beams &ere utili7ed %or better dose homo$eneity* Multilea% collimators MECs# helped to bloc+ e2cessive ," doses in the open tan$ential %ields* The '(' techni)ue used portals treated throu$h the same $antry an$le to reduce hi$h dose re$ions 'i$ure 1-2#* The medical dosimetrist accomplished this by convertin$ the 112D isodose level to a structure in the T!S* Ne2t, the medical dosimetrist loo+ed in the beam?s eye vie& o%

the '(' portal and ad3usted the MEC to cover the 112D structure* ,nce calculated, all o% the %ields &ere appropriately &ei$hted* The medical dosimetrist then converted the 10BD isodose level to a structure to increase dose homo$eneity and lo&er the ma2imum dose re$ion* (n the supraclavicular %ield, there &as a 3-.F $antry rotation to reduce dose to the spinal cord* The MECs &ere customi7ed to protect the humeral head and spinal cord* 'or the mastectomy scar, electrons &ould deliver dose to the scar and limit the dose to ad3acent tissue* The medical dosimetrist used B me$a-electron volts Me4# &ith a 1 cm bolus at 10. cm source-to-s+in distance SSD#* 1 bloc+ &as created in the T!S that &as 2 cm around the scar* The medical dosimetrist set the $antry at 3.F &ith the collimator at 10F* 1 2.22. cm %ield si7e &as lar$e enou$h to cover the entire mastectomy scar* 1 calculation point &as placed at a depth o% 2*1 cm, the ma2imum dose dma2# o% B Me4* 'or !atient 2, the challen$e o% deliverin$ a prescription dose o% .0*- 9y in 2; %2 to the tan$ential %ields &as complicated by the reconstructed breast* Dose constraints $iven &ere to +eep the ma2imum spinal cord dose less than -. 9y %or the composite plan* 1ll attempts &ere made to limit the mean heart dose less than 3 9y* The le%t lun$ dose &as to be as lo& as reasonably achievable* The prescription dose %or the conventional tan$ential %ields &as prescribed to a calculation point placed by the medical dosimetrist at a depth o% 11*- cm &ithin the medial tan$ent %ield and 1-*B cm &ithin the lateral tan$ent %ield* The medical dosimetrist placed the calculation point near the mid-plane depth o% the medial and lateral tan$ential beams, in the center o% the superior and in%erior e2tents o% the le%t chest &all volume, and appro2imately 3 cm %rom the le%t chest &all* ,pen tan$ential %ields o% : M4 and 1; M4 beams &ere utili7ed %or better dose homo$eneity* The MECs helped to bloc+ e2cessive doses to the heart, lun$s, and spinal cord in the open tan$ential %ields* 'or the '(' techni)ue, the medical dosimetrist converted the 112D isodose level to a structure in the T!S* Ne2t, the medical dosimetrist loo+ed in the beam?s eye vie& o% the '(' portal and ad3usted the MEC to cover the 112D structure 'i$ures =;#* ,nce calculated, all o% the %ields &ere appropriately &ei$hted* The medical dosimetrist then converted the 10BD isodose level to a structure to increase dose homo$eneity and lo&er the ma2imum dose re$ion* The supraclavicular %ield also %eatured a 3-.F $antry rotation to reduce dose to the spinal cord* The MECs &ere customi7ed to protect the humeral head and spinal cord* 1 10F enhanced dynamic &ed$e &as added to push dose a&ay %rom the %ield 3unction o% the tan$ent and supraclavicular %ields*

The chest &all %or patient 3 &as prescribed to receive -0*. 9y in 1. %2 at 2*= 9y per %2* ,b3ectives included/ ma2imum spinal cord dose less than -. 9y, the mean heart dose belo& 2 9y, and the le%t lun$ dose to be as lo& as reasonably achievable* The prescription dose %or the conventional tan$ential %ields &as prescribed to a calculation point placed by the medical dosimetrist at a depth o% =*; cm &ithin the medial tan$ent %ield and 11*; cm &ithin the lateral tan$ent %ield* The medical dosimetrist placed the calculation point near the mid-plane depth o% the medial and lateral tan$ential beams and the center o% the superior and in%erior e2tents o% the le%t chest &all* ,pen tan$ential %ields o% : and 10 M4 beams &ere utili7ed %or better dose homo$eneity* 'or the '(' techni)ue, the medical dosimetrist converted the 110D isodose level to a structure in the T!S* Ne2t, the medical dosimetrist loo+ed in the beam?s eye vie& o% the '(' portal and ad3usted the MEC to cover the 110D structure 'i$ures 12-13#* ,nce calculated, all o% the %ields &ere appropriately &ei$hted* The medical dosimetrist then converted the 10=D isodose level to a structure to increase dose homo$eneity and lo&er the ma2imum dose re$ion* 'or the mastectomy scar, electrons &ould deliver dose to the scar and limit the dose to ad3acent tissue* The medical dosimetrist used B Me4 &ith a 1 cm bolus at 110 cm SSD* 1 bloc+ &as created in the T!S that &as 2 cm around the scar* The medical dosimetrist set the $antry at 2;F &ith the collimator at 2.F* 1 2.22. cm %ield si7e &as lar$e enou$h to cover the entire mastectomy scar* 1 calculation point &as placed at a depth o% 2*1 cm, the dma2 o% B Me4* The chest &all %or patient - &as prescribed to receive .0*- 9y in 2; %2 at 1*; 9y per %2* Dose constraints $iven &ere to +eep the ma2imum spinal cord dose less than -. 9y %or the composite plan* 1ll attempts &ere made to limit the mean heart dose less than 3 9y* The prescription dose %or the conventional tan$ential %ields &as prescribed to a calculation point placed by the medical dosimetrist at a depth o% 11*. cm &ithin the medial tan$ent %ield and ;*0 cm &ithin the lateral tan$ent %ield* The medical dosimetrist placed the calculation point near the mid-plane depth o% the medial and lateral tan$ential beams and the center o% the superior and in%erior e2tents o% the le%t chest &all* ,pen tan$ential %ields o% : and 10 M4 beams &ere utili7ed %or better dose homo$eneity* 'or the '(' techni)ue, the medical dosimetrist converted the 112D isodose level to a structure in the T!S* Ne2t, the medical dosimetrist loo+ed in the beam?s eye vie& o% the '(' portal and ad3usted the MEC to cover the 112D structure 'i$ures 1=-1;#* ,nce calculated, all o% the %ields &ere appropriately &ei$hted* The medical dosimetrist then converted the 10;D isodose level to a structure to increase dose homo$eneity and lo&er the ma2imum dose re$ion*

'or the mastectomy scar, electrons &ould deliver dose to the scar and limit the dose to ad3acent tissue* The medical dosimetrist used B Me4 &ith a 1 cm bolus at 10. cm SSD* 1 bloc+ &as created in the T!S that &as 2 cm around the scar* The medical dosimetrist set the $antry at 30F &ith the collimator at 10F* 1 20220 cm %ield si7e &as lar$e enou$h to cover the entire mastectomy scar* 1 calculation point &as placed at a depth o% 2*1 cm, the dma2 o% B Me4* The chest &all %or patient . &as prescribed to receive -0*. 9y in 1. %2 at 2*= 9y per %2* ,b3ectives included/ ma2imum spinal cord dose less than -. 9y, the mean heart dose belo& 2 9y, and the le%t lun$ dose to be as lo& as reasonably achievable* The prescription dose %or the conventional tan$ential %ields &as prescribed to a calculation point placed by the medical dosimetrist at a depth o% ;*2 cm &ithin the medial tan$ent %ield and 10*. cm &ithin the lateral tan$ent %ield* The medical dosimetrist placed the calculation point near the mid-plane depth o% the medial and lateral tan$ential beams and the center o% the superior and in%erior e2tents o% the le%t chest &all* ,pen tan$ential %ields o% : and 1; M4 beams &ere utili7ed %or better dose homo$eneity* 'or the '(' techni)ue, the medical dosimetrist converted the 110D isodose level to a structure in the T!S* Ne2t, the medical dosimetrist loo+ed in the beam?s eye vie& o% the '(' portal and ad3usted the MEC to cover the 110D structure 'i$ures 23-2-#* ,nce calculated, all o% the %ields &ere appropriately &ei$hted* The medical dosimetrist then converted the 10=D isodose level to a structure to increase dose homo$eneity and lo&er the ma2imum dose re$ion* 'or the mastectomy scar, electrons &ould deliver dose to the scar and limit the dose to ad3acent tissue* The medical dosimetrist used B Me4 &ith a 1 cm bolus at 110 cm SSD* 1 bloc+ &as created in the T!S that &as 2 cm around the scar* The medical dosimetrist set the $antry at 3.F &ith the collimator at 3.F* 1 10210 cm %ield si7e &as lar$e enou$h to cover the entire mastectomy scar* 1 calculation point &as placed at a depth o% 2*1 cm, the dma2 o% B Me4*

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Plan Analysis & Evaluation The ob3ective o% radiation therapy in the mana$ement o% !M"T is to minimi7e the ris+ o% locore$ional recurrence &hile minimi7in$ the dose to ,"* The )uality o% the plan %or !M"T can be assessed by ho& &ell the plan covers the chest &all and doses to the le%t lun$ and heart* The . cases must be loo+ed at individually as to ho& &ell dose ob3ectives and normal tissue tolerances &ere met* 1 summary o% the ma2imum and mean doses %or each case is presented in Table -* 'or patient 1, the cumulative plan &as able to achieve all o% the dose constraints* The cumulative dose ob3ectives and constraints &ere evaluated 'i$ure 3-:#* The ma2imum point dose in the heart &as ;03*3 centi$ray c9y#, 123*B c9y in the spinal cord, -;1.*3 c9y in the le%t lun$, and 121*2 c9y in the ri$ht lun$* Mean doses include 12B*B c9y in the heart, .B*2 c9y in the spinal cord, ;.=*: c9y in the le%t lun$ and 11*; c9y in the ri$ht lun$* The cumulative plan %or patient 2 also achieved the dose ob3ectives and ade)uate prescription dose covera$e 'i$ures B-11#* The ," on the composite plan?s D45 re%lected ma2imum doses o% --:0*B c9y in the heart, 1==*. c9y in the spinal cord, -B;:*- c9y in the le%t lun$, and ;31*: c9y in the ri$ht lun$* Mean doses include 31=*B c9y in the heart, :-*3 c9y in the spinal cord, 12;0*B c9y in the le%t lun$ and 33*. c9y in the ri$ht lun$* The plan %or patient 3 also achieved the dose ob3ectives and ade)uate prescription dose covera$e 'i$ures 1--1:#* The ," on the chest &all plan?s D45 re%lected doses o% 32;2*. c9y in the heart, 2B*= c9y in the spinal cord, 3B:3*; c9y in the le%t lun$, and 32*1 c9y in the ri$ht lun$* Mean doses include 1=-*B c9y in the heart, =*- c9y in the spinal cord, .-0*1 c9y in the le%t lun$ and .*- c9y in the ri$ht lun$* The cumulative plan %or patient - also achieved the dose ob3ectives and ade)uate prescription dose covera$e 'i$ure 1B-22#* The ," on the composite?s plan?s D45 re%lected ma2imum doses o% 3BB;*: c9y in the heart, 1-:*: c9y in the spinal cord, .12=*0 c9y in the le%t lun$, and 1:-*2 c9y in the ri$ht lun$* Mean doses include 2B2*- c9y in the heart, --*0 c9y in the spinal cord, 12.0*. c9y in the le%t lun$ and 23*1 c9y in the ri$ht lun$* The cumulative plan %or patient . also achieved the dose ob3ectives and ade)uate prescription

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dose covera$e 'i$ure 2.-2;#* The ," on the composite?s plan?s D45 re%lected ma2imum doses o% 1=B-*3 c9y in the heart, 120*: c9y in the spinal cord, 3B:=*- c9y in the le%t lun$, and 10B*c9y in the ri$ht lun$* Mean doses include 13B*3 c9y in the heart, 3;*; c9y in the spinal cord, ==1*; c9y in the le%t lun$ and 1:*: c9y in the ri$ht lun$* (n analy7in$ Table -, the mean and ma2imum doses %or patient 2 and patient - &ere hi$her than the other patients* !atient 2 had hi$her doses to critical structures than the other patients because this patient had reconstructive breast sur$ery* "ecent studies indicate that implant-based breast reconstruction can create problems in patients receivin$ !M"T*10 (n patients &ith le%t-sided reconstructions, the heart and lun$ &ere spared at the e2pense o% %ull chest &all and internal mammary nodes covera$e* !atients 2 and - both had a substantial amount o% tissue to irradiate &ithin the chest &all* 1$ain, properly &ei$htin$ the mi2ed ener$y beams and usin$ the '(' techni)ue provided an acceptable treatment plan* 1lthou$h the ," doses &ere hi$her %or patients 2 and -, the medical dosimetrist established a $ood compromise bet&een ade)uate chest &all covera$e and +eep the ," doses as lo& as reasonable achievable* 1ll o% the 3D-C"T plans presented proceeded throu$h )uality assurance G1# &ith an independent chec+ %or monitor unit M6# calculation and passed &ithin the tolerance set o% H<.D* The precision o% this treatment re)uired that the position o% the breast be reproduced e2actly on a daily basis* Results and Discussion !atients in this study bene%ited %rom receivin$ !M"T because it reduces the ris+ o% recurrence and improves lon$-term survival*3 8ene%its are %or patients at the $reatest ris+ o% recurrence0 these include positive nodes, positive mar$ins, and lymphovascular invasion* 1lthou$h !M"T can improve local control and survival, this does not diminish the importance o% systemic ad3uvant therapy* 1 speciali7ed mana$ement plan %or patients should be developed to ma2imi7e their therapeutic ratio* "adiotherapy can result in lon$-term morbidity and mortality, so it is vital that !M"T is planned care%ully* !rinciples o% radiation biolo$y, radiation physics, mathematics, and anatomy must be understood %or treatment plannin$* "adiation %ields used %or !M"T are reasonably standard, but

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each %ield is individuali7ed accordin$ to patient anatomy and the structures at ris+* Treatment plannin$ demands e2perience and care%ul attention to detail %or the best patient care* The $oal o% !M"T is to not only ensure acceptable dose is delivered to the tar$et, but also minimal dose is $iven to the heart, lun$s, and spinal cord* This can be achieved &ith mi2ed ener$y beams and the '(' techni)ue*

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"i#ures

"i#ure $% !atient 1/ 8eam?s eye vie& o% the '(' le%t medial tan$ent*

"i#ure &% !atient 1/ 8eam?s eye vie& o% the '(' le%t lateral tan$ent*

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"i#ure 3% !atient 1/ Transverse vie& o% the chest &all plan* The $reen isodose line represents the 100D prescription line*

"i#ure '% !atient 1/ Transverse vie& o% the supraclavicular plan* The $reen isodose line represents the 100D prescription line*

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"i#ure (% !atient 1/ Transverse vie& o% the electron boost plan* The $reen isodose line represents the 100D prescription line* ,ne cm o% bolus applied daily*

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"i#ure )% !atient 1/ Cumulative D45*

"i#ure *% !atient 2/ 8eam?s eye vie& o% the '(' le%t medial tan$ent*

17

"i#ure +% !atient 2/ 8eam?s eye vie& o% the '(' le%t lateral tan$ent*

"i#ure ,% !atient 2/ Transverse vie& o% the chest &all plan* The $reen isodose line represents the 100D prescription line*

18

"i#ure $-% !atient 2/ Transverse vie& o% the supraclavicular plan* The $reen isodose line represents the 100D prescription line*

"i#ure $$% !atient 2/ Cumulative D45*

19

"i#ure $&% !atient 3/ 8eam?s eye vie& o% the '(' le%t medial tan$ent*

"i#ure $3% !atient 3/ 8eam?s eye vie& o% the '(' le%t lateral tan$ent*

20

"i#ure $'% !atient 3/ Transverse vie& o% the chest &all plan* The $reen isodose line represents the 100D prescription line*

"i#ure $(% !atient 3/ Transverse vie& o% the boost plan* The $reen isodose line represents the 100D prescription line* ,ne cm o% bolus applied daily*

21

"i#ure $)% !atient 3/ Cumulative D45*

"i#ure $*% !atient -/ 8eam?s eye vie& o% the '(' le%t medial tan$ent*

22

"i#ure $+% !atient -/ 8eam?s eye vie& o% the '(' le%t lateral tan$ent*

"i#ure $,% !atient -/ Transverse vie& o% the chest &all plan* The $reen isodose line represents the 100D prescription line*

23

"i#ure &-% !atient -/ Transverse vie& o% the supraclavicular plan* The $reen isodose line represents the 100D prescription line*

"i#ure &$% !atient -/ Transverse vie& o% the electron boost plan* The $reen isodose line represents the 100D prescription line* ,ne cm o% bolus applied daily*

24

"i#ure &&% !atient -/ Cumulative D45*

"i#ure &3% !atient ./ 8eam?s eye vie& o% the '(' le%t medial tan$ent*

25

"i#ure &'% !atient ./ 8eam?s eye vie& o% the '(' le%t lateral tan$ent*

"i#ure &(% !atient ./ Transverse vie& o% the chest &all plan* The $reen isodose line represents the 100D prescription line*

26

"i#ure &)% !atient ./ Transverse vie& o% the supraclavicular plan* The $reen isodose line represents the 100D prescription line*

"i#ure &*% !atient ./ Transverse vie& o% the electron boost plan* The $reen isodose line represents the 100D prescription line* ,ne cm o% bolus applied daily*

27

"i#ure &+% !atient ./ Cumulative D45*

28

Tables Table $% Chest Call !rescription and Treatment !lannin$ !arameters Prescription and Treatment Planning Parameters Case Site Patient 1 Ee%t chest &all Patient 2 Ee%t chest Patient 3 Ee%t chest Patient 4 Ee%t chest &all Patient 5 Ee%t chest &all

&all &all Prescription : M4 and 1; M4 Standard .0*- 9y in 2; : M4 and 10 M4 5ypo%ractionated -0*. 9y in

8eam >ner$y 'ractionation !rescription Dose

: M4 and 1; M4 Standard .0 9y in 2. %2

: M4 and 10 M4 Standard .0*- 9y in 2; %2

: M4 and 1; M4 5ypo%ractionated -0*. 9y in 1. %2

%2 1. %2 Treatment Planning Parameters 2# Co-planar beams 12BF, 30BF 0F 3D-C"T< '(' 2# Co-planar beams 12.F, 30.F 1-F, 3-:F

8eam 1rran$ement 9antry 1n$les Collimator !lannin$

2# Co-planar beams 130F, 310F 0F 3D-C"T< '('

2# Co-planar beams 130F, 310F 0F

2# Co-planar beams 11;F, 2B;F 0F

3D-C"T< '(' 3D-C"T< '(' 3D-C"T< '('

Techni)ue Note/ The couch an$les are set to 0F %or all beams*

29

Table &% Supraclavicular 'ield !rescription and Treatment !lannin$ !arameters Case Site Prescription and Treatment Planning Parameters Patient 1 Patient 2 Patient 3 Patient 4 Supraclavicula r area 8eam >ner$y 'ractionation !rescription Dose 8eam 1rran$ement 9antry 1n$les Collimator !lannin$ 1# 8eam 3-.F 0F 3D-C"T : M4 Standard .0 9y in 2. %2 Supraclavicula N<1 Supraclavicula r area : M4 Standard .0*- 9y in 2; Patient 5 Supraclavicular area : M4 5ypo%ractionated -0*. 9y in 1. %2 1# 8eam 3-.F 0F 3D-C"T

r area Prescription : M4 N<1 Standard N<1 .0*- 9y in 2; N<1

%2 %2 Treatment Planning Parameters 1# 8eam N<1 1# 8eam 3-.F 0F 3D-C"T N<1 N<1 N<1 3-.F 0F 3D-C"T

Techni)ue Note/ The couch an$les are set to 0F %or all beams*

30

Table 3% 8oost !rescription and Treatment !lannin$ !arameters Prescription and Treatment Planning Parameters Case Site Patient 1 Mastectomy scar Patient 2 N<1 Patient 3 Mastectomy scar Prescription N<1 N<1 N<1 B Me4 Standard B 9y in 3 %2 Patient 4 Mastectomy scar Patient 5 Mastectomy scar

eam Energy !ractionation Prescription Dose

B Me4 Standard 10 9y in . %2

B Me4 Standard 10 9y in . %2

B Me4 Standard B 9y in 3 %2

Treatment Planning Parameters eam Arrangement Source-to-S"in Distance #SSD$ %antry Angles Collimator Planning 1# >lectron beam 10. SSD 3.F 10F 3D-C"T N<1 N<1 N<1 N<1 N<1 1# >lectron beam 110 SSD 2;F 2.F 3D-C"T 1# >lectron beam 10. SSD 30F 10F 3D-C"T 1# >lectron beam 110 SSD 3.F 3.F 3D-C"T

Tec&ni'ue Note/ The couch an$les are set to 0F %or all beams*

31

Table '% !lan 1nalysis and >valuation Plan Analysis and Evaluation (rgans at )is" 5eart Ee%t lun$ "i$ht lun$ Spinal cord Patient 1 Dmean Dma* 12B*B ;03*3 ;.=*: 11*; .B*2 -;1.*3 121*2 123*B Patient 2 Dmean Dma* 31=*B --:0*B 12;0*B 33*. :-*3 -B;:*;31*: 1==*. Patient 3 Dmean Dma* 1=-*B 32;2*. .-0*1 .*=*3B:3*; 32*1 2B*= Patient 4 Dmean Dma* 2B2*3BB;*: 12.0*. 23*1 --*0 .12=*0 1:-*2 1-:*: Patient 5 Dmean Dma* 13B*3 1=B-*3 ==1*; 1:*: 3;*; 3B:=*10B*120*:

32

References 1* De&ar I1* !ostmastectomy radiotherapy* Clin (ncol* 200:01; 3#/1;.-1B0* doi/10*101:<3*clon*200.*11*00:* 2* Chao JS, !ere7 C1, 8rady EC* )a+iation (ncology ,anagement Decisions* 3rd ed* !hiladelphia, !1/ Eippincott Cilliams K Cil+ins0 2011* 3* "a$a7 I, ,livotto (1, Spinelli II* Eocore$ional radiation therapy in patients &ith hi$h-ris+ breast cancer receivin$ ad3uvant chemotherapy/ 20-year results o% the 8ritish Columbia randomi7ed trial* - .atl Cancer /nst* 200.0B= 2#/11:-12:* doi/10*10B3<3nci<d3h2B=* -* 9ebs+i 4, Ea$leva M, Jeech 1, Simes I, Ean$lands 1,* Survival e%%ects o% postmastectomy ad3uvant radiation therapy usin$ biolo$ically e)uivalent doses/ 1 clinical perspective* - .atl Cancer /nst* 200:0B; 1#/2:-3;* doi/10*10B3<3nci<d33002* .* Co2 ID, 1n$ JJ* )a+iation (ncology/ )ationale0 Tec&ni'ue0 )esults* Bth ed* !hiladelphia, !1/ Mosby, (nc0 2010* :* Lan$ IT, 5o 1L* "adiation therapy in the mana$ement o% breast* Surg Clin . Am* 20130B3 2#/-..--=1* doi/10*101:<3*suc*20* =* "echt 1, >d$e Sb, Solin EI, et al* !ostmastectomy radiotherapy/ 9uidelines o% the 1merican Society o% Clinical ,ncolo$y* - Clin (ncol* 200101B .#/1.3B-1.:B* ;* Eee I, 5on$ S, Choi J, et al* !er%ormance evaluation o% %ield-in-%ield techni)ue %or tan$ential breast irradiation* -pn - Clin (ncol* 200;03; 2#/1.;-1:3* doi/10*10B3<33co<hym1:=* B* 5arris I", Murphy-5alpin !, McNeese M, Mendenhall N!, Morro& M, "obert NI* Consensus statement on postmastectomy radiation therapy* /nt - )a+ (ncol io P&ys* 1BBB0-- .#/B;B-BB0* 10* Jrono&it7 SI, "obb 9E* "adiation therapy and breast reconstruction/ 1 critical revie& o% the literature* Plast )econstr Surg* 200B012- 2#/3B.--0;* doi/10*10B=<!"S*0b013e31;1aeeB;=*