1

Hybrid Volumetric-Modulated Arc Therapy and Segmented Field-in-Field Technique for

Post-Mastectomy Chest Wall and Regional Lymph Node Irradiation
Karen Lang, BS, RT(T); Adam Schwartz, BS; Brianne Loritz, BS, RT(T); Randi Finley, CMD,
BS, RT(T); Kimberly S. Corbin, MD.
ABSTRACT

Keywords: breast cancer, hybrid VMAT, field-in-field, internal mammary lymph nodes
Introduction
In 2016, the American Society of Clinical Oncology (ASCO), treatment guidelines
recommended post-mastectomy radiation therapy (PMRT) for breast cancer patients with high-
risk or node positive disease.1 Radiation treatment to this area included the chest wall or
reconstructed breast, internal mammary lymph nodes (IMN), supraclavicular nodes, and axillary
nodes for patients post-surgery.1 Such treatment has led to increased survival rates and decreased
locoregional recurrence (LRR) for post-mastectomy patients.2-3 Three randomized trials have
established the benefit of PMRT and reported a 70% decrease in LRR for diagnosed breast
cancer stages I-III. 2-5 At 15 years PMRT has shown to decrease breast cancer mortality by 5%
for node-positive breast cancer patients.2-5 The objectives for treatment to the chest wall and
regional lymph nodes are complete dose coverage to the target volume (TV) and minimized dose
to normal tissue (NT).
For chest wall and nodal irradiation, two of the major limiting organs at risk (OAR) are
the heart and ipsilateral lung. Researchers such as Darby et al6, have proposed a mean heart dose
of < 4Gy, should be considered to avoid increased cardiac morbidity. Along with this, other
studies have proven indications of increased mortality from heart disease and induced lung
cancer, 10-20 years post-radiotherapy.6-7 By incorporating current techniques such as field in
field segments with multi leaf collimation (MLC) and respiratory gating through deep inspiration
breath-hold (DIBH), decreased dose to healthy lung and heart is achieved.6-8 The DIBH
technique increases the volume of lung tissue as well as the separation between the chest wall
and heart, allowing dose sparing to the heart, without compromising TV coverage.7-8
Today, the standard treatment for PMRT patients is a three-dimensional (3D) tangential
field treatment technique.9-12 This treatment has proven its success but falls short for patients
presenting with challenging anatomical features, specifically when IMN are involved in the
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treatment field. Inclusion of the IMN for tangential beams, can increase heart dose significantly
due to the location of the IMN that lie deep and medially in the sternum.9 Concerns for
anatomically complex treatments using tangential fields include dose distribution inhomogeneity,
poor conformity, high dose to the heart, ipsilateral lung, and contralateral breast.9 Dose specific
objectives, for limiting heart and ipsilateral lung doses, have led to the investigation of inverse
optimization, intensity modulated radiotherapy (IMRT) and volumetric-arc therapy (VMAT) for
more complex breast cancer treatment.9-12
Many studies have explored inverse planning techniques and discovered a trade-off
between improved target dose coverage and increased low-dose to surrounding tissues.9-12
Detrimental effects of a low-dose bath to surrounding tissue has not been proven but continues to
be investigated.6 For IMRT and VMAT, less heart, ipsilateral lung, and contralateral breast doses
were reported and found superior to 3D tangential beams.10-11 The most evident differences
between IMRT and VMAT was less monitor units (MU) delivered by VMAT plans leading to
less overall treatment delivery time.12 Still, with such high expectations for prescription dose TV
coverage and OAR constraints, continued research is necessary for optimal beam arrangements
that will maximize TV coverage and minimize dose to healthy tissue.
Combination of a hybrid VMAT and segmented 3D field in field technique was
researched to compare its treatment outcomes with current treatment strategies for complex
treatment fields such as irradiation to the chest wall and regional lymph nodes. This retrospective
study was specific to post-mastectomy patients receiving radiation treatment to the chest wall
and regional lymph nodes including supraclavicular, axillary, and IMN. The objective of this
study was to compare a hybrid VMAT technique to VMAT alone. The dose homogeneity, PTV
conformity, heart dose, and lung doses were evaluated to determine if a hybrid VMAT technique
should be considered superior for treatment planning over VMAT alone.
Materials and Methods
Patient Selection
All patients selected for this study were post-mastectomy breast cancer patients who
received radiation treatment at the same radiation oncology clinic. Of these patients, 4 were
right-sided and 6 were left-sided chest walls, female, and between the ages of 29-72. For the
simulation, a computed tomography (CT) scan of the patient was completed with a free-
breathing (FB) and DIBH technique. The evaluation of each patient's ability to breath hold for
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treatment was assessed by the radiation therapists and radiation oncologist at the time of
simulation. Patients who were unable to successfully perform DIBH were not included in the
study.
Patients were positioned supine, with arms above their head on a breast board or Vac-lok
vacuum immobilization device. The FB and DIBH scans were completed on a wide-bore
Siemens Somatom Definition AS scanner with 2 mm axial slice thickness. The scanning
parameters began at the elbows and ended below the inferior aspect of the inframammary fold.
The entire lung was included in the scan for accurate lung volume statistics. For the DIBH scan,
a Varian Real-Time Position Management (RPM) system was used to monitor patient breathing.
For daily treatment, an Optical Surface Monitoring System (OSMS) was used to verify the
patient replicated a similar breath hold in reference to the breath hold captured by the RPM at the
time of simulation.
Contouring
Patient datasets from the CT simulation were imported into the Eclipse treatment
planning system (TPS) for delineation of the target and OAR volumes. The contours were
completed by the radiation oncologist and medical dosimetrist on the DIBH scan. The radiation
oncologist completed contours for the target volume, heart, coronary arteries, esophagus, thyroid,
and the brachial plexus. The medical dosimetrist was responsible for contouring the spinal cord
and lungs. The isocenter was placed by the medical dosimetrist inside the chest wall near the
center of the PTV to maximize leaf travel, due to large treatment fields.
The Radiation Therapy Oncology Group (RTOG) Breast Cancer Atlas for Radiation
Therapy Planning was used to define the clinical target volume (CTV) by the radiation
oncologist.14 For the CTV, the chest wall was included which was considered 3 mm beneath the
skin surface, following along the inner edge of the ribs. The medial border of the CTV was
determined by the location of the midsternal IMN. The inferior border was considered 2 cm
inferior to the inframammary fold or the inferior border of an intact contralateral breast. The
superior border included the caudal border of the clavicular head.
The regional lymph nodes included in the treatment field were the axillary lymph nodes
I-III, supraclavicular lymph nodes, and IMN. A 5 mm margin was added to the CTV to create the
planning target volume (PTV). The PTV was cropped back 3 mm from the body and out of the
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lung contour to exclude the dose buildup region. Therefore, the overall PTV evaluated included
the chest wall, axillary lymph node levels I-III, supraclavicular lymph nodes, and IMN.
Treatment Planning
For this study, two treatment planning techniques were completed for 10 patients on the
Eclipse Version 15.1.15 TPS using the Analytical Anisotropic Algorithm (AAA) calculation.
The prescription for the patients was a daily dose of 200 cGy in 25 fractions, 5 days per week,
for a total dose of 5000 cGy to the chest wall and regional lymph nodes. There was 0.5 cm of
bolus added in the TPS to cover the chest wall for daily treatment. The treatments were
completed on a Varian Truebeam linear accelerator that used 6/10 MV energy. Using the beam's
eye view (BEV) the medical dosimetrist was able to determine the appropriate gantry angles for
the tangential fields and partial arcs. The location of the contralateral breast, heart, ipsilateral
lung, and PTV, especially the medially located IMN were considered when choosing gantry
angles.
The field width was less than or equal to 20 cm to then maximize modulation for the
VMAT techniques. For these treatments, a mono-isocentric setup with half-beam blocking was
not feasible because dose from the VMAT contributed to both the regional lymph nodes and
chest wall. The major priority for both treatment techniques was to achieve a dose distribution
with 90% of the PTV receiving 90% of the prescription. The medical dosimetrists ultimately
aimed to cover 95% of the PTV receiving 100% of the prescription dose. As for the IMN, the
goal was 90% coverage (45 Gy) to at least 90% of the IMN.
The pure VMAT plan consisted of 4 partial arcs that moved between optimal tangent
angles. These arcs were typically 185 degrees apart but varied slightly based on patient
anatomy. The first and second arcs used 5-15 degree complementary collimator angles. The third
and fourth arcs consisted of upper and lower arcs with a 2-3 cm overlap at the chest wall and
supraclavicular junction. The collimator was turned to 90-degrees to improve conformity and
carve out the dose to the ipsilateral lung around the chest wall.
Similarly, to the pure VMAT plan, the hybrid plan also consisted of 4 partial arcs with an
additional 2 tangential fields. The goal was to optimize the tangential beams and minimize heart
dose. The VMAT contribution was used to achieve a more conformal dose around the PTV
where the tangents were lacking conformity. Optimal tangential gantry and collimator angles
where chosen to include the entire PTV while accommodating the slope of the chest wall to
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minimize dose to the heart and ipsilateral lung. At least 3cm flash over the chest wall was used to
assure maximum coverage to the PTV surface and potential setup inconsistencies from
robustness. Subfields were added on each tangential field, open over the CW in the planes of the
heart (Figure 1). The subfields provide a hard field edge blocking the heart. In the hybrid
planning, the segmented fields, collectively contributed approximately 80% of the total dose.
One hundred cGy was delivered from the field in field tangents and 100 cGy from the partial
arcs. In the optimizer, for the VMAT planning, the tangential beam plan was used as the base
plan.
Plan Comparison
To evaluate the hybrid VMAT and pure VMAT treatment techniques, dose-volume
histograms (DVH) were generated to collect data for dosimetric analysis. Three parameters used
to compare the treatment techniques included dose homogeneity, PTV dose conformity, and
volume of healthy tissues irradiated. For this study, the statistical data used to evaluate the plan
quality were dose maximum, V110%, V95%, D95%, D50%, D5%, the conformity index (CI), Healthy
Tissue Conformity Index (HTCI), and homogeneity index (HI). The V110% is equal to the volume
D5 % −D95 %
of the target receiving 110% of the prescribed dose. The HI was calculated by, HI = D50 %

where the D95%, D50%, and D5% equal the dose to 95%, 50%, and 5% of the volume, respectively.
V95 %
The CI was calculated by, CI = where V95%was the volume included in the 95% isodose
TV
TVRI
line and TV(cc) was the volume of the target.15 The HTCI was calculated by, HTCI = V where
95 %

V95%was the volume included in the 95% isodose line and TVRI was the volume of 95% isodose
line contained within the PTV5000.15 The healthy tissue dosimetric parameters used for the
comparison of dose to the heart were (V4%, V25%, and Dmean) and for ipsilateral and contralateral
lung (V4%, V10%, V20%, and Dmean).
Results
In comparing plan quality, OAR and PTV specific indices and parameters were used and
are displayed in (Table 1). Dose volume histograms function as a valuable co-metric to compare
plan quality between hybrid and VMAT plans, which can be seen in (Figure 3). Specific to dose
conformality, the conformity index (Conformity IndexVMAT= 1.14 v. Conformity Indexhybrid=
1.21) and Healthy Tissue Coverage Index (HTCIVMAT= 0.86 v. HTCIhybrid= 0.81) indicate the
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Discussion
The inclusion of regional lymph nodes for PMRT breast cancer patients is not a new
concept but is extremely important when discussing the likelihood of local recurrence. The study
by Strom et al20, reported 50% of patients who did not receive nodal irradiation presented with
lymph node recurrence. Adequate dose coverage of the regional lymph nodes therefore, cannot
be overlooked, even for patients with difficult anatomy. The goal of this study was to determine
if the hybrid VMAT technique would sufficiently protect the heart, lungs, and contralateral
breast without compromising the PTV when compared to the VMAT only technique.
When VMAT was used in combination with 3D field in field segments, the hybrid
VMAT partial arcs contributed dose to the low dose areas in the PTV where the 3D tangents
were unable to achieve the desired dose. This could be done without increasing dose to the heart
and lungs. Another advantage of the hybrid plan was it did not add any complexity to the
treatment setup for radiation therapists, as a single isocenter was used so the patient was not
adjusted between 3D tangents and VMAT. As previously studied, the VMAT dose fall off
occurred in all directions, leading to a larger volume of healthy tissue receiving low dose.10-13
Therefore, a sharp dose gradient was not achieved for either planning technique. Some of the
disadvantages of the hybrid VMAT compared to VMAT alone were higher difficulty reducing
the dose maximum, longer planning time, increased cost for patient, and extra tangential fields
that lead to a slightly longer treatment time. The pure VMAT plans produced better PTV
conformity, confining a larger ratio of the prescription dose to the PTV while the hybrid plans
displayed an advantage in overall dose uniformity within the PTV. Both pure VMAT and hybrid
VMAT plans were able to adequately cover 95% of the PTV with 100% of the prescription dose.
After evaluation of the PTV coverage, lung, and heart doses for these patients, there was
not a clear indication as to which treatment type was superior. Ultimately, both planning
techniques were able to produce acceptable plans for patient treatment and the decision to treat
with hybrid VMAT or VMAT alone became contingent on anatomical factors. The most
influential factor was the position of the heart. Examples noted in this study include a patient
case where the heart and IMN were directly abutting and another patient whose heart overlapped
the PTV. This anatomy posed challenges for both treatment techniques but especially for the
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hybrid VMAT in limiting heart dose because the heart could not be excluded from the tangent
angles without blocking significant amount of PTV. In these scenarios, the pure VMAT plans
performed better in PTV coverage and protecting the OAR.
The hybrid VMAT and VMAT alone both produced plans with a Dmean below 4 Gy to the
heart. As predicted, the hybrid VMAT was able to better spare the heart than the VMAT plan
alone, as the heart Dmean was an average of 0.5 Gy lower. The ipsilateral lung Dmean and V20 were
slightly higher for the hybrid VMAT plans while the V5 and V10 low dose values were less for the
hybrid VMAT. Although the dose to the contralateral breast was not specifically recorded in this
study, the plans were evaluated by observing isodose distributions and approved by a radiation
oncologist to determine that contralateral breast dose was acceptable.
The hybrid VMAT technique is a viable treatment option for patients with unusual
anatomic shape, unusual intrathoracic organs, multimodality therapy that causes increased
cardiac toxicity, or patients with pre-existing conditions that compromise cardiac function. For
situations when it is difficult to achieve low dose to OAR with VMAT, a hybrid VMAT plan can
be considered. Slight adjustments in beam arrangements can produce significant differences in
dosimetric outcomes. Therefore, continual research to find optimal beam arrangements and
techniques for complex treatments such as chest wall and nodal radiation, remain relevant in the
field of radiation oncology. Overall, the ideal treatment method varied on a patient-to-patient
basis. It would be up to the radiation oncologist and patient in the end, to decide which treatment
method should be used.
Conclusion
The purpose of this study was to compare hybrid VMAT with VMAT alone in the
delivery of external beam radiation for patients post mastectomy with nodal disease. This
retrospective study concluded that for most treatment scenarios a hybrid VMAT technique can
help achieve lower doses to the heart over VMAT alone, depending on the location of the heart.
Hybrid VMAT is not able to achieve better PTV conformity or dose homogeneity over VMAT
alone. Hybrid VMAT was able to achieve appropriate PTV coverage in all instances. On average
the dose to the heart was 0.5 Gy less. For the contralateral lung the hybrid VMAT delivered less
low dose but for the ipsilateral lung the pure VMAT V20 was ~3.38 Gy less than the hybrid
VMAT.
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Add to conclusion, future research, study limitations (limited # of patients), and how we
could have improved the study had it been a prospective study.
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References
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cancer and all regional nodes improves target volumes coverage and reduces treatment time
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Figures
(still need to reference figures in text)

Figure. 1. Patient 10 - BEV of the subfield from the medial tangent of the hybrid plan.
Approximately 80% of the total dose is given through this field and it’s paired opposing subfield.

Figure 2. Patient 10 - cumulative DVH showing hybrid vs VMAT only plans.

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Figure 3. Patient 10 - comparison of isodose line distributions on axial views for the hybrid (left)
and the VMAT only (right) plans. The white line represents the 5000cGy isodose line, the blue
line represents the 4500cGy isodose line and yellow line is the 500cGy low-dose spillage.
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Tables
Table 1.
Plan comparison parameters and mean values for VMAT and Hybrid plan comparison.
VMAT Hybrid
Mean Minimum Maximum Mean Minimum Maximum T-test
PTV5000
D5% (Gy) 52.6 52.1 53.6 52.6 52.2 53.7 0.748
D50% (Gy) 51.2 50.9 51.8 51.1 50.8 51.4 0.076
D90% (Gy) 49.8 49 50.2 49.4 47.8 50.1 0.057
D95% (Gy) 49.1 47.5 49.7 48.4 44.6 50 0.11
Dmean (Gy) 51.1 50.8 51.7 50.8 50.2 51.2 0.03
V95% (Gy) 98.4 94.98 99.7 97.1 91 99.6 0.076
HI 0.069 0.047 0.113 0.082 0.049 0.179 0.232

Total Lung
V5% 62.6 54.4 67.5 51 37 64.5 0.005
V10% 33.7 28.4 40.7 28.6 22.3 37.9 0.013
V20% 13 11.8 14.3 14.2 11.1 18.3 0.041
Dmean (Gy) 10.2 9.2 11.3 9.8 7.7 12.3 0.259

Contralateral
Lung
V5% 36.5 27.3 50.7 30.6 16.7 40.3 0.077
V10% 10.3 5.3 16.8 6.9 1.5 13.2 0.086
V20% 0.8 0 2.3 0.5 0 1.3 0.036
Dmean (Gy) 4.8 2.7 5.8 4 2.7 4.7 0.009

Ipsilateral
Lung
V5% 84.3 71 95.6 71.6 58.2 85.2 0
V10% 54.9 43.7 70.2 50.5 43.5 63.4 0.058
V20% 24.6 22 27 28 23.7 33.6 0
Dmean (Gy) 15.1 13.4 17.1 15.6 13.4 19 0.193

Heart
V4% 29.4 12.9 43.6 20.7 2.7 46.7 0.01
Dmean (Gy) 3.9 2.6 5.6 3.4 1.8 6.7 0.126

Plan MUs 673.3 564 812 674.9 579 823