Capstone Outline –

Radiation therapy treatment of the prone breast using EZFluence: A case study
I. ABSTRACT –
II. Introduction
A. Breast cancer remains the most commonly diagnosed cancer in women
worldwide, and the fifth leading cause of death from cancer overall.1
B. Since its inception, independent studies have recognized the benefits of whole
breast irradiation in the prone position as compared to the supine position; these
benefits include decreasing acute toxicity, cosmetic changes, risks of radiation‐
induced lung cancer, and cardiac toxicity.2
1. Other benefits for prone breast radiation therapy include improved dose
coverage, better homogeneity, less hotspots within treatment volume, lower
ipsilateral lung and heart dose, lower contralateral breast dose, and reduced
skin reactions.3
C. One new software has been developed, known as EZFluence, which is used to
create an optimal fluence pattern to generate a homogenous dose distribution for
breast radiation treatments.8
D. To date, there is very limited data demonstrating the benefits of EZFluence as
compared to manual field-in-field (FiF) techniques for supine and prone breast
patients.8
E. The purpose of this study was to provide information on the use of the EZFluence
software script that may help to improve prone breast planning time, organs at risk
(OAR) sparing, and overall dose uniformity to the target.
F. Based on their research, Keenan et al5 found that in cases when the volume of the
breast receiving ≥ 105 percent of the volume (V105) ≥ 30cc with conventional
fractionation have a strong indicator for acute skin toxicity in general breast
planning. For this reason, V105 was also a criteria evaluated in this study.
III. Case Description
A. Patient Selection
1. Patient selection was based on various factors and narrowed to a study
group of 10 female individuals with breast cancer who met the criteria of
 having intact, pendulous breasts (post-lumpectomy) without nodal
involvement.
a. Only patients that were set up in the prone position, per the attending
radiation oncologist’s request, were included.
b. The range of the planning target volume (PTV) size for our included
patients was 547-1090cc; the mean PTV size was 860 cc.
2. Planning was done retrospectively to include the whole affected breast to a dose of
42.56 Gy using both non-divergent medial and lateral 3-dimensional conformal
radiation therapy (3D CRT) tangential beams produced by manual FiF techniques
and EZFluence software. Dose from any boost after the initial 42.56 Gy was not
included in this study.
3. All 10 patients received a CT simulation with a GE Lightspeed 16 multi-slice CT
scanner.
a. All patients were setup in the prone position on a CDR Systems
prone breast board with their arms up prior to treatment planning.
b. Breast borders and the lumpectomy scar were delineated with
radiopaque wire stickers per the radiation oncologist.
c. Alignment reference markers were used for positioning and
subsequent markings were placed for future set-up (figures 1a and 1b).
4. Isocenter was chosen by the attending radiation oncologist at the time of CT
simulation and was located at the approximate center of the breast volume (roughly
at the midpoint of the breast tissue external separation and in proximity of the chest
wall).
5. Patients excluded from this study were those which were CT simulated in a supine
position regardless if the scan was performed with or without bolus.
B. Target Delineation
1. All target delineation was performed in Varian Medical Systems Eclipse
treatment planning system (TPS), version 15.6. Targets were delineated for
treatment planning by the radiation oncologists; All pertinent OAR were
contoured by the medical dosimetry interns. All targets were verified by the
 attending physician to ensure accuracy and consistency. Target structures were
defined per the following:
Target Structure
1. Cavity
2. PTV_Lumpectomy_4256
3. PTV_Lumpectomy_Eval
4. PTV_Breast
5. PTV_Breast_Eval
Determining Factors
Contour using all available clinical and radiographic
information including the excision cavity volume,
architectural distortion, lumpectomy scar, seroma and/or
extent of surgical clips
Cavity + 1.0 cm expansion
Since a substantial part of the Lumpectomy PTV often
extends outside the patient (especially for superficial cavities),
the Lumpectomy PTV is then copied to a Lumpectomy PTV
Eval which is edited. This Lumpectomy PTV Eval is limited
to exclude the part outside the ipsilateral breast and the first 5
mm of tissue under the skin (in order to remove most of the
build-up region for the DVH analysis) and excluding the
Lumpectomy PTV expansion beyond the posterior extent of
breast tissue (chestwall, pectoralis muscles, and lung) when
pertinent. The lumpectomy PTV should not cross midline
Considers reference clinical breast at time of CT. This
includes the apparent CT glandular breast tissue and
incorporates consensus definitions of anatomical borders.
The breast PTV includes the lumpectomy cavity. It is limited
posteriorly to the anterior surface of the pectoralis, serratous
anterior muscle excluding chestwall, boney thorax, and lung.
In general, the pectoralis and/or serratous anterior muscles are
excluded from the Breast PTV unless clinically warranted by
the patient’s pathology
The Breast PTV Eval is intended to exclude the portion of the
Breast PTV that extends outside the patient. The Breast PTV
is copied to a Breast PTV Eval which is edited. This Breast
PTV Eval is limited anteriorly to exclude the part outside the
patient and the first 5 mm of tissue under the skin (in order to
remove most of the build-up region for the DVH analysis)
 2. The general OAR for prone breast treatment planning were contoured as well,
which included the bilateral lungs, heart, liver, and spinal cord. Contouring of
OAR was performed per the Radiation Therapy Oncology Group (RTOG)
contouring atlas recommendations.
C. Treatment Planning
1.The CT scans of the 10 patients in this study were imported from CT simulation to
the Eclipse TPS. Each patient was prescribed a radiation dose of 42.56 Gy to the
intact whole breast delivered in 16 fractions at 2.66 Gy per fraction.
a. The radiation oncologist placed radiopaque wire stickers at the time of CT
simulation on the patient’s midsagittal plane and approximately 2.0 cm
beyond the palpable breast tissue in the superior, inferior, and lateral aspect.
These wires were used to determine the approximate breast tissue borders and
assist in defining beam angles, collimator angles, and field sizes during
treatment planning by the radiation oncologist based on patient anatomy and
radiopaque wires placed at time of CT simulation.
b. Two fields were tangentially aligned to the PTV to create non-divergent
opposed fields.
c. Two different 3D-CRT plans were created for each patient, 1 utilizing the
manual FiF technique and 1 utilizing the EZFluence software script. All plans
were constructed using opposed non-divergent tangential field arrangements
with 6 MV energy photon beams.
2. Treatment planning for the manual FiF plans utilized the following methods:
a. Open multileaf collimator (MLC) leaves were set for the initial medial and
lateral tangent fields.
b. A reference point was placed within the field, and the plan was normalized so
that 100% of the prescription dose to be delivered to that point.
c. The dose was calculated and the 107% dose cloud was turned on. The
reference point and field weighting were adjusted until adequate coverage to
the PTV_Breast_Eval was determined.
i. The reference point was not covered by the 107% dose cloud.
 d. Field-in-Fields were created for every 2% interval starting at the global
maximum dose.
e. The process of blocking the dose clouds occurred until the 104% isodose line
was reached and as much as the V105 was removed, while still keeping
appropriate coverage to targets. The Subfield weighting was still set to 0% at
this point.
3. Treatment planning for the EZFluence plans utilized the following methods:
a. The same structure set, primary open tangent fields and MLC as used in the
manual FiF plans were utilized.
b. No plan normalization was enabled.
c. Dose was calculated and the EZFluence script was initiated.EZFluence creates
a PTV_EVAL_EZ structure on the patient to calculated the initial fluences.
This target is formed with the following guidelines:

PTV_EVAL_EZ Target Guidelines

Cropped 0.5 cm from the defined body surface
Cropped 0.5 cm from the field edges
Cropped 0.5 cm from identified OAR structures (Lung, Heart, Spinal
Cord)
d. EZFluence automatically accounts for the flash, using the nearest fluence
intensity in the patient.
e. Calculated fluence options were displayed. The user had the option to optimize
plans based on maximum dose or dose to a volume. Fluence options were
modifiable by dragging a scroll bar to left/right until the preferred DVH was
demonstrated.
f. The maximum number of field segments was limited to 8 for each tangential
field.
g. The minimum number of monitor units (MU) for each tangential field was 4.
h. The FiFs were exported back to Eclipse.
1. The exported FiF were then imported in Eclipse and calculated.
a. Individual FiF were visible within Eclipse and were further manipulated
prior to merging. The process of blocking the dose clouds occurred until
 the 104% isodose line was reached and as much as the V105 was
removed, while still keeping appropriate coverage to targets.
i. All plans were generated with the goal of achieving at least 95% of the whole
breast PTV_Breast_Eval and the PTV_Lumpectomy_Eval structures receiving
at least 95% of the prescription dose. The OAR and critical structure dose
constraint objectives were also kept below goal amounts. The treatment plan
goal summary for the OAR and critical structures were as follows:
Structure Volume Receiving (Dose)

Ipsilateral Lung ≥ 16 Gy (V16) ≤ 10%

≥ 8 Gy (V8) ≤ 15%
≥ 4 Gy (V4) ≤ 25%

Liver Mean Dose (Dmean) ≤ 2.8 Gy

Spinal Cord Dmax ≤ 50 Gy (used for reporting purposes)

Heart Dmean ≤ 3.2 Gy and Dmax ≤ 16 Gy

j. The initial dose was calculated using a grid size of 0.25 cm with the analytical
anisotropic algorithm (AAA) from Eclipse TPS.
k. In order to equally compare both manual FiF and EZFluence plans, the
EZFluence plan was normalized so that 100% of the prescription dose covered
the same volume of PTV (V100) as in the manual FiF plan. This was
performed on a patient-by-patient basis, which was then analyzed across the
entire 10 patients in this study.
l. Dose volume histograms and statistic tables were then evaluated and planning
measures compared. Values assessed were the amount of the PTV receiving ≥
95% of the prescribed dose, the percentage of V105, as well as the
aforementioned dose metrics to the ipsilateral lung, heart, liver, and spinal
cord.
D. Plan Analysis & Evaluation
1. The use of the EZFluence software script for prone breast radiotherapy planning
showed improvement in planning times and reduced the PTV volume receiving
 105% of prescribed dose. However, dose to the OAR increased using EZFluence
as visualized in the following table:
Heart
Heart
(Right Lung V95% Planning
Planning (Left Side V105
Side (Mean PTV_Breast_Eval Time
Technique Treatment (cc)
Treatment - cGy) (cc) (Minutes)
- cGy )
- cGy)
Manual
249.82 493.4 59.45 9.99 95.55 40.7
FiF
EZFluence 254.9 518.4 61.07 1.75 95.97 15.4
% Change
2.0% 5.1 % 2.7% 82.5% 62.2%
for 0.4% Increase
Increase Increase Increase Decrease Decrease
EZFluence

3. A secondary MU verification software, RadCalc, was utilized to evaluate all plans

within 3% accuracy.
IV. Discussion
A. These findings coincided with those suggested by the 2018 study by Yoder et al4,
which demonstrated the usefulness of EZFluence in breast cancer treatment planning
on patients in the supine position.
B. The treatment planning time was drastically reduced when utilizing EZFluence
software.
C. EZFluence also reduced the V105% while maintaining coverage to the
PTV_Breast_Eval.
D. Dose to the OAR increased when utilizing EZFluence.

V. Conclusion
A. Based on the results of this case study, running the EZFluence script, as opposed to
using a manual FiF technique, produced a marked improvement in the overall
time needed to plan treatment for breast patients in the prone position.
B. Treatment planning time averaged 40.7 minutes when using EZFluence and 15.4
minutes when planning with a manual FiF technique, which was a 62.2%
improvement.
C. Utilizing the EZFluence script also proved effective at controlling dose to OAR as
well as the percentage of V105 within the plan, while maintaining coverage to the
PTV.
D. The main limitation to this study is that there was a small sample size,
yet the results for each of the 10 patients were consistent across all the measured
constraints that were applied.
E. EZFluence has proven to be a viable choice when it comes to the treatment planning
of prone breast patients. However, further research and evaluation should be
conducted to prove its usefulness in plans other than breast cases.
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