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Megan Whitley July Case Study July 22, 2013 Electronic Compensation for Radiotherapy of the Right Breast History of Present Illness: The patient, MB, is a premenopausal 45 year old Filipino woman who palpated a lump in her right breast in the spring of 2012. The patient delayed a mammography until November 2012, when she underwent a bilateral diagnostic mammogram of her right breast, including the palpable lump. She also had a right breast ultrasound which revealed a 2.1 centimeter (cm) mass with indistinct margins. There were amorphic calcifications seen on the mammogram, which on previous mammograms were thought to be benign. An ultrasound-guided biopsy revealed an infiltrating ductal carcinoma (IDC) with histologic grade 2, nuclear grade 2-3, and mitotic grade 3 with an overall Nottingham grade of 2. Infiltrating ductal carcinoma is breast cancer that has spread outside the membranes that line the milk ducts.1 This type of breast malignancy is the most common, accounting for 70% to 80% of all breast cancer.1 In this Nottingham scoring system, there are three considerations determining the pathology: the differentiation or how well the tumor cells try to recreate normal glands, nuclear features such as pleomorphism or how "ugly" the tumor cells look, and the mitotic activity or how much the tumor cells are dividing.2 Each of these indicators are scored from 1-3, summing for a total score from 3-9.2 The total establishes the grade using the following ranges: Grade 1 tumors have a score of 3-5, Grade 2 tumors have a score of 6-7, and Grade 3 tumors have a score of 8-9.2 In MBs case, her nuclear grade of 2 was worth 3 points as well the mitotic grade of 3, totaling 6 points and achieving a Nottingham grade of 2. MB discussed treatment options with her obstetrics and gynecology physician (OBGYN) who recommended breast-conserving surgery, which was performed in December 2012. A sentinel lymph node dissection was done and the breast tumor was removed. The pathology from the lumpectomy determined that there was also ductal carcinoma in situ (DCIS) with grade 2 to 3 histology along with comedo necrosis. It was estrogen and progesterone receptor status positive. The one lymph node taken from the sentinel lymph node dissection was negative. The patient underwent diagnostic imaging including a bone scan on 1/15/12, which was negative. She also had a computed tomography (CT) scan of the chest, abdomen, and pelvis, which demonstrated no evidence of metastatic disease, although there was a left upper lobe 5-millimeter (mm) abnormality of unknown significance. She

discussed adjuvant treatment options with the medical oncologist (MO). The MO recommended chemotherapy but the patient was reluctant. She was then referred to a radiation oncologist for radiotherapeutic options of breast conserving therapy. Past Medical History: MB is gravida 3 and para 2, with a spontaneous abortion approximately 10 years ago. She has regular menses every 28 days, and has had 2 prior cesarean sections. She had a pregnancy test done on 12/17/12, which was negative. Social History: The patient denied any alcohol or tobacco use. She lives with her husband and two children. She works as an office manager for her husbands dental office. Her father suffered from hypertension and cirrhosis of the liver. Her mother was also hypertensive. She had a maternal aunt who had breast cancer at age 70 and a maternal cousin who had breast cancer at age 60. She had a grandfather who had neck lymph node malignancy but shes unclear on the details. Medications: Daily she takes a multivitamin along with grapeseed oil extract, mangosteen juice, and apple pectin. MB has allergies to Vicodin, which causes nausea, vomiting, and dizziness. She is also allergic to latex, which causes pruritis. Radiation Oncologist Recommendations: The radiation oncologist (RO) discussed with the patient the national and international group of studies looking at breast conserving surgery alone versus breast conserving surgery with adjuvant radiation. She decided that the most appropriate approach was to add adjuvant radiotherapy immediately, but only if the patient was not to receive systemic therapy. If the patient complied with chemotherapy, radiation would start upon completion. The discussion determined that the plan would likely be a hypofractionated 20 fraction course of whole breast irradiation followed by a boost. The RO stated that standard tangential photon radiation would provide appropriate and efficacious treatment for MBs breast cancer. The toxicities of whole breast irradiation were discussed, which could include, but would not be limited to, skin irritation and breakdown, edema, and fatigue. The Plan (prescription): After MB and her husband had their concerns addressed, it was decided that tangential right breast irradiation would be administered using a 6 megavoltage (MV) energy. The initial prescription was written to a total dose of 4256 cGy for 266 cGy per fraction, totaling 16 fractions. The boost would follow at a rate of 250 cGy per fraction to a total of 1000 cGy. The RO requested electronic compensators (ECs) be placed on the tangents.

Patient Setup/Immobilization: The patient was placed in a supine position on a wing board a Vac-Lok and B headrest on the wingboard. A knee wedge was placed beneath the knees. Both arms were extended above her head, holding handles in the B1 position. The radiation oncologist marked the extent of the right breast tissue with superior, inferior, medial, and lateral markers, lumpectomy scar, and nipple. The laser origin was demarcated with 3 fiducial markers. The scan included 2.5 millimeter (mm) slices. After the scan was complete, the radiation oncologist set the isocenter, the table was shifted, and the treatment isocenter was marked on the patient. The images were then transferred to the picture archiving and communication system (PACS) software and Eclipse treatment planning software (TPS) version 10.0. Anatomical Contouring: After the patients scan was imported into Eclipse for planning, contouring was done of both the lungs separately, and then a total lung volume combination structure was created. Other contouring included the heart, spinal cord, carina, liver, body, scar wire plus the medial, lateral, superior, and inferior field delineating wires, and the thyroid gland (Figure 1). The radiopaque marks that are used to indicate regions of interest have a higher atomic number than that of human tissue. This allows for visualization on the scan, outlining regions of interest. The medical dosimetrist revised the density of the marks and/or wires to the Hounsfield value of 1. This instructed the algorithm not to calculate the change in homogeneity, which would cause an associated decrease in transmission. This decrease in transmission would impact the treatment coverage throughout the breast, but especially superficially, in the buildup region. This would both negatively impact the plan, and cause an inaccurate representation of the field, since these marks are only present at time of simulation, and not treatment. Next, the radiation oncologist contoured the clinical target volume (CTV); in this case the lumpectomy cavity. The medical dosimterist placed a 1 cm expansion volume around the CTV, labeling it Cavity + 1. Both the CTV and the expansion are represented in Figure 2. A plan was generated focusing the prescribed dose on both the expansion and the CTV. Beam Isocenter/Arrangement: The isocenter was placed at the time of simulation. The 2 field tangential beam arrangement was established. The patients body habitus and the location of the cavity did not require the penetrability of 18 megavoltage (MV) energy, allowing for two 6 MV tangents. The location of the cavity and MBs body habitus can be seen in Figure 2. The gantry angles used for MB were 65 degrees on the medial beam and 241.5 for the lateral beam (Figure 3). A 5-6 degree collimator rotation was added to each. This collimator angle was utilized to

remove as much lung tissue as possible, setting the field to follow along the chest wall. This is illustrated in Figure 2. Treatment Planning: The planning for MB was relatively simple and straight forward. MB had no complications associated with the location of her cavity, breast volume, or body habitus. The presence of these characteristics can create difficulties with achieving proper tumor coverage. Their presence often demands the use of mixed energies, complicating the plan. However, MB was an ideal candidate for single energy, 6 MV, lateral tangential fields. The right medial beam was placed by the RO at the time of simulation. The lateral beam was placed to oppose the medial beam. The gantry angle was tweaked to account for divergence. When two beams are opposed in a breast plan, the divergence from the posterior field edges creates a hot area within the anterior lung. To remove this hot area the gantry angles are altered to make a flat trajectory of abutment at the posterior field edge(Figure 4). For the field weighting, equal distribution of 50% to the medial and 50% to the lateral was suitable for coverage. The dosimterist then constructed the electronic compensators (ECs) and the fields were assigned within the TPS. After creating the irregular field compensators, adding the skin flash of 2 cm, and allocating the transmission factors, planning the fluence for the fields began. Determining the fluence is done by observation of the isodose lines throughout the treatment area. By impacting the plans fluence the isodose lines move and the coverage changes. Construction of an ideal breast plan is determined by a decreased lung dose, an increased tumor dose, and conformal coverage with a low region of hot spot. By painting out the fluence in certain areas depicted by isodose lines, a well-developed plan can be achieved. It is important to remember not to paint over the calculation point while altering the fluence. This will cause the algorithm confusion, since the dosimterist intends for 100% of the dose to be focused at this point. The confusion will create many flaws in the plan, requiring repeated planning. After the hot spot was decreased to 106.4%, the RO was alerted to review the plan. The dose to the lungs was minimal at 215 cGy to 20% of the total lung volume, while the coverage to the tumor was satisfactory, receiving 4256 cGy (total dose) to 96% of the cavity (Figure 5). All of the requirements for the plan had been achieved, thus the RO approved the plan. Quality Assurance/Physics Check: After the plan was approved by the RO, a second check was done in RadCalc to verify the calculations. Both of the beams in the second check required a differentiation of less that 2% to pass. MBs plan passed the second check (Figure 6). When

ECs are used, physics performs a quality assurance (QA) test to verify the accuracy of the plan. Once the plan was approved and ready for treatment, the final step was to generate and perform a trial fraction, making sure that the information accurately transferred to the record and verify software, and that the plan behaved in the manner in which it was intended. The trial fraction was done on the treatment machinery, a Varian Trilogy IX, and verified by the physics quality assurance tool, a Delta4 phantom. The fluence that registered within the Delta4 was compared to the approved treatment plan fluence. For the plan to pass QA, 95% of all the points tested within the phantom must have a 3% deviation from the predetermined dose. This plan passed QA, represented in Figure 7. Conclusion: Although MBs plan was less complicated than others, it provided a great stage for self-confidence building. For many professionals, a lack of self-confidence can be an issue. It can also be a detriment to a career. When opportunities are available to grow and enhance ones knowledge, foundation, and fundamentals, they must be taken. This was an example of capitalizing on an experience and enhancing fundamentals. What was achieved in this plan, and the ease at which it was achieved, provided evidence of progress and learning. Progress and learning are keys to improving ones conviction that a goal can be accomplished. The dosimetric skills gained with this plan equates to success and appreciation in the clinical internship environment.

Figures

Figure 1. The is a multiplanar view depicting the organs at risk (ORs) contoured.

Figure 2. A medial digitally reconstructed radiograph (DRR) depicting both the Cavity shown in red, and the Cavity + 1 shown in green.

Figure 3. The beam report generated by Eclipse, defining the treatment parameters.

Figure 4. An axial slice depicting the alignment of the posterior field edges of both tangents, used to eliminate the divergence into the lung.

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Figure 5. A DVH representing the amount of radiation received by each structure.

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Figure 6. RadCalc documentation that verifies the calculation passed the second check.

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Figure 7. QA check verifying that the electronic compensators passed the acceptance criteria.

References

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1. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010: 869-876. 2. Argani P, Cimino-Mathews A. Overview of Histologic Grade: Nottingham Histologic Score (Elston Grade). Johns Hopkins Pathology. 2012. http://pathology.jhu.edu/breast/grade.php Accessed July 24, 2013.