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Nick Piotrowsi Dos 731 Research Methods July 26, 2013 Right Breast Carcinoma History of Present Illness: JS is a 41 year old female with a tumor extension 1, no lymph node extension, and no metastatic disease (T1C N0 M0) right breast carcinoma. A mammogram was performed due to the discovery of a palpable mass by the patient. The mammogram and right lumpectomy revealed the disease with a 1.5 centimeter (cm) diameter. The tumor was located 7 cm superiorly and laterally to the nipple and possessed irregular borders Past Medical History: The patient has had relatively no prior medical issues, but there are strong family connections to disease. She had a cesarean section in 1999 giving birth to her only child. In 2004 after multiple failed attempts to have another child, she had an infertility workup. At the end of January, JS had a right breast core biopsy, and a right lumpectomy to remove her current disease. Social History: JS is a healthy individual that works out 3 times a week, has never smoked, or consumed alcohol. Her family has an extensive cancer history, primarily breast cancer. Her great grandmother, cousin, and aunt all survived after having early stage breast cancer. Two other cousins both passed away at age 37, one from ovarian cancer, and the other from late stage breast cancer. Medications: JS is currently taking a variety of medications including 325 milligrams (mg) of acetaminophen, 125 mg of amoxicillin, 10 mg of Prednisone, 250 mg of Cefuroxime Axetil, 20 mg/milliliter (ml) of Cheratussin, and 250 mg of Azithromycin. She has no known drug allergies. Diagnostic Imaging: After discovering a palpable mass in the right breast, JS had a bilateral mammogram that corresponded with the initial examination. An ultrasound confirmed the mass in the upper outer quadrant of the right breast. A magnetic resonance imaging (MRI), core biopsy, and sentinel lymph node biopsy helped to reveal no extension into the lungs, or axilla. Finally, computed tomography (CT) scan was performed in order to plan the radiation therapy treatments. Radiation Oncologist Recommendations: A right breast lumpectomy was performed as recommended, and JS was sent to the radiation oncologist for post-operative radiation. The post-

operative radiation dose recommended was 52.56 Gray (Gy) in a total of 20 fractions over 4 weeks. The Plan (prescriptions): As recommended by the radiation oncologist, JSs plan was taken to 52.56 Gy. The initial plan consisted of 16 fractions at 2.66 Gy/fraction, resulting in 42.56 Gy. Once finished, JS would be treated with a 4 fraction boost at 2.5 Gy/fraction. This additional 10 Gy allowed the tumor volume to receive the total 52.56 Gy. Patient Setup/Immobilization: During the treatment planning CT, JS was placed supine on the table with her arms raised above her head. In order to help with immobilization, she was positioned on a wingboard with a vac-lock created around her arms and upper body. To keep her mandible out of the field her head was turned to the left as it was her right breast being treated. Radio-opaque markers were placed on the clinical borders of the fields on all sides, as well as on the lumpectomy scar (Figure 1). The isocenter was not set in the simulation by the physician, but BBs were placed on the skin to assist with patient set up. Anatomical Contouring: Breast cancer cases at this facility require a variety of major organs to be contoured. The heart, liver, lungs, carina, and spinal cord were all contoured, as well as the radio-opaque wires. These wires were forced to a density of -1000 Hounsfield Units (HU), to assure they did not affect the treatment planning calculations. The lumpectomy cavity was contoured by the physician, and a 1.0 cm margin was added to create a planning target volume (PTV). In addition, this PTV was cropped 0.5 cm away from the skin, and 0.8cm away from the right lung. Beam Isocenter/Arrangement: As the beam isocenter was not set during the simulation, it was the job of the dosimetrist to do so. While occasionally the isocenter will be set in the lung, and half beam blocked, this was not one of those cases. The isocenter was placed in the center of the breast near the edge of the PTV. As the isocenter was placed 10.1 cm right and 7.5 cm anterior of the simulation marks, those were the daily shifts. From there the jaws were opened 5.5 cm anteriorly, and 4 cm deep. This allowed for the chest wall to be treated and 3 cm of lung. The medial tangent had a gantry rotation of 60 degrees, with a collimator rotation of 352 degrees to help spare the lung. The lateral tangent arrangement was determined by matching the angle of the posterior field edge to match divergence. This resulted in a gantry angle of 235 degrees and a collimator rotation of 8 degrees. To bring dose deeper into the breast, two beams of the same

angles were also created, but instead of 6 megavoltage (MV) energies, they were 18MV beams. These beams were weighted 4:4:1:1 with the 6MV beams contributing the majority of the dose. Treatment Planning: Using treatment planning system Eclipse 10.0, JSs right breast treatment plan was designed. The goal of this initial treatment plan was to get 42.56 Gy to the breast while minimizing dose to critical structures such as the heart and right lung. In order to ensure the coverage of the entire breast, there were no blocks needed for this plan. For the 6MV beams, irregular surface compensators were used to modify the dose. A 2 cm margin of dose was added anteriorly to ensure the coverage of the breast each day and avoid marginal miss (Figure 2). After the initial calculation, a global maximum of 116% was produced. Using the irregular surface compensation, the dosimetrist was able to minimize this global maximum to 105.5% while maintaining sufficient coverage around the breast (Figure 3). While a wedge technique is also efficient at decreasing a global maximum, irregular surface compensation has shown better results.1 Reviewing the dose volume histogram (DVH), 94% of the PTV received 100% of the dose, and 100% of the cavity also received 100% of the dose (Figure 4). The physician also put constraints on the heart and right lung, at 10% of the volume to receive less than 25 Gy, and 30% of the volume to receive less than 20 Gy respectively. These constraints were met as 10% of the heart received 0.64 Gy, and 30% of the lung received 3.4 Gy. Quality Assurance (QA)/Physics Check: Before printing, the monitor units that were calculated by Eclipse 10.0 were double checked using RadCalc. Once the numbers were found to be within the 2% tolerance, the plan was sent to the medical physicist for quality assurance (QA) of the irregular surface compensation. After approval, it was double checked and approved by both the physicist, as well as the attending physician. Conclusion: This plan was a perfect example of a standard breast plan at this facility. Electronic compensation has proven to be the method of choice, and using mixed energy has shown multiple benefits. It has taken numerous plans and different methods to reach these conclusions. While the same technique will not work for each patient, this is typically a good starting point for most breast plans. For any case, there are methods that have been proven to be more effective than others, but these are only templates. If they worked for each patient, there would no longer be a high demand for dosimetrists. The change in patient anatomy allows for creativity and the drive to create the best treatment plan possible.

Figures

Figure 1: Radio-opaque marks labeling the field borders and lumpectomy scar.

Figure 2: 2 cm anterior margin.

Figure 3: Dose distribution with 105.5% dose maximum.

Figure 4: DVH summary

References 1. Emmens DJ, James HV. Irregular surface compensation for radiotherapy of the breast: correlating depth of the compensation surface with breast size and resultant dose distribution. The British Journal of Radiology. 2010;83:159-165. Available at: http://bjr.birjournals.org/content/83/986/159.full.pdf. Accessed July 26, 2013.