1 Ashley Pyfferoen April Case Study April 19, 2013 Tangential and Parallel Opposed Fields for Treatment

of Left Chest Wall and Supraclavicular Nodal Areas History of Present Illness: AM is a 39 year-old female who underwent a screening mammogram of the left and right breast in June of 2012. The mammogram revealed an oval lesion in the left axillary tail of the left breast. Additional imaging was ordered that established a mass located at the 1 oclock posterior depth position that had high suspicion of malignancy. An ultrasound confirmed the palpable and mammographic findings adding that the mass was mobile. An ultrasound guided biopsy pathology report revealed invasive ductal carcinoma, grade 3. A microscopic investigation confirmed suspicions of high mitotic activity and was found to be estrogen receptor (ER) and Human Epidermal Growth Factor Receptor 2 (HER-2) negative but weakly positive for the progesterone receptor (PR). The patient met with a medical oncology surgeon and discussed diagnosis, prognosis, expectations, options for treatment, risks, recovery times and recovery activities. After initial consultation, the patient decided on a bilateral mastectomy with bilateral reconstruction and the possibility of post-operative radiation. In August of 2012, AM underwent a bilateral skin-sparing total mastectomy, left sentinel lymph node biopsy, and left full axillary dissection. At this time, bilateral breast tissue expanders were inserted for the implants. The right mastectomy was for prophylactic purposes only. The pathology report of the left side revealed invasive ductal carcinoma, grade 3, 3.4 centimeters (cm), located in the upper outer quadrant at the 2 oclock position, without peritumoral intralymphatic tumor emboli, without dermal lymphatic involvement and with no involvement of the skin or nipple. One lymph node out of 28 tested positive for metastatic carcinoma. It was 9 millimeters (mm) in dimension without extension. The right sided specimen was found to have invasive ductal carcinoma, grade 1, 0.6 cm in dimension and located in the upper outer quadrant. There was no sentinel lymph node procedure performed because the right sided mastectomy was prophylactic. This right sided specimen was ER and PR positive. These results were discussed with AM with the possibility of an axillary dissection on the right side. She ultimately decided on observation and declined another surgery. She met with a chemotherapy oncologist that recommended Tamoxifen for 5 years and adjuvant chemotherapy in the form of Doxorubicin and

2 Cyclophosphamide, as well as Paclitaxel. After surgery and chemotherapy, patient AM met with a radiation oncologist to discuss a course of radiotherapy to the left chest wall. After a thorough discussion of the risks, benefits, and alternatives to a course of adjuvant radiotherapy, the patient chose to proceed with radiation treatments upon conclusion of the chemotherapy regimen. Past Medical History: The patient denies chronic or past medical history and is otherwise, healthy. She has had past surgical procedures including a laparoscopic surgery for endometriosis, an oophorectomy and a tonsillectomy. Social History: Patient AM is a premenopausal, married restaurant owner. She denies the use of tobacco and has some moderate alcohol consumption. She has several family members with a history of breast and/or ovarian cancer including her mother who was diagnosed with left breast cancer at age 25 and right breast cancer at age 28. The patient followed up with medical genetics and was found to have the breast cancer (BRCA) gene mutation. Medications: The patient is currently taking herbal drugs, Hydrocodone/acetaminophen, Ondansetron, Pegfilgrastim, Povidone-iodine ointment and Prochlorperazine. Diagnostic Imaging: In early June of 2012, the patient underwent a routine mammogram screening that indicated abnormalities in left breast. An ultrasound was performed on the left breast and revealed a lesion located at the 1 oclock position. An ultrasound-guided biopsy revealed invasive ductal carcinoma of the left breast tissue. Radiation Oncologist Recommendations: The radiation oncologist reviewed the information documented by the medical oncologist. After a long discussion with AM, he decided to proceed with external beam radiation therapy to the left chest wall and supraclavicular/axillary nodal region. The radiation oncologist elected to treat the left chest wall with photon tangential beams using a 3-Dimensional (3D) conformal treatment plan. Tangential beams have shown to have a decreased effect on cardiac tissue because the beam is directed toward the breast tissue only, thus skimming only the wall of the heart.1 To ensure that the chest wall is receiving adequate dose, the radiation oncologist chose to treat with 1 cm bolus daily. The physician elected to treat the supraclavicular and axillary nodes with parallel-opposed beams. Studies have shown that women with at least 1 positive lymph node in this area have a higher survival rate when treated with radiotherapy then women who were not treated.2 Also, this benefit was shown to be greatest for women with only 1-3 positive lymph nodes. 2

3 The Plan (prescription): The radiation oncologists plan to treat the left chest wall and left supraclavicular nodes consisted of a basic 3D conformal plan using photon energy. The chest wall was treated with opposite tangential fields to ensure the chest wall was covered adequately and the supraclavicular nodes were treated with parallel opposed beams. The chest wall plan was optimized using the segmented field technique to improve dose homogeneity. To further improve dose to the skin surface, a 1cm piece of bolus was secured to the skin daily. The parallel opposed beams used to treat the nodal areas were copied and modified to improve dose homogeneity to the area as well. The left chest wall and lymph node area were prescribed to 5040 centigray (cGy) at 180cGy per fraction for 28 fractions and treated concurrently. Patient Setup/Immobilization: In late March 2013, the patient presented for a computed tomography (CT) simulation scan in the radiation oncology department. She was placed in the supine position head first into the scanner. A CIVCO wing board was placed under the patient to remove her arms from the fields and maintain immobilization (Figure 1). A head and neck rest was secured to the table for patient comfort and a cushion was placed under her knees for lumbar back support (Figure 2). BBs were placed anteriorly and laterally (left and right) on the patients skin to define a reference point for treatment planning. Radiopaque wires were placed on the patient (medially, laterally, inferiorly and superiorly) to determine field borders and gantry angles for the chest wall beams. Exac-Trac imaging was used to aid in daily reproducibility and immobilization. Anatomical Contouring: In conclusion of the CT simulation, the axial images were uploaded in the Philips Pinnacle3 8.0 radiation treatment planning system (TPS). The radiation oncologist contoured the brachial plexus to track dose to this region while treating the supraclavicular nodes. The medical dosimetrist contoured organs at risk (OR) including the left lung, right lung and heart. In addition, the dosimetrist also contoured the radiopaque wires to determine the field sizes and gantry angles of the chest wall beams. The radiation oncologist reviewed these OR structures and the wire contours and made necessary adjustments. The medical dosimetrist was then given the prescription of the plan to proceed. Beam Isocenter/Arrangement: The patient was treated on a Varian Clinac 21EX machine. For simplicity purposes, 1 isocenter was used for the treatment of both anatomical areas. It was placed just inferiorly to the clavicular heads and midline between the patients shoulder and sternum. In this case, the isocenter acted as a midline between the 2 sets of external beams

4 (Figures 3-5). The technique beam-splitting was used to keep 1 isocenter and allow for a faster treatment time and easier patient set up for the radiation therapists. In the beam-spitting technique, the isocenter acts as a superior border for the chest wall field and as an inferior border for the supraclavicular field (Figures 6-7). After the isocenter was selected, each anatomical treatment area was planned separately. The chest wall and supraclavicular node plans are noted separately below. Chest Wall: The gantry angles for the tangential beams were determined when the lateral and medial wires were superimposed. The medial tangent or right anterior oblique (RAO) field was determined to be 313 degrees () and the gantry angle for the lateral tangent or left posterior oblique (LPO) field was measured at 133. This plan did not require a couch or collimator rotation. The inferior borders of the chest wall fields were determined based on wire that was placed on the patient during simulation. In addition, 1 cm of flash was administered laterally to account for patient movement (Figure 6). The physician then drew a multi-leaf collimator (MLC) blocked pattern to shield the left lung and heart (Figure 6). After the MLC pattern was drawn, the patient separation was measured along the central axis (CA) on the thickest CT slice. The separation was measured to be 27.78cm. Using department guidelines, the dosimetrist determined the plan would require dual energy to provide adequate dose coverage. In addition to the original tangential beams, the dosimetrist added 2 more beams at the same gantry angles as specified above. The dosimetrist used 6 megavoltage (MV) photon energy on one beam and 15 MV photon energy on the other beam containing the same gantry angle. This was also performed on the other tangential set of beams as well. Supraclavicular Nodes: The gantry angles for the lymph node parallel opposed beams were determined based on department protocol and rotated to treat off the spinal cord. The gantry angle for the right anterior oblique (RAO) beam was measured at 345 and the angle for the left posterior oblique (LPO) was determined to be 169. Similar to the chest wall portion of the plan, a couch or collimator rotation was not required. The superior border of the field was placed 4 cm inferior to the patients chin to ensure adequate margin (Figure 7). The medial border was determined from spinal cord placement and the lateral border was determined based on physician discretion of nodal locations (Figure 7). The radiation oncologist then drew an MLC blocked pattern to shield the humeral head and spinal cord margin (Figure 7). Because the nodal chain is located anteriorly, the physician instructed the use 6MV energy on the RAO beam to ensure

5 there was no dose sparing near the skin surface. The dosimetrist measured the patients separation over this anatomical region and determined to obtain the best uniform dose distribution, the LPO beam would require 15 MV photon energy. Therefore, the dosimetrist elected to treat this area with a mix of 6 MV and 15 MV photon energies. Treatment Planning: Considering the circumstances of the patient, the goal of this radiotherapy treatment was curative. With this information, the dosimetrist attempted to achieve the best dose uniformity to the breast while limiting hot spots. To avoid confusion, the chest wall and supraclavicular treatment plans are listed separately below. Chest Wall: Before optimizing the treatment plan, the dosimetrist constructed a 1cm piece of bolus on the treatment planning computer to accurately reflect the dose to the chest wall when bolus is placed on the patient during treatment (Figure 8). Because the isocenter cannot be the calculation point for both plans, a calculation point was added medially along the CA of the tangential beams (Figure 9). The beams were altered to deliver the prescription dose to the calculation point as opposed to the isocenter. The daily fractionated dose between the RAO 6MV, RAO 15MV, LPO 6MV and LPO 15 MV fields were weighted at 31.50%, 21.00%, 28.50% and 19.00%, respectively. After initial calculations, dose distributions to the breast were not sufficient. There were areas receiving both more and less dose then what was prescribed. To decrease hot spots, 3 segmented fields were added to each of the 4 beams. The segmented fields included the original MLC blocks and additional MLC blocks drawn by the medical dosimetrist to reduce the dosage to hot spots near the lateral edge of the breast (Figure 10). These segmented fields, or control points, were weighted accordingly on each beam to ensure the hot spots were minimized to the correct ratio. After several calculations, the dose homogeneity improved within tolerance. The isodose curves presented a fairly uniform conformal dose to achieve this goal (Figure 11). The physician reviewed the plan and confirmed the dose delivered the lungs and heart was within tolerance using the dose volume histogram (DVH) (Figure 12). He accepted the plan with a normalization of 100% of the prescribed dose for daily treatment. Supraclavicular Nodes: Similar to the chest wall plan, a calculation point for the parallel opposed beams was selected. The calculation point was placed midline between the inferior and superior borders. It was placed in tissue approximately 4 cm from the lung interface to ensure an adequate dose distribution (Figure 13). After initial calculations, the dose distribution was poor and the use of modulated fields was required. The RAO and LPO beams were copied and modified to

6 decrease the areas receiving higher than prescription dose (Figure 14). The daily fractionated dose between the RAO, RAO modulated field, LPO and LPO modulated fields were weighted at 53.00%, 4.00%, 38.00% and 5.00%, respectively. After several calculations, the dosimetrist determined the dose homogeneity was within tolerance. Using the DVH, the dosimetrist was able to confirm that the dosage to the brachial plexus was less than 5% over prescription at the request of the radiation oncologist (Figure 12). The isodose curves presented a uniform conformal dose to achieve this goal (Figure 15). The physician reviewed this plan and accepted with a normalization of 100% of the prescribed dose for daily treatment. Quality Assurance/Physics Check: The monitor units (MUs) were reviewed for the left chest wall and supraclavicular treatment plan. To verify that the MU calculation was correct, a calculation program was used. All of the MUs for the treatment plan were within tolerance (5%) of the calculations computed by the program. The physicist also verified that the prescription and treatment fields were correct, the digitally reconstructed radiographs (DRRs) were associated properly and the patients treatment schedule was accurate. Conclusion: This treatment plan presented many difficulties for the dosimetrist. The biggest difficulty was eliminating portions of the chest wall that were overdosed. I was able to achieve a suitable dose distribution with 50% of the beam weight on the 15 MV beams. The physician was uncomfortable using that high of a percentage since department protocol suggests not going over 30%. He instructed me to compromise and keep the 15 MV beam weight at 40%. I found it very difficult to eliminate the areas of overdose due to her body habitus and the size of her expander. I was unable to relieve the areas receiving 15% over prescription dose and truly found the difficulty in treating larger patients. The supraclavicular region was slightly easier to plan but also found that it was more difficult than usual with such a large separation. This was a great learning experience because I worked on this patient for several days. At one point I was told there was nothing else I could do to improve the dose simply because of her body habitus. I still tried to get a better distribution but was not successful. I am glad I encountered these difficulties so I know and understand what to expect in the future.

7 Figures

Figure 1. Patient is immobilized on a CIVCO wing board.

Figure 2. A cushion was used for patient comfort and immobilization.

Figure 3. Isocenter placement in axial view.

Figure 4. Isocenter placement in sagittal view.

Figure 5. Isocenter placement in coronal view.

Figure 6. Field size borders and MLC blocks in beams eye view (BEV) window for the chest wall treatment plan.

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Figure 7. Field size borders and MLC blocks in beams eye view (BEV) window for the supraclavicular nodal area treatment plan.

Figure 8. One cm bolus constructed on the chest wall.

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Figure 9. Calculation point placement for chest wall tangential beams.

Figure 10. An example of a segmented field for the RAO 6 MV beam.

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Figure 11. Isodose line distribution in 3 levels (red= 5040cGy).

Brachial Plexus

Total Lungs
Heart

Figure 12. Dose Volume Histogram (DVH).

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Figure 13. Calculation point placement for left lymph node parallel opposed fields.

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Figure 14. A modulated field for the LPO 6 MV beam.

Figure 15. Isodose line distribution in 3 levels (red=5040cGy).

15 References 1. Harris E, Correa C, Hwang WT, et al. Late cardiac mortality and morbidity in early-stage breast cancer patients after breast-conservation treatment. J Clin Oncol. 2006:24(25):4100-4106. 2. Kuske R. The role of postmastectomy radiation in the treatment of early stage breast cancer: back to the future. Ochsner J. 2000:2(1):14-18.