1

Whole Breast Nodal Irradiation by Supine VMAT and Prone 3D Planning: A Case
Study
Authors: Ashley Coffey, B.S., R.T.(T), Lisa Stevenson, B.S., R.T.(T), CMD, Ashley
Hunzeker, M.S., CMD, Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD
Medical Dosimetry Program at University of Wisconsin- La Crosse, WI
Abstract (To be done later)
Introduction:
Case Description:
Conclusion:
Keywords:
Introduction
The cumulative lifetime incidence of breast cancer is 1 in 8 U.S. women.1 In fact,
breast cancer is so common, it has been ranked the second most common malignancy
affecting women living in the United States after skin cancer. Although breast cancer is
prevalent, the survival rates have been steadily increasing since 1989 as a result of earlier
diagnosis and the development of more effective treatments. The increase in survival
necessitates a greater need for therapies with decreased toxicity to normal tissues, providing
better cosmetic outcomes and decreasing the risk of radiation-induced secondary
malignancies.2
Three-dimensional conformal radiation therapy (3DCRT) supine, often treated with
three fields monoisocentrically, was the gold standard for many years. However, the
monoisocentric technique had limitations that included less than optimal planning target
volume(PTV) coverage, problematic junctions between the breast and nodal fields and
increased radiation dose to surrounding healthy tissues.2 Nearly a decade ago, advances in
technology paved the way for intensity modulated radiation therapy (IMRT) techniques that
increased PTV coverage, better dose homogeneity, and decreased dose to surrounding
structures.3 In 2007, volumetric modulated arc therapy (VMAT) technique was introduced
clinically for breast cancer treatment and has since become a widely accepted method for
treating left sided breast cancer patients. Although VMAT has comparable PTV coverage to
IMRT, it has better dose conformity, decreasing maximum dose to surrounding tissues, less
monitor units (MUs) and decreased treatment time.2

Recently, 3DCRT prone breast techniques have garnered interest in the radiation
oncology community. The prone position naturally pulls the breast away from the chestwall
allowing for the possibility of greater dose sparing to organs at risk (ORs). There is currently
a lack of data comparing supine VMAT to prone nodal breast treatments. In this study, three
patients that were simulated in the prone and supine positions were planned using a supine
VMAT and prone 3DCRT technique to compare PTV coverage as well as dose to OR
including the heart, ipsilateral lung and contralateral breast.
Case Description
Patient Selection and Set-up
Patient selection was based on women with breast cancer and nodal involvement. All
patients in this study were diagnosed with grade 2 or 3 invasive ductal carcinoma and an
intact breast. Patients were simulated in both prone and supine positions to attempt to reduce
organ dose and deliver adequate dose to the breast and nodes. They were all scanned in a
General Electric (GE) Computed Tomography (CT) large bore scanner head first. For the
supine scan, the patient was placed on a 15 tilt breast board with the ipsilateral arm up and
their head turned in the opposite direction. In the prone scan, the patient was placed on their
stomach on top of a prone breast board that sits 24.5 cm off the CT table. There was an
opening on the affected side that allowed for the breast to fall forward and the supraclavicular
area to be exposed in order to treat nodes without obstruction. The head was also turned away
from the affected side and a VacLok bag was used to support the arms. Radio-opaque CT safe
wires were placed on the skin to delineate the edges of the breast tissue and tattoos were
placed on the patient to reproduce daily setup. On Board Imaging (OBI) was used daily for
each patient.
Target Delineation
Target delineation was performed by the physician and dosimetrist on Philips Pinnacle 9.8
treatment planning system (TPS). Contours were created on the planning CT and expanded
following the RTOG 1304 protocol.4 The protocol provided guidelines for contouring all
target volumes and structures which included: lumpectomy, breast, supraclavicular nodes,
axillary nodes, and internal mammary nodes(IMN). All clinical target volume (CTV)

contours can be found in the RTOG anatomy atlas.5 Critical organ contoured included the
ipsilateral and contralateral lung, contralateral breast, heart, and thyroid.
The lumpectomy gross tumor volume (GTV) was contoured with available imaging
and included the lumpectomy cavity, lumpectomy scar, seroma, and surgical clips.
Lumpectomy CTV was created from a 1cm expansion of the lumpectomy GTV that avoided
the pectoralis muscles, 5 mm from the skin, and did not cross midline. Lumpectomy PTV
was created by expanding the CTV by 7 mm in all directions excluding the heart..
Breast CTV is classified as all palpable breast tissue which was delineated at the time
of simulation with radio-opaque wires in the CT simulation. The Lumpectomy CTV was
included in this contour and excluded 5 mm of skin on the surface, the pectoralis, chestwall,
ribs, and lung. The Breast PTV is the Breast CTV with 7 mm expansions that avoided the
heart and did not cross midline. Breast PTV Eval was created by copying the Breast PTV and
edited to exclude air outside the patient, 5 mm skin, and anything deeper than the anterior
surface of the ribs. Breast PTV Eval was used for constraints in planning and DVH analysis.
Supraclavicular CTV was contoured using the RTOG Breast Cancer Atlas.5
Supraclavicular PTV was created by expanding the supraclavicular CTV by 5 mm in all
directions. The supraclavicular PTV did not include the thyroid, trachea, esophagus, lung,
and was contracted 5 mm from the skin surface.
Axillary CTV was contoured from the remaining, undissected axillary nodes. The
physician used the operative reports and other diagnostic imaging to determine what axillary
nodes needed to be included in planning. Typically, level I and II axillary nodes are removed
so the level III nodes and any other remaining nodal levels must be included in the axillary
CTV. Axillary levels can be found on the RTOG Breast Cancer Atlas.5 Axillary PTV included
a 5 mm expansion of the CTV excluding lung. Internal Mammary Node CTV included the
internal mammary nodes and thoracic vessels in the first 3 intercostal spaces. The IMN PTV
was 5 mm medially, laterally, superiorly, and inferiorly. The IMN PTV excluded the sternum,
lung, or heart.
Treatment Planning
Each patient used for planning had scans performed on the same day in both prone
and supine position. A total of 3 patients were planned with 3DCRT in the prone position and

with VMAT in the supine position. Each patient had a prescription dose of 50 Gy in 25
fractions to the whole breast and nodal regions. The lumpectomy was to receive a boost of 10
Gy in 5 fractions. The conformal plans for all patients utilized single isocenter tangents for
the whole breast along with an anterior and posterior supraclavicular field.
Patient 1 was planned supine using a VMAT technique that utilized 4 200 partial arcs
with split beams to allow more adequate multi-leaf collimator (MLC) range. The dose was
prescribed to a maximum dose of the 100% isodose line and the hot spot was 105.6%. All
protocol constraints were met for target volumes, contralateral breast, and the contralateral
lung. However, constraints were not met for the ipsilateral lung and heart. Patient 1 was also
planned prone using 6 MV tangential beams and a right anterior oblique (RAO) and a left
posterior oblique (LPO). The beams angles were decided based on coverage of the
IMN_PTV while avoiding as much heart as possible as well as axillary level III coverage.
The dose was prescribed to a maximum dose of the 94% isodose line which made the hot
spot 106%. The dosimetric results for OR and PTV targets for both plans on Patient 1 are
listed in Table 1.
Patient 2 Supine
Patient 2 Prone
Patient 3 Supine
Patient 3 was planned prone using 6MV and 18MV tangential beams and a right
anterior oblique (RAO) and a left posterior oblique (LPO). The beams angles were decided
based on coverage of the IMN_PTV while avoiding as much heart as possible as well as
axillary level III coverage. One challenge with planning Patient 3 in the prone technique was
delivering adequate dose per protocol guidelines to the IMN PTV while still meeting heart
constraints. The dose was prescribed to a maximum dose of the 92% isodose line which
made the hot spot 108%. All protocol constraints were met for target volumes and OR.
Plan Analysis and Evaluation
(More suited for analysis..lets see if it can be utilized). Patient 3 was not in the most
efficient position for prone planning. The contralateral breast was not positioned correctly on
the board and therefore was partially in the board opening utilized for the affected breast. It

was avoided by adjusting the angled utilized however, it was not ideally positioned for
accuracy and reproducible treatments. Even with the challenges presented in positioning and
heart location, all dose constraints were met and the coverage to remaining nodal PTVs and
the lumpectomy site was easily accomplished.

Conclusion (To be done later)

References
1.

Breast Cancer. American Cancer Society website.

http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics.
Accessed June 5, 2016.
2.
Teoh M, Clark CH, Wood K, Whitaker S, Nisbet A. Volumetric modulated arc
therapy: a review of current literature and clinical use in practice. Br J Radiol. 2011; 84:
967-96.
3.

Zhao H, He M, Cheng G, et al. A comparative dosimetric study of left sided

breast cancer after breast-conserving surgery treated with VMAT and IMRT. Radiat
Oncol. 2015; Nov 17; 10:231.
4.
Mamounas E, White J. NRG Oncology NSABP Protocol B-51/RTOG Protocol
1304. Radiation Therapy Oncology Group (RTOG).
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=1304.
Published 2013. Updated 2016.

5.

RTOG Breast Cancer Atlas. Radiation Therapy Oncology Group website.

https://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx. Accessed
June 7, 2016.

Table 1. Constraints for Patient One

Constraints

Per Protocol

Acceptable
Variation

Patient 1
Prone

Breast PTV_Eval

95% of 47.5Gy

90% of 45Gy

A-95.9%

SCL PTV

95% of 47.5Gy

90% of 45Gy

A-98.5%

Axillary PTV

95% of 47.5Gy

90% of 45Gy

A-97.6%

IMN_PTV

95% of 45Gy

90% of 40Gy

P-99.0%

Heart

<5% at 25Gy

<5% at 30Gy

P-0.10%

Heart mean

4Gy

5Gy

P-2.09Gy

IpsiLung

<30% at 20Gy

<35% at 20Gy

P-25.4%

Table 2. Constraints for Patient Two

Patient 1
Supine

Table 3. Constraints for Patient Three

Constraints

Per Protocol

Acceptable
Variation

Patient 3
Prone

Breast PTV_Eval

95% of 47.5Gy

90% of 45Gy

A-97.0%

SCL PTV

95% of 47.5Gy

90% of 45Gy

A-98.7%

Axillary PTV

95% of 47.5Gy

90% of 45Gy

P-98.4%

IMN_PTV

95% of 45Gy

90% of 40Gy

A-90.3%

Heart

<5% at 25Gy

<5% at 30Gy

A-4.35%

Heart mean

4Gy

5Gy

A-4.39Gy

IpsiLung

<30% at 20Gy

<35% at 20Gy

P-15.6%

Patient 3
Supine