SOP_Breast DMG_version 2_18-05-2017

Breast unit SOP

1. Checklist while giving ROIS appointment
Appointment to be given by JR in consultation with SR/ Consultant
A. Verification of patient identity: Name and file number
B. Review of imaging and outside reports
C. Review of pathology reports
D. Review history of any previous treatment, esp. radiotherapy details
E. Review of Joint clinic decision/ consultant review
F. Final plan in Joint Clinic: Decision to treat and indication of radiotherapy

Points A-F to be documented in cis by JR/SR. To be checked by senior

G. Decide the site to be treated and appropriate technique. Special attention to be paid in
choosing the treatment unit if patient requires IMN radiation, axillary radiation, RT to
oligometastatic site along with breast RT, bilateral breast radiotherapy, large breast size,
unavoidable folds within the target volume, re-irradiation, pacemaker and known cardio-
pulmonary co-morbidities.

H. If special procedures are needed (Tomotherapy (direct and helical), Rapid Arc, IMRT,
DIBH, IGRT, 4CRT, Prone breast treatment) discuss with the consultant prior to giving simulation
dates.

I. Discuss the eligibility of suitable patients for ongoing studies (Node Negative Breast
Cancer RCT, Fractionation trial for whole breast reconstruction post mastectomy) and
(Synchronous Bilateral Breast Cancer, APBI etc.) for treatment at ACTREC/TMH as per
appointment and decision of PI.

J. Check for shoulder movements and refer to occupation therapy/ physiotherapy

department if found to be inadequate for radiotherapy planning.

K. Patients planned for Telecobalt / Clinac-6EX machines that have been given a simulation
appointment on Friday should be called earlier on Tuesday.

L.
➢ Benefits and risks associated with radiotherapy to be explained to the patient.

These Guidelines are to serve as guidance for workflow in the respective group of care provider and not a
replacement of medical advice or a legal document
 SOP_Breast DMG_version 2_18-05-2017

➢ Date, day, time and venue of simulation (Tuesday, Annex basement 126 B at 1.30 PM and
Friday, HBB basement, 4DCT room at 9.30 AM.) to be specified in writing.
➢ Patients to provide/bring pre-treatment imaging like MMG when done outside especially
important for planning boost for OBC.
➢ Explain the process of simulation, expected time for planning and starting treatment, the
cost of treatment especially for IMRT/IGRT cases. Prescribe contrast if needed after
ascertaining normal creatinine clearance. Ask to bring previous images (films or CDs) if
needed for planning (get them uploaded on PACS)
➢ Surgical OPD review if wound is not healing, large dog ear hampering radiotherapy planning
and if drainage is required. Medical oncology review if patient is symptomatic for
chemotherapy related toxicity (hematological / neurological),
➢ Review receptor status and check if indicated, current menstrual status and advice
regarding contraception in appropriate patients.
➢ If post Sx patient has >10 nodes positive check if metastatic W/U is done prior to simulation.
➢
Things to document in EMR: Date, day, quota, special procedure if required, expected last day
of chemo/ date of surgery, available imaging, complete staging of the disease, site/s and dose
fractionation and special instructions given by consultants.
.
2. Checklist for simulation
Simulation and documentation by JR, supervised by SR.

 Verification of patient identity with name and file number on his/her smart card.
 Check last date of chemo/ surgical scar healing/ sutures and drain removal, any signs of
recurrence of disease, contrast allergy, target to be treated, technique, machine, special
procedures or instructions from consultants.
 Verify patient name and number against one another after technologist makes entry.
 Patient generally to be simulated in supine position on ACTREC/ Medtech/ small
thermocol breast board with or without knee rest with arms over head, eliminating skin
folds and head turned to opposite side in case of node positive patient (SCF RT). Wire
the entire breast and any surgical scar (s), place fiducials to mark the extent of the
target volume (superior: inferior border of clavicle, Inferior: 2 cm margin to infra-
mammary fold or opposite breast, Medial: midline or across to cover the surgical scar
completely, Lateral: mid-axillary line or 2cm beyond palpable breast tissue).
 Anterior and lateral topogram to be taken to ensure that the chest wall is horizontal to
the couch.
 Take limited CT cuts, 3 to 5 slices around entry and exit fiducials to check for CLD,

These Guidelines are to serve as guidance for workflow in the respective group of care provider and not a
replacement of medical advice or a legal document
 SOP_Breast DMG_version 2_18-05-2017

ensure that the CLD is at least 1 cm and not > 2.5 cm.
 Take 3-5 mm CT cuts from angle of mandible to upper abdomen. Ensure at least 4-5 cm
of extra cuts superiorly and inferiorly depending up on the target volume in case of
IMRT/IGRT to obtain adequate scatter for dose distribution. Have a preliminary look at
the scan for checking roll / seroma / metastasis / infection.
 In addition to the patient details note the following in the planning and import register
and in EMR: side of treatment, machine allocated, dose fractionation, Y length noted
during simulation.
 Collect diagnostic imaging if needed for planning
 Confirm LMP, last CT, Sx dates, quadrant of breast lump and clinical stage at diagnosis.
 Refer to CGC when she has F/H/O cancer or is younger than 40 years at presentation.
 Document surgical scar over breast /chestwall accurately
 Document cosmesis
 Verify patient name and number with one another after physicist imports the images.
Also verify the number of images.
 Patient tattoos are done once the plan is finalized by the consultant on Friday, usually
while on Tuesday the fiducial points are tattooed. To mention tattoos done before or
after applying shift on the plan printout as well as in the EMR
 Boost planning: Review clinical (pre and post chemo), radiological and pathological
details for tumour localisation size. Patient to be positioned depending upon location
scar, breast volume so as to make treatment area parallel to the couch and avoid folds.
Mark the outline of the borders on the patient: give 2 cm margin to the tumor and
ensure the palpable lumpectomy cavity is within the marked borders. Wire the
provisional field size and surgical scar and take 3-5 mm CT cuts. Evaluate the images for
adequacy of field borders; Depth X 4 gives electron energy which will cover the tumor
bed by 80% isodose.
 Boost in patients with SIB/ oncoplasty/ operated outside without clips to be finalised by
consultant.
 Enter simulation information in excel sheet: name, case number, starting date, machine,
technique, LD of chemo/ surgery.

3. Image importing and registration

Importing to be done by simulating team and checked by SR
 Ensure that the patient is imported into ARIA with the correct number of CT
slices.
These Guidelines are to serve as guidance for workflow in the respective group of care provider and not a
replacement of medical advice or a legal document
 SOP_Breast DMG_version 2_18-05-2017

 Verify patient name and number with one another after physicist imports the
images.
 For patients undergoing re-simulation the images to be imported in the same
course but the course name should contain the date of simulation. (CT_date)

4. Contouring finalization
Contouring to be done by planning team JRs and SR, to be finalized by
consultant
□ Contour heart (esp. Ca left breast), lungs in all cases.
□ Left anterior descending artery to be contoured forl cardiac high risk patients to
ensure shielding with MLCs.
□ IMRT Plan: contour heart, lungs, contra-lateral breast spinal cord, thyroid, esophagus
(if SCF is to be treated) and brachial plexus in case of re-irradiation.

□ All cases treated with 40Gy / 15 fractions with the following exceptions who are
planned to a Dose of 50Gy in 25 fractions:

➢ IMC / Axillary Nodal RT required.

➢ MRM with WHOLE BREAST RECONSTRUCTION depending upon the
randomization arm of ARIA-BR trial
➢ CONSET trial.
➢ Synchronous B/L breast treated on tomotherapy with SIB (61 Gy/ 25 fraction)
➢ Malignant Phyllodes
➢ Re-irradiation

□ Dose constraints: Ipsilateral lung: V12Gy < 15%, Heart (left): V2Gy < 30% and V10Gy
<5%, Hotspot (107%) : <2 cc ideal but may accept up to 5 cc. To keep OAR doses as low
as reasonably achievable.

5. Physics handover and Treatment planning

 Physicist should be given information like side of treatment, machine allocated, date
of starting, dose fractionation and Y length noted during simulation for bi-tangential
planning.
 Ensure physicist allottment for IMRT planning through ROIS,provide important
dosimetric target.

These Guidelines are to serve as guidance for workflow in the respective group of care provider and not a
replacement of medical advice or a legal document
 SOP_Breast DMG_version 2_18-05-2017

6. Plan finalization
 Once the plan is done the physicist labels plan as PRE, informs the unit JR/SR.
Responsible JR/SR reviews the plan before the consultant review.
 PTV coverage (Min.95%, slice by slice, DVH as per ICRU 83), OAR doses, Dmax
v107%–any corrections are conveyed to the physicist. Plan is then evaluated and
finalized by the consultant.
 Check isocentre and user origin. Set-up fields required (EPID/CBCT). Set delta couch
shifts.
 Recheck if prescribed dose/ fractionation is in alignment with proposed/planned
ones.
 Plan is labelled as Final_(consultant initials) and preferably approved by a physicist
alongside
 Transfer plan to ROIS
 Plan printout along with relevant DVH/isodoses DRR taken attached to the
preplanning sheet printout.
 All details of patient simulation, RT planning (Roll depth, AP setup TSD, Entry/Exit
shift if any) and special instructions are noted in the preplanning paper also and
ROIS. Signature of consultant on the plan printout taken with date.
7. Post planning audit
□ Get all the files and completed RT papers inclusive of dosimetry sheet of simulated
patients for cross audit on TPS, resolve all queries written in audit remarks before RT
starting and document whether the queries have been satisfied or not. Check hormonal
therapy starting when indicated . Ensure high risk consent and additional investigations
(PFT, DLCO, 2D ECHO, HRCT) if indicated. One should take printout of the DVH in case of
IMRT along with plan report.

8. Machine allotment and ROIS entry

Written consent to be taken prior to RTstarting.

 Machine allotment to be done on the day of starting according to ROIS.

 ROIS entry to be done after DICOM transfer with specific simulation instructions.

These Guidelines are to serve as guidance for workflow in the respective group of care provider and not a
replacement of medical advice or a legal document
 SOP_Breast DMG_version 2_18-05-2017

9. Pre-Treatment preparation
 Once the plan is finalized and machine allotted the patient is called for treatment.
 Check payment to be done before starting radiotherapy.
 Look for specific audit instructions before starting.
 Counsel the patient with respect to duration, expected RT reactions and skin care.
 Check all plan parameters and details on RT chart.
 ROIS is done using DICOM transfer for conformal technique / the ones done using TPS.
 ROIS is done by a JR and counter-checked by a Co-JR/SR
 All details of simulation/ treatment protocols to be entered in ROIS also for the
therapists’ information
 Check for payment details.
 Send for physics calculation and final approval
 Plan Implementation is done on the machine by the unit SR after verification of patient
ID and appropriate positioning/immobilisation device refer to CIS/ preplanning audit
paper.
 Use parameters on the plan printout for PI (the shifts refer to the movement of the
couch when the observer is at the foot-end of the patient)
 Permitted variation in machine parameters: Gantry -5°, Collimator: 3°, Isocentre
variation < 1 cm. 5 mm gap to be kept empirically between tangents and SCF unless
planned.
 Field markings to be done on machine after PI and then shown to consultant.
 Tick the column against PI in the PPA paper with signature

10. Treatment delivery

 Verification of patient ID
 Ensure that the right plan has been selected for patient treatment
 Supervise patient positioning and immobilization- check if correct immobilization
device is being used
 Verify if PI points are visible and intact
 Verify treatment accessories
 Set up to be seen by SR on day1, field markings to be done on machine after PI,
 Show to consultant if any doubt. For IMRT plans, implement appropriate onboard
imaging.

10. Weekly review and phase 2 implementation

 Patients on RT are reviewed once weekly at least in the OPD, review assessments are
These Guidelines are to serve as guidance for workflow in the respective group of care provider and not a
replacement of medical advice or a legal document
 SOP_Breast DMG_version 2_18-05-2017

entered in ROIS and in the PPA sheet.

 Marking review done by consultant after 1#. Subsequently call after 5 #.
o To check at first review:
 Whether receiving RT daily on all weekdays (Saturdays also if 6#/week
planned)
 Whether the patient is comfortable with the time slot on the machine
 Whether following all precautionary instructions
 Whether taking adequate & well balanced diet
 Review to be done by JR/SR and shown to consultant at every alternate review or if
patient has unexpected or high toxicity/ non-compliance.
 Patient to be sent to planning team at around 12# for boost planning.

11. Treatment completion and debriefment

To be done by OPD JR and checked by SR
 Verification of patient identity

 Reverification of all treatment details through ROIS, CIS and PPA paper

 ROIS Conclusion Notes on EMR, Document toxicity, clinical examination

 Schedule next visit after 6 months while continuing on appropriate hormonal therapy,
Explain medicines to continue, Advise to report early if any new complaints or grade III
skin reactions.

These Guidelines are to serve as guidance for workflow in the respective group of care provider and not a
replacement of medical advice or a legal document