1

Lisa Stevenson
Case Study: Breast
April 1, 2016
Partial Arc VMAT for Right Breast Cancer
History of Present Illness: JP is a 69 year old postmenopausal Caucasian female who presented
with two abnormal lesions of the right breast on a screening mammogram in October 2015. The
lesions were located in the one oclock and two oclock position of the upper inner quadrant.
High resolution ultrasound estimated the adjacent lesions to be 7.0mm and 4.0mm in size.
Ultrasound guided needle core biopsy revealed moderately differentiated invasive ductal
carcinoma positive ER, positive PR, and negative Her-2. Positive ER and PR status indicates
that growth of the tumor cells is driven by estrogen and progesterone. These patients typically
require hormonal therapy.1
JP then underwent a right partial mastectomy with Sentinel Lymph Node Biopsy (SNLB)
on November 9, 2015. The pathology revealed two foci of grade 2 invasive ductal carcinoma and
rare foci of intermediate grade DCIA within the surgical margins. The largest lesion measured
18.0mm and the second lesion measured 13.0mm. The margins of invasive carcinoma were
negative were negative with the closest margin measuring 3.0mm. The margins of DCIS were
negative with the closest margin measuring 17.0mm. No lymphovascualar invasion (LVI) was
found and one sentinel lymph node was negative. Surgical pathology staged JP as T1cN0M0.
JP was found to have an Oncotype DX score of 37 which is considered high risk.
Oncotype DX is a 21 gene assay used predict the risk of distant spread in patients who are
positive for ER but have no lymph node invasion. Patients who have an Oncotype DX score of
31 are considered high risk and would benefit from chemotherapy in addition to hormonal
therapy.2 Given her high risk status, JP received four cycles of chemotherapy using a
combination of Taxotere and Cytoxin. She completed chemotherapy on February 18, 2016. JP
tolerated chemotherapy very well complaining mainly of fatigue.
After completing chemotherapy, JP was scheduled for a radiation therapy consultation.
Since JP had opted to undergo a partial mastectomy for breast conservation, the radiation
oncologist strongly recommended radiation treatments to the entire right breast followed by

boost to the tumor bed. The radiation oncologist then thoroughly outlined the details of the
patients condition as well as the potential benefits of adjuvant radiation treatment to the patient
and her husband. The potential acute and late complications of radiation treatment were also
discussed with them in detail. After the completion of radiation treatment, JP will be referred
back to her medical oncologist to initiate antiestrogen hormonal therapy.
Past Medical History: JP has a past medical history including GE reflux, hypertension, and
hyperlipidemia. She has also underwent multiple surgeries including hysterectomy, hip
replacement, and lumpectomy with SLNB in November 2015. The patient has an allergy to
Morphine and states that exposure induces nausea, vomiting, and diarrhea.
Current Medications: JP is currently using the following pharmaceuticals: Nexium, Lipitor,
Lininopril, and Metoprolol Tartrate.
Social History: JP is married and lives with her husband. JP used to smoke one pack of
cigarettes per day for 20 years prior to quitting 6 years ago. She denies having had any
emphysema or COPD. She occasionally drinks beer and denies any illicit drugs. JP reported
that her father died from pancreatic cancer at the age of 86 as well as a sister who is a breast
cancer survivor. The patient reports no other cancer in her family but her family history is
positive for heart disease, high blood pressure, and allergies.
Diagnostic Imaging: In October 2015, JP presented with two abnormal lesions of the right
breast on a screening mammogram in October 2015. The lesions were located in the one oclock
and two oclock position of the upper inner quadrant. High resolution ultrasound estimated the
adjacent lesions to be 7.0mm and 4.0mm in size. Ultrasound guided needle core biopsy revealed
moderately differentiated invasive ductal carcinoma positive ER, positive PR, and negative Her2. After pathology indicated that ultrasound guided biopsies were malignant, JP underwent a
right partial mastectomy with SNLB on November 9, 2015. The pathology revealed two foci of
grade 2 invasive ductal carcinoma and rare foci of intermediate grade DCIA within the surgical
margins. The largest lesion measured 18.0mm and the second lesion measured 13.0mm. The
margins of invasive carcinoma were negative were negative with the closest margin measuring
3.0mm. The margins of DCIS were negative with the closest margin measuring 17.0mm. No
LVI was found and one sentinel lymph node was negative

Radiation Oncologist Recommendations: Following a full evaluation of JPs medical history,

pathology reports, and breast conservation surgical history, the radiation oncologist strongly
recommended JP undergo post chemotherapy adjuvant radiation therapy to her entire right breast
followed by a cone down to the lumpectomy site. The physician initially intended to treat the
patient using two tangential beams and a forward planning technique to create a more uniform
dose distribution. After reviewing the patients CT simulation images, the physician noted that
patient is large breasted as well as barrel chested. In addition, the cavity is located near the
medial edge of the treatment field which also raised concern over adequate coverage when taking
her anatomy into account. Concerns regarding higher than acceptable dose to the patients right
lung were also raised. Although a VMAT technique is typically reserved for left breast cases due
to the necessity of lowering dose to the heart, the radiation oncologist opted to utilize a VMAT
technique on JP as it has been shown to be more effective than conventional tangential fields to
ensure adequate coverage of the cavity and to decrease dose to the ipsilateral lung.3 Furthermore,
VMAT has proven to be more effective than conventional tangential fields and IMRT to decrease
dose inhomogeneity which has been show to be the most important prognostic indicator of RTinduced effects including fibrosis, erythema, moist desquamation and oedema.3 A traditional
electron boost will still be used at the end to boost the tumor bed.
The Plan (prescription): The radiation oncologists recommended course of treatment included
partial arc VMAT to the entire right breast followed by an electron boost to the lumpectomy
cavity. The prescription dose for the initial whole breast VMAT plan was 45Gy at 1.8Gy per
fraction for 25 fractions. The lumpectomy boost electron was prescribed to a dose of 16Gy at
2.0Gy per fraction over 8 fractions. The composite dose to the tumor bed was 61Gy. For the
purposes of this paper, only the whole breast VMAT plan will be reviewed.
Patient Setup/Immobilization: JP underwent a CT simulation scan to prepare for radiation
treatements in March 2016. The patient was positioned supine on a carbon fiber breast board
with both arms raised over her head and firmly supported by adjustable arm support (Figure 1).
A headrest was selected that matched the curvature of her spine for comfort and her head was
turned to the left to avoid the beam. A sponge was placed under the patients knees for additional
comfort and her feet were banded to preclude her from crossing them and potentially rolling
during treatment. The radiation oncologist used CT wire to delineate the field borders as well as

the surgical scar. The patient was then scanned using 3mm slices on a Phillips Big Bore CT
scanner. After the patient was scanned, the radiation oncologist selected an isocenter and the
patient received a midline tattoo as well as leveling tattoos on her sides. Photos were also taken
of her treatment position. The CT simulation data was then transferred to the Philips Pinnacle 3
TPS version 14.0.
Anatomical Contouring: Once all of the simulation data was loaded into the TPS, the physician
contoured the right breast volume using the CT wires indication the field borders as a guide. The
cavity was also contoured. The dosimetrist then shrank the PTV in 4mm from the skin in order
to allow for dose build up and to avoid high doses to the skin. The organs at risk (OR) that were
contoured included the heart, right lung, left lung, both lungs, spinal cord, and the liver. Several
rings as well as a normal tissue contour were also added to help shape the dose distribution. A
2cm contour was also made outside of the external contour and labeled flash.
Beam Isocenter/Arrangement: The dosimetrist verified the isocenter that was placed in the
center of the right breast tissue during the CT simulation to ensure that that position was
adequate for treatment planning (Figure 2-5). The patients treatment plan was assigned to the
Varian Trilogy linear accelerator and 6 MV energy was selected as is protocol with all VMAT
cases to reduce the neutron contamination that occurs with higher energies. Four arcs were
selected based on the external patient contour and the steep angle of the breast and lung
interface. All arcs covered a range of 220-60 degrees although 2 were clockwise and 2 were
counterclockwise to allow for reduced treatment time. Arcs 1 and 2 had a 5 degree collimator
rotation, while arcs 3 and 4 were set to 85 degrees in order to allow more MLC blocking options
for the optimizer. No couch rotation was used. Due to the size of the PTV, a split beam
technique was used and the optimizer was programed to use the given field sizes as the
maximum field size. This was necessary because the width of the field needed to cover more
than the 14.5cm MLC can travel (Figure 6).
Treatment Planning: A Philips Pinnacle3 TPS version 14.0 was used to create the VMAT plan
for this right breast. The objectives of this plan were to use VMAT arcs to create a more
homogenous dose distribution to the breast, ensure adequate coverage of the lumpectomy site
which was toward the medial edge of the treatment field, and to limit the dose to the lung and
other ORs as much as possible (Figure 7). The prescription dose for the arcs were prescribed as

a mean dose to the PTV. The beam weighting was set to 25% percent for each beam initially
however the optimizer ultimately determines the necessary beam weighting during the inverse
planning process. The objectives for the treatment plan were entered into the inverse planning
system as follows: the PTV was assigned minimum dose, maximum dose, and uniform dose
corresponding to the prescription dose and weighted heavily. The flash contour was assigned a
dose of half the prescribed dose and given a very low weighting. This contour is present for the
sole purpose of preventing the MLC from closing completely in on the external contour of the
breast. The physician requested the heart to receive less than 10Gy (V10) was to be less than 10%,
the right lung 20Gy (V20) was to be reach no more than 17% or as low as possible. To achieve
these objectives the rings and normal tissue contours were given objectives corresponding to the
isodose lines that they needed to contain and given moderate weighting. The normal tissue
contour was assigned a maximum dose corresponding to the 20% idosdose line. The plan was
optimized several times and a few contours were added to eliminate hot spots. Once the PTV
was covered by at least 95% of the prescription dose, the dosimetrist reviewed the dose to the
ORs to make sure they were all within tolerance. The DVH indicated that heart received a
maximum dose of 13 Gy and the 10Gy(V10) was around 3% (Figure 8). The right lung volume at
20Gy(V20) was approximately 8% while the total lung 20Gy9V20) was near 5%.The physician the
approve the plan at a normalization of 100% of the prescription.
Quality Assurance/Physics Check: A monitor unit check was performed using the RadCalc
software program. Each field easily fell within the 5% tolerance allowed between the TPS and
RacCalc monitor unit calculations. The physicist then performed a final check which included
delivery of the plan on the Trilogy using a Sun Nuclear MapCheck diode array system. The plan
passed the secondary QA by falling within 5% tolerance.
Conclusion: The VMAT technique worked very well to limit lung dose and promote dose
homogeneity in this challenging case. A few obstacles that the dosimetrist ran into during
treatment planning included the large size of the PTV, eliminating hot spots to achieve less dose
inhomogeneity, and finding ways to limit lung dose while not losing coverage to the PTV and
cavity. In order to adequately cover the PTV, the dosimetrist had to split all of the beams and also
add 2 more beams with collimator turned to 85 to allow the MLC to adjust from 2 directions.
This helped to reduce the ipsilateral lung dose and allowed for better coverage of the PTV. Then,

multiple contours were added to areas where the dose exceeded 105% and optimized to bring the
hot spot below 107% while not creating an area with less than optimal coverage. Although
VMAT techniques for breasts are usually used for left sided cases to avoid the heart, this case
clearly supports its use over tangential beams on right sided breast cases that include excessive
amount of lung tissue due to variations in patient anatomy such as large breasts and/or a barreled
chest.

References
1. Chao, K Perez, C, Brady. L. Radiation Oncology Management Decisions. 3rd ed.
Philadelphia PA: Lippincott Williams & Wilkins; 2002
2. Klein ME, Dabbs DJ, Shuai Y, et al. Prediction of the Oncotype DX recurrence score: use of
pathology-generated equations derived by linear regression analysis. Modern Pathology.
2013;26(5):658-664.
3. 1. Virn T, Heikkil J, Myllyoja K, Koskela K, Lahtinen T, Seppl J. Tangential volumetric
modulated arc therapy technique for left-sided breast cancer radiotherapy. Radiation Oncology.
2015;10

FIGURES

Figure 1. Patient positioned on a breast board with arms up, knee support, and feet banded in CT
simulation.

Figure 2: Isocenter placement Lateral and AP view.

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Figure 3. Isocenter placement in the axial view.

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Figure 4. Isocenter placement in the sagittal view.

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Figure 5. Isocenter placement in the coronal view.

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Figure 6. VMAT field sizes were set to split beams in order to cover the entire PTV. These field
sizes were then locked to prevent the TPS from changing the field sizes.

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Figure 7. VMAT dose distribution of the right breast. The PTV is displayed in orange and the
cavity is indicated by green. The yellow isodose line indicates 95%, blue is 100%, the outer
white line is 50% of the dose.

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PTV (orange) Cavity (green)

Figure 8.

Dose Volume

Left
Lung

Right

Both
Lungs
Heart

Figure 8. . The DVH indicated that heart received

a
maximum dose of 13 Gy and the 10Gy(V10) was around 3% (Figure 9). The right lung volume
at 20Gy(V20) was approximately 8% while the total lung 20Gy9V20) was near 5%.