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Sadie Wilhite
Case Study
April 7, 2017
Left Chest Wall VMAT
History of Present Illness: Patient LB is a 52 year-old female presenting with a palpable left
breast lump in July of 2016. A breast ultrasound and mammogram confirmed a 1.6cm left breast
mass. A left breast core biopsy was performed and proved the mass to be a grade 3 invasive
ductal carcinoma that was positive for estrogen receptors (ER) and negative for progesterone
receptors (PR). ER and PR results help determine the patients prognosis and how the tumor will
respond to chemotherapy and hormone therapy.1 The ultrasound also provided information of
metastatic disease in the axillary lymph nodes. A left axilla fine needle aspiration was performed
July 22, 2016 to reveal positive adenocarcinoma. The positron emission tomography (PET) scan
revealed the left breast mass, along with left axillary, supraclavicular, internal mammary (IM)
and possible para-aortic lymph node involvement. Due to the size of the tumor and nodal
metastatic involvement, this patient was staged as T1N3M1. In August of 2016, the patient began
neoadjuvant chemotherapy. In January 2017, the patient underwent a right-simple mastectomy
and a left-modified radical mastectomy. Post mastectomy, minimal residual disease was found in
the left breast (between 5 and 10mm). Lymphovascular invasion was present, with 2 of 8 positive
nodes in the left breast.
In late January, LB was referred to the radiation oncology department for postoperative
radiation therapy treatment. No adjuvant chemotherapy was planned. The radiation oncologist
and patient discussed the plan of treating the left chest wall and involved lymph nodes with
radiation therapy. Complications, side effects, and benefits of chest wall irradiation were
discussed with the patient. At this time, the patient needed time to heal from the recent
mastectomies. LB returned to the radiation oncology department February 9, 2017. Information
involving the treatment was then again discussed with the patient and the consent form was
signed for 5 weeks of radiation therapy treatment.
Past Medical History: LB has a past medical history of hypertension and hyperlipidemia. The
patient is BRCA 1 positive. Carriers of this mutation are at an increased risk of developing both
breast and ovarian cancers.2 The patients past surgeries include recent prophylactic bilateral
salpingo-oophorectomies and bilateral mastectomies. Right-simple and left-modified radical
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mastectomies were performed. Previous breast mammogram screenings have been performed.
The patient reported no allergies.
Social History: LB is an employee at the University of Missouri as a clinical coordinator
supervisor. She is married with two grown children. The patient has no history of smoking or any
type of tobacco use, and has very minimal alcohol use. LB states that her grandmother died of
breast cancer at the age of 32 and her grandfather had a history of throat cancer. The patient also
stated that her mother died in her 40s due to atherosclerosis and her sister died in her 30s due to
lupus.
Medications: LB uses the following medications: Anastrozole, Hydrochlorothiazide, Lisinopril,
Rivaroxaban, Oxycodone, Omega-3 polyunsaturated fatty acids (fish oil), and a multivitamin.
Diagnostic Imaging: After finding a palpable left breast mass in July 2016, a breast ultrasound
and mammogram were preformed to confirm a 1.6cm left breast mass. The ultrasound provided
information of left axillary lymph node involvement as well. A left breast core biopsy and a left
axilla fine needle aspiration were performed on July 22, 2016. Left breast grade 3 invasive ductal
carcinoma that was ER positive and left axilla adenocarcinoma were confirmed. A PET scan was
done August 02, 2016. The PET scan revealed disease in the left supraclavicular, left IM, and left
para-aortic lymph nodes, along with the already confirmed left breast mass and left axillary
lymph nodes. On January 5, 2016, the patient underwent a right-simple mastectomy and a left
modified-radical mastectomy. A second PET scan was performed on January 25, 2016. The
previously seen left breast mass and nodal involvement were now resolved. When comparing
with the previous PET scan, bilateral fluid collections were seen and identified as seromas. The
radiation oncologist then staged LB as T1N1M0, due to no present residual disease post
mastectomy.
Radiation Oncologist Recommendations: After reviewing LBs most recent PET scan, along
with her past medical history, diagnosis, and pathology report, the radiation oncologist
recommended postoperative radiation to the left chest wall, along with the left supraclavicular,
axillary, and IM nodal areas. Most of the patients gross disease was resected during her
mastectomy, except for the IM/para-aortic lymph nodes. The radiation oncologist decided to
include these lymph nodes in the radiation treatment area, due to the likelihood of residual
disease in this area. Volumetric modulated arc therapy (VMAT) was the recommended radiation
treatment technique for this patient. The radiation oncologist recommended VMAT rather than
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the conventional wide tangent fields, due to the depth of the IM nodes and their location in
reference to the heart. With the use of VMAT, this large treatment volume will be better covered
while sparing normal tissue and creating a more homogeneous plan.2 At the time of consultation,
it was recommended that the patient wait 2 weeks before beginning treatment, in order to give
additional postoperative healing time.
The Plan (prescription): Due to the extent of the disease, the radiation oncologist recommended
VMAT treatment to the left chest wall, with inclusion of the IM, supraclavicular and axillary
lymph nodes. The plan was to include two partial arc beams. The prescribed dose for the VMAT
plan was 50Gy at 2Gy per fraction for 25 fractions. There was no addition boost prescribed for
this patient. The patient was treated on free breathing. The intent of the radiation treatment was
to improve local control and chance of cure.
Patient Setup/Immobilization: As of February 9, 2016, the chest wall seromas had completely
healed and the patient was ready for radiation treatment. LB underwent a 4D computed
tomography (CT) simulation scan. The 4DCT tracks the patients breathing, and scans the patient
during 10 separate phases of the breathing cycle. The radiation oncologist reviewed the images
of each phase and the amount of internal tumor and heart motion were determined. The patient
was scanned head first in the supine position, with both arms over her head on a Civco Medical
Solutions wing board immobilization device. There was a sponge placed under the patients
knees for support. The radiation oncologist marked the superior, inferior, medial and lateral
treatment borders, and the radiation therapist placed BBs over these marks. A wire was also
placed over the left mastectomy scar, so that this area was easily determined on the treatment
planning system (TPS). A user origin was set on the CT scanner and was marked with BBs.
Shifts in the X, Y and Z planes to isocenter were later determined.
Anatomical Contouring: After the completion of the CT simulation, the dataset was imported
into the Varian Eclipse treatment planning system. The physician viewed the 4DCT images in the
different recorded breathing phases and determined the patient was to be treated on free
breathing due to minimal movement of the area of interest during the breathing phases. The free
breathing CT dataset was fused with the previous PET CT. The physician then contoured four
separate clinical target volumes (CTVs) on the free breathing dataset. All on the left side, the
chest wall CTV, IM lymph nodes CTV, supraclavicular lymph nodes CTV, and axillary lymph
nodes CTV were contoured. The scar wire that was placed on the patients postoperative scar at
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the time of the CT simulation helped determine the chest wall CTV borders. These four CTVs
were then combined to create a total CTV and the planning target volume (PTV) was created
with a 0.5cm margin around this CTV volume. The lower PTV boundaries including the chest
wall CTV, IM node CTV and lower axillary CTV were then adjusted to 0.1cm inside the body
contour in order to reduce dose and spare the skin surface in this area. This chest wall area
contains a 0.5cm bolus over the skin surface. The upper portion of the PTV, including the
supraclavicular CTV and the upper axillary CTV was adjusted to 0.5cm inside the body contour
because this portion of the treatment area does not contain the bolus. The dosimetrist then
contoured the organs at risk (OR) on the CT free breathing dataset. These structures included the
right and left lungs, spinal cord, heart, esophagus and contralateral chest wall. The dosimetrist
was given the radiation dose prescription and the beam energies to be used prior to beginning the
planning process.
Beam Isocenter/Arrangement: The length of the entire PTV was 22cm. Isocenter was placed at
the center of this volume, 11cm from the top of the PTV and 11cm from the bottom. Isocenter
was placed at the edge of the chest wall, 4cm from the skin surface, and 1cm posterior to the
PTV. The radiation treatment was done on a Varian Truebeam linear accelerator. The VMAT plan
utilized two 6 MV arcs. One beam arced in the clockwise direction, ranging from 290 to 140.
The second beam arced in the counterclockwise direction, ranging from 140 to 290. A 15
collimator rotation was utilized on each beam, and there was no couch rotation on either of the
beams. The field size of each beam was determined by the dosimetrist in order to include the
entire PTV throughout each 210 arc. Both beams had a field size of 27cm width x 28cm length.
The multi-leaf collimator (MLC) modulation was determined by the TPS optimization, based on
the OR and treatment volume constraints put in the system by the dosimetrist.
Treatment Planning: The VMAT treatment planning was done on the Varian Eclipse TPS and
the treatment was delivered on a Varian Truebeam linear accelerator. The radiation oncologist
gave dose objectives, with most concern given to the heart and total lung irradiation. The dose
prescription was prescribed to the PTV volume using the two 6MV 210 arcs. The target volume
and OR objectives were entered in the TPS under VMAT optimization as upper, lower and mean
objectives. The PTV was given a maximum dose objective of 104% of the prescribed dose
(52Gy) and a minimum dose objective of the prescribed dose (50Gy). OR constraints were
entered so that the maximum spinal cord dose was below 4500cGy, the mean heart dose was to
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be below 400cGy or as low as possible and the volume of the total lung receiving 2000cGy (V20)
was below 15%. No specific constraints for the contralateral chest wall were given, but the dose
was to be kept as low as possible. Normal tissue objectives were set to control the dose
distribution outside of the target volume and to prevent hot spots from being placed in this area.
The TPS VMAT optimization was performed and objectives were changed until an acceptable
plan was produced. At this time the dosimetrist viewed the target volume and the OR on the dose
volume histogram (DVH). The final DVH (Figure 8) revealed the maximum spinal cord dose to
be 1890.4cGy, the mean heart dose to be 880.7cGy, and under 15% of the total lungs receiving
2000cGy. The 95% isodose line covered 99% of the PTV, with the point of lowest dose being
within the IM node region. The dosimetrist and radiation oncologist would have liked 100% of
the PTV to be covered by the 95% isodose line, but reduced coverage was forced in order to
reduce the dose to the heart. The plan was assigned a normalization of 99%. All OR constraints
were obtained besides the mean heart dose. The dose to the heart was reduced as much as
possible, but with the treatment of the deep IM nodes, the dosimetrist was limited on how much
this dose could be reduced. Though it has been found that VMAT technique is the best option
when wanting to spare lung and heart tissue, the dosimetrist also tried both a wide tangent 3D
plan and a conformal arc intensity-modulated radiation therapy (IMRT) plan in hopes to lower
the mean heart dose.3 The wide tangent 3D plan produced the highest mean heart dose of
1432cGy. The IMRT plan produced a slight improvement from the 3D plan, with a mean heart
dose of 1124cGy. The IMRT plan did slightly improve the PTV coverage, but it was not enough
to justify the increased dose to the heart. It was decided that the VMAT plan would provide the
best coverage of the PTV, while sparing normal tissue and critical structures. The VMAT plan,
including the final DVH, was reviewed and approved by the radiation oncologist.
Quality Assurance/Physics Check: The RadCalc program was used as a monitor unit (MU)
second calculation to check the MU calculated in the TPS for this VMAT plan. Our department
has a tolerance of 3% difference from the TPS MU calculation to the RadCalc calculation. This
plan had a 0.1% difference at isocenter, falling within the acceptable limits. A quality assurance
(QA) plan was created on the TPS and the plan was run on the Varian Truebeam linear
accelerator, using the ArcCheck diode array system. The plan was within the departments
tolerance of 3% difference and passed the VMAT QA check. The physicist then reviewed the
entire plan and approved the plan for treatment.
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Conclusion: This VMAT treatment plan was a complex case, involving many treatment areas to
be covered. The placement of the treatment volumes produced multiple challenges for the
dosimetrist. The most challenging objective of this plan was to keep the mean heart dose as low
as possible, while adequately covering the PTV. In attempt to lower the mean heart dose, the
dosimetrist created three separate plans to compare coverage and dose to the OR. I was able to
see a wide tangent 3D plan, a conformal arc IMRT plan and a VMAT plan be created all on the
same patient. Though only the VMAT plan was used for treatment, I was able to compare the
advantages and disadvantages of all three of these plans. This helped me understand which plan
would produce the best coverage and OR sparing, and why certain techniques are used in
specific situations. I was able to look at each plan and take into account all factors that would
influence the patients overall treatment and better understand the reasoning behind the radiation
oncologists decision to use the VMAT treatment plan. This VMAT plan produced the best
coverage of the chest wall and included lymph nodes, while sparing normal tissue, in order to
achieve the goal of local control and an improved chance of cure.
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References
1. Chao KSC, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
2. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2012.
3. Tyran M, Mailleux H, Tallet A, et al. Volumetric-modulated arc therapy for left-sided
breast cancer and all regional dose improves target volumes coverage and reduces
treatment time and doses to the heart and left coronary artery compared with a field-in-
field technique. J Radiat Res. 2015;56(6):927-937. https://doi.org/10.1093/jrr/rrv052.
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Figures

Figure 1. AP and Lateral views of isocenter placement. The red volume is the PTV.
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Figure 2. Isocenter placement in the axial view.

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Figure 3. Isocenter placement in the coronal view.

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Fig
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ure 4. Isocenter placement in the sagittal view.

Figure 5. VMAT arc start and stop angles (medial and lateral) with MLC modulation.
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Figure 6. Supraclavicular and axillary treatment area dose distribution in axial view. The 95%
isodoseline (orange) is shown covering almost the entire PTV (red). The 100% isodose line is
represented by the light blue line.
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Figure 7. Chest wall treatment area dose distribution in the axial view. The 95% line (orange) is
shown covering almost the entire PTV (red). The 100% isodose line is represented by the light
blue line.

Figure 8. The dose volume histogram (DVH) demonstrates the dose related to the tissue volume
of the OR, PTV, and CTVs.