Kyle Garafolo

Clinical Oncology Assignment

Directions: Please choose a treatment plan that includes one of the anatomic regions below:
• Primary Lung/Mediastinum or Breast/chest wall with lymph nodes

Patient History
88-year-old woman who had no contact with the medical system for about 40 years before her
presentation with a central ulcerated right sternal breast mass with suspected invasion into the bony
or cartilaginous chest wall, an additional right upper outer quadrant mass, and right axillary
adenopathy and was diagnosed with with multicentric right breast cancer, IIIC cT4cN1M0, with biopsy
proven disease at the ulcerated right lower inner quadrant mass (RLIQ) and in the upper outer
quadrant mass (RUOQ), IDC, grade 3, ER+ (70%, 90%; RUOQ, RLIQ, respectively), PR-low/negative
(0%, 5%), HER2-negative (FISH, at both sites). She responded well to neoadjuvant chemotherapy
(AC-T) with resolution of axillary nodes and improvement in breast masses with no residual frank
mass in the upper outer quadrant and improvement in the ulcerated mass. She was recommended
against surgery given her advanced age and the complexity and morbidity of the required chest wall
resection and so referred for consideration of definitive radiation.

She is otherwise well and eager to treat the cancer definitively. We discussed a conventionally
fractionated approach to a total dose of 66+ Gy in 2 Gy fractions: 46 Gy SCV, 50 Gy whole breast,
16-20 Gy boost to the ulcerated mass. No markings in place to allow boosting of upper outer
quadrant mass, consider quadrant boost.

1. How was this patient positioned for simulation? What positioning devices/accessories were used,
how and why? (5 points)

This patient was positioned supine head first on the treatment table. Patient positioning
devices included: wingboard with a clear B headrest, custom vaclok bag, black pad, both arms raised
above her head holding onto poles (indexed at B1), and a knee sponge.

These devices were used for several reasons. First and foremost, the patient must be
immobilized on the treatment table so that treatments can be reproducible and motion can be
minimized. Additionally, a pad and knee cushion were added to aid in patient comfort, which will also
help reduce patient motion. Lastly, the patient had both arms raised above her head to aid in patient
setup and to allow for the tangential beams to traverse through the breast tissue without going
through the patients arms.

2. Discuss the target dose as defined by your physician and the rationale behind the total dose and
fractionation regimen. Include any references or current research to help answer the question. (5
points)

• Right Breast: 180cGy/Fx x 28 Fx = 5040cGy (custom 3mm 9cm x 13cm bolus over ulcerative
lesion)
• Right SCV/nodes: 180cGy/Fx x 28 Fx = 5040cGy
 • Right LIQ boost: 200cGy/Fx x 8 Fx (total of 6640 cGy) - 90% ISL, 3mm bolus, mix of 9E and
6E

Given that the patient was considered not to be a candidate for surgery due to her age and
complexity/morbidity of surgery, it is recommended to irradiate the breast, supraclavicular nodes,
internal mammary nodes, and axillary nodes.1 Suggested doses to the entire breast are 50 Gy in
1.8-2.0 Gy daily fractions; Internal mammary nodes, supraclavicular fossa nodes, and axillary nodal
areas should receive 45-50 Gy over 5-6 weeks.1 Any gross nodal disease should receive an
additional boost of 10-15 Gy with electrons.1 Given the patient’s clinical history, I feel these
recommendations are consistent with the physician’s radiation prescription.

3. What specific avoidance structures were contoured? Include a screen shot of your contoured target
and organs at risk. Create and embed a table of OAR tolerance doses based on your physician
prescription and include any associated QUANTEC values.  List the contraindications if tolerance
doses were to be exceeded.  (20 points)

Targets:
• GTV - Ulcer
• GTVn - Suspicious nodes
• CTV_Breast_R - Breast tissue
• CTV_Ulcer - GTV + margin
• CTV_UOQ - UOQ Lump
• PTV_RLump_5040 - CTV_UOQ + margin
• LN_Axillary_R - Axillary LNs
• LN_IMN_R - Internal mammary LNs
• LN_Supraclav_R - Supraclavicular LNs

Targets - Upper/Breast
Targets - Lower/ulcer

Avoidance Structures:
• Esophagus (upper) - Yellow
• Heart - Pink
• Liver - Yellow
• Lungs (L/R) - L: Orange; R: Light Green
• Spinal Cord - Blue
• Thyroid - Magenta

Structure Constraint Toxicity Rate Toxicity Endpoint

Mean<34 Gy 5-20% Grade 3+ esophagitis
Esophagus V35<50% <30% Grade 2+ esophagitis
V50<40% <30% Grade 2+ esophagitis
Long term cardiac
Heart V25<10% <1%
mortality
Mean<30-32 Gy <5% RILD (in normal liver
Liver
Mean<42 Gy <50% function)
V20≤30% <20%
Mean 7 Gy 5%
Mean 13 Gy 10% Symptomatic
Lung
Mean 20 Gy 20% pneumonitis
Mean 24 Gy 30%
Mean 27 Gy 40%
Spinal Cord 50 Gy (max) 0.2% Myelopathy
Thyroid (JHH) V26<20%
OAR with Targets - Upper

OAR with Targets - Lower

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4. Identify any involved lymph node regions (chains) in your treatment port. Embed a screen shot of
the nodal regions with corresponding labels. (15 points)

Axillary LNs Axillary LNs

Supraclavicular LNs Supraclavicular LNs

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Internal Mammary LNs Internal Mammary LNs

5. Use your IMAIOS Subscription and other anatomy references to describe the anatomical
“boundaries” (physical limits) of the area treated. (examples: hard palate, nasal chonae). Embed a
diagram and/or screen shot of your CT data to point out the boundaries. (20 points)

Breast Boundaries2
• Superior
• Superior extent of palpable breast tissue
• Edge of the head of the clavicle
• Inferior
• 2cm below the inframammary fold or 2cm below lowest edge of the breast
• Medial
• At midline of patient, as determined with palpation of suprasternal notch and xiphoid process
• Important to avoid contralateral breast
• Lateral
• Midaxillary line or 2cm beyond breast tissue
• Anterior
• Flash to include entire breast
• Posterior
• Include the chest wall; will result in 1-2cm posterior to the edge of the ribcage
Supraclavicular and Axillary fields2
• Superior
• In general, above the acromioclavicular joint; superior border needs to cover target volume
(supraclavicular fossa)
• Avoidance of flash over the skin of the supraclavicular area - helps to reduce the skin reaction
• Medial
 • Insertion of the sternomastoid muscle into manubrium; posteriorly, the beam avoids the spinal
cord and runs along the edge of the vertebra
• Laterally
• Approximately 2-3cm lateral of the humeral head if covering the full axilla; coracoid process if
covering level III axilla and avoiding the dissected axilla
• Inferior
• Inferior edge of the clavicular head, which is the superior border of the tangent fields (match
line)
• The inferior half of the beam is blocked at the supraclavicular field isocenter, making a straight
edge at the inferior border thus preventing divergence of dose into the tangent fields

Posterior Axillary boost fields2

• Superior
• Follows the clavicle
• Medial
• Midclavicular line
• Lateral
• Same as the supraclavicular field
• Inferior
• Same as the supraclavicular field
Internal Mammary fields2
(Included in tangent ports)
• Superior
• Inferior border of the supraclavicular field
• Medial
• Midline or 1cm to the contralateral side
• Lateral
• 4cm from midsternum
• Inferior
• Desired number of interspaces to be treated
Ulcer Boost (electron)

6. Describe, in detail, the radiation treatment technique used to treat this anatomical region. (20
points)
Examples: Technique type (VMAT, IMRT, Conformal), VMAT-Number of arcs, their direction, collimator
rotations, number of degrees. Beam angles, couch rotations, field design, wedges, use of split fields,
etc. Include all specific setup information to describe your process.  Include any screen shots to help
describe your plan design.

This plan was completed using a 3D conformal technique. A single isocenter was used to treat
the patient. A total of 5 fields were used to treat the initial targets to a dose of 5040 cGy: 2 fields were
utilized to treat the supraclavicular (6x) and posterior axillary nodes (18x). A total of 3 fields were used
to treat the breast tissue and internal mammary nodes. Mixed energy and Field-in-field techniques
were used for the tangents. The field-in-fields were merged to create step-n-shoot fields for treatment
delivery. A 3mm thick 9cm x 13cm custom bolus was placed over the lower/medial ulcer to increase
skin dose; this structure was included in the tangent fields. A half beam block technique was utilized
between the supraclavicular and tangent fields to prevent beam divergence from encroaching onto
the other fields. Field characteristics can be seen on the attached screen shots below:

Tangents/SCV

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Two custom enface electron fields were created to boost the ulcer. These fields utilized mixed
energies (6e/9e) and were treated to the 90% isodose line. A 3mm thick bolus was placed over this
field during treatment. The field characteristics can be seen on the attached screen shots below.
Ulcer Boost

7. Include a final DVH of your treatment plan with appropriate labels and discuss your ability to meet
the target and OAR tolerance guidelines. (15 Points)

DVH for initial plan (additional boost dose not factored in)

Dose constraints for nearly all OAR were met. The right lung posed the greatest challenge due
to its proximity to the targets. The mean dose to the right lung was 1602 cGy. According to the
QUANTEC chart, there will be a slight risk of symptomatic pneumonitis. Additionally, the V20 for the
right lung was at 31.3%, which is a 1.3% increase over the threshold per QUANTEC. Again, this
increases the risk of symptomatic pneumonitis. The thyroid gland constraint was not met either: V26
was at approximately 60%. The targets did not receive complete prescription coverage; however,
given the patient’s age, I am confident the physician felt the risk/rewards were still favorable.
References
1. Clifford Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed.
Philadelphia, PA:Lippincott Williams & Wilkins; 2011.
2. Washington CM, Leaver, D. Principles and Practice of Radiation Therapy. 4th ed. St. Louis, MO:
Elsevier Mosby; 2016.