1

Minimizing clearance issues with prone breast patients on Varian linear

accelerators through isocenter placement
Lauren Wilson; Rob Rohe, BS, R.T.(T); Julie Bradley, M.D.

Nishele Lenards, PhD, CMD, R.T.(R)(T), FAAMD; Ashley Hunzeker, MS, CMD; Matt
Tobler CMD, R.T.(T); Sabrina MS, CMD, R.T.(T); Ashley Coffey CMD, R.T.(T)

Medical Dosimetry Program at the University of Wisconsin-La Crosse, WI

I. Abstract
II. Introduction
A. PI: Details and statistics on breast cancer. Different treatment techniques
used and OAR. Introduce benefits of treating patients with pendulous
breasts prone. (Reference: Yao S et al,1 Deseyne P et al,2 Boyages J et al,3
Fahimian B et al.4)
B. PII: Cover general disadvantages of prone breast treatments. Discuss
immobilization device and setup reproducibility strategies (Figure 1 & 2 &
3). (Reference: Yao S et al,1 Fahimian B et al,4 Huppert N et al,5 Lakosi F
et al,6 Nguyen SM et al.7)
C. PIII: Cover Varian accelerators and explain tertiary MLC. Make
connection between tertiary MLC and less clearance. (Reference: Huppert
N et al,5 Lakosi F et al,6 Nguyen SM et al,7 Gupta A et al,8 Mohan R et al,9
Boyer A et al.10)
D. PIV: Summarize introduction points
1. Problem: Prone breast set ups occasionally result in collisions of
the gantry head with the immobilization device and/or patient
positioning system depending on the isocenter location, which can
negatively impact treatment and patient experience (Figures 3 & 4).
2. Purpose: To compare plan isocenter locations to determine if a
guideline can be established to prevent collisions of the gantry head
with the immobilization device and patient positioning system in all
directions while maintaining quality treatment plans.
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3. Hypothesis: Therefore, the research hypothesis (H1) is that an

isocenter location guideline can be developed to prevent collisions
with the prone breast immobilization and gantry head, while still
creating a clinically acceptable treatment plan. The null hypothesis
(H0) is that a guideline isocenter location cannot be developed that
will prevent collisions and create a clinically acceptable plan.
III. Materials and Methods
A. Patient selection and setup
1. PI: Patient population
a. 14 patients
b. Inclusion criteria (left/right sided breast irradiation, prone
breast treatment position, treated at same clinic, treated on
Varian linac, treated on Civco Horizon breast board)
c. Exclusion criteria (no regional lymph nodes)
2. PII: Equipment set-up image
a. Prone breast position set-up
i. Civco Horizon breast board, immobilization devices
(Reference: Fahimian B et al4)
ii. Figure of clearance for Varian linear accelerator and Civco
breast board
b. Set-up reproducibility (Reference: Nguyen SM et al7)
i. Immobilization (Figure 4 & 5)
ii. Cone-beam CT or set-up images
B. Isocenter Location
1. PI: Objectives
a. Objectives to be met after isocenter shifts
i. CTV, heart, lungs
b. OAR: Mean heart dose, mean lung dose, D95 heart dose, D95
lung dose, D1 heart dose, D1 lung dose
i. Meets RTOG 1005 constraints, 5% difference original plan
OAR D95, D1 and mean
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c. Target: PTV (% volume receiving 90%, 95%, 100% of dose)

i. Within 5% difference original plan
2. Isocenter Location (Reference: Van Asselen et al12)
a. PI: Move isocenter location from original treated plan
i. Shifts based on measured clearance of Civco Horizon to
gantry head
ii. Medially within +/- 6 cm medio-laterally
iii. Measurements taken from table top with immobilization
device to gantry head to avoid collision with Civco breast
board
iv. Anterior isocenter shift to table top measurement of less
than or equal to 16cm (Figure 6)
v. Minimal superior or inferior shifts as needed due to field
size limitations.
b. PII: Recalculate plan with new isocenter placement
i. Recalculate from retrospective case with previous isocenter
outside of collision metric guidelines
ii. Verify isocenter within guidelines so that no collision
possible
iii. Adjust plan as needed to aim to meet OAR and target
objectives specified
C. Plan Comparison
1. PI: Evaluated metrics
a. OAR: Mean heart dose, mean lung dose, D95 heart dose, D95
lung dose, D1 heart dose, D1 lung dose
i. Meets RTOG 1005 constraints, within 5% difference
original plan
b. Target: PTV (% volume receiving 90%, 95%, 100% of dose)
i. Within 5% difference original plan
2. PII: Isocenter metrics
a. Isocenter: location within clearance parameters
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i. within +/- 6 cm medio-laterally

ii. Anterior isocenter shift to table top measurement of less
than or equal to 16cm
iii. Difference between original and new isocenters
iv. Clearance confirmed if immobilization and PPS were not
within the 39.4 cm distance that was measured from the
head of the gantry to isocenter
D. Statistical Analysis
1. PI: Evaluated metrics
a. Q-Q plots, Shapiro-Wilk
b. Wilcoxin Signed Rank test will be used for OAR and target
metrics (Figure 4)
c. False Discovery Rate will be used if needed to address
multiple comparisons
d. P < 5.0 is considered statistically significant
2. PI: Evaluated metrics
a. Benjamini-Hochberg adjustment (false discovery rate) applied
for type 1 error for multiple testing
IV. Results
A. P1: Objectives (Table 1)
1. WSR test OAR
a. OAR objectives met to allow for acceptable plan
2. PII: WSR test targets
a. Target objectives met to allow for acceptable plan
B. PII: Isocenter location (Table 2)
1. New isocenter locations
a. Within clearance parameters
i. defined as within 6 cm mediolaterally of midline and less
than or equal to 16 cm from the top of the patient position
system
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b. Isocenter within parameters and objectives acceptable =

hypothesis accepted
V. Discussion
A. PI: Summarize objectives results in relation to the isocenter location
1. Importance of objectives for clinically acceptable plan
a. Isocenter location only possible if plan considered overall
appropriate
B. PII: Summarize isocenter locations
1. Isocenter guideline limitations
a. Within clearance parameters
i. defined as within 6 cm mediolaterally of midline and less
than or equal to 16 cm from the top of the patient position
system
b. Isocenter within parameters to avoid collisions
c. Average isocenter shifts from retrospectives plans
i. Original isocenters not within clearance parameters
C. PIII: Summarize study to recap
1. Importance of isocenter and clearance
VI. Conclusion
A. PI-PII: Summarize the study
1. Problem: Prone breast set ups occasionally result in collisions of
the gantry head with the immobilization device and/or patient
positioning system depending on the isocenter location, which can
negatively impact treatment and patient experience (Figures 3 & 4).
2. Purpose: To compare plan isocenter locations to determine if a
guideline can be established to prevent collisions of the gantry head
with the immobilization device and patient positioning system in all
directions while maintaining quality treatment plans.
B. PII: Limitations/future research
1. Limitations: all patients were collected from 1 institution with the
same TPS, machine and algorithm
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2. Future research: Different TPS/Linear Accelerator/immobilization

device, apply this study to another anatomical location, larger patient
sample size
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