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Janice Chuang, Simran Rai, Sunhee Lee

Research Methodology- Research Proposal Document
April 4, 2022

Working Title
Effects of target volume coverage in lateral peripheral breast tissue with flattening filter free
beams for breast patients with high tangential separation
Problem Statement
The problem is that when whole breast patients have a tangential separation greater than 21 cm
mixed energies may be used for adequate homogenous coverage of the breast, however, this can
lead to a loss of peripheral dose in the outer region of breast tissue which is of concern for
patients with a medial or lateral superficial surgical cavity receiving whole-breast irradiation.
Purpose Statement
The purpose of this study was to determine if 10MV Flattening Filter Free (FFF) beams can
increase surface dose coverage in the breast and superficial surgical cavity compared to clinically
relevant treatments using mixed energy for patients receiving whole breast radiation.
Hypothesis Statements
H1! : The first research hypothesis (H1) is that FFF beams for breasts will increase the volume of
the whole breast receiving 95 percent of the prescription dose.
H1" : The first null hypothesis (H1" ) is that FFF beams for breasts will not increase the volume
of the whole breast receiving 95 percent of the prescription dose.
H2! : The second research hypothesis (H2) is that FFF beams for breasts will increase minimum
cavity dose by 5 percent.
H2" : The second null hypothesis (H2" ) is that FFF beams for breasts will not increase minimum
cavity dose by 5 percent.
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Summary

The adjuvant use of radiotherapy in breast conserving therapy has resulted in excellent

long term local control for early-stage breast cancer.# However, improvements in local control

can still be made for higher stages of disease. As breast-conserving therapy becomes more

common it becomes increasingly important to provide proper radiation dose coverage to areas

that are at risk for local recurrence. The goal of adequate dose coverage for a treatment planner is

particularly difficult in areas that are near the outer region of the breast. Problems can occur

when whole breast patients have a tangential separation of greater than 21 cm, so the planner

must typically resort to using 10 MV or mixed energies for adequate coverage of the breast. The

skin sparing effect of higher energies contributes to a loss of dose coverage in subcutaneous

tissue closer to the skin surface. This loss of surface coverage in the outer region of breast tissue

can possibly lead to a higher risk of local recurrence.

Flattening Filter Free (FFF) beams have been shown to display favorable beam

characteristics that would suggest a greater likelihood of target coverage closer to the surface of

the patient. The unique beam characteristics of flattening filters may allow for a homogenous

dose of the whole breast while maintaining dose near the surface. This is because 6MV and 10

MV FFF beams have a greater surface dose than their flattened counterparts.$ Additionally, for

10 MV FFF beams the depth of electron equilibrium is shallower than a 10 MV flattened beam

in field sizes larger than 10x10 cm. Flattening Filter Free beams have also been shown to

decrease treatment times adding to its benefits.% It can be reasoned that a FFF beam when

modulated correctly can provide homogenous dose distribution within the breast while

maintaining a favorable dose closer to the skin surface.

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The availability of energies that can provide adequate target coverage along with a low

area of hot spots is one such limitation of conventional breast planning. In general, it is seen as

desirable to deliver a homogenous dose distribution to breast tissue without excessive hot spots.

This is in part because excessive areas of high dose have been linked to poorer cosmetic

outcomes.4 This objective becomes increasingly difficult to balance with target coverage as a

patient has an increased tangential separation. This is in part because the greater monitor units

needed to deliver dose to the entire breast create much larger high dose areas that in many cases

cannot be eliminated with lower energies. Conversely, when higher energies such as 10 MV are

used in these cases, a loss of dose in the peripheral region of the breast is often reported.& This is

due to the skin-sparing effect seen in higher energy photon beams. When dose is evaluated to the

whole breast it is common for an evaluation structure to be utilized. This structure in many cases

will be cropped 5 mm from the surface of the patient to yield the beast eval structure from the

breast. Although dose in this peripheral region of the breast is left out by the eval structure since

it is not prioritized as much as other areas of the breast, many radiation oncologists do in fact

include it in their target volume.6 Furthermore, this area becomes of particular importance in

instances where the surgical cavity is superficial since the cavity is the most common area of

local recurrence. The minimum dose seen in superficial cavities can suffer when higher energies

are incorporated into the plan. Due to the unfavorable beam characteristics of a 10 MV or higher

energy regarding surface target coverage of breast tissue, a mixed energy approach is often

utilized. Mixed energy treatments are often more difficult and take longer to plan leading to a

disrupted workflow in the radiation oncology clinic. Furthermore, mixed energies can in many

cases lead to increased treatment times since subfields cannot often be combined when energy
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varies. This leaves a need for a more seamless planning method that maintains target volume

coverage near the surface.

The problem is that when whole breast patients have a tangential separation greater than

21 cm mixed energies may be used for adequate homogenous coverage of the breast, however

this can lead to a loss of peripheral dose in the outer region of breast tissue which is of concern

for patients with a medial or lateral superficial surgical cavity when receiving whole breast

radiation. The ability of FFF beams to provide increased superficial dose may be able to address

this issue. The purpose of this study was to determine if 10MV Flattening Filter Free (FFF)

beams can increase surface dose coverage in the breast and cavity compared to clinically relevant

treatments using mixed energy. There is limited research on the clinical implications of using

FFF beams to increase the relative dose near the surface. Researchers tested the hypotheses that

FFF treatments would increase volume of the whole breast receiving 95 percent of the

prescription dose and minimum cavity dose, for breast patients by 5 percent compared to

clinically relevant mixed energy plans.

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References

1. Wrubel E., Natwick, R., & Wright, P. G. Breast conserving therapy is associated with
improved survival compared with mastectomy for early-stage breast cancer: A propensity
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2. Kragl G, Wetterstedt S, Knäusl B, et al. Dosimetric characteristics of 6 and 10MV
unflattened photon beams. Radiotherapy oncol. 2009;93(1):141-146.
https://doi.org/10.1016/j.radonc.2009.06.008
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breath-holds using a flattening-filter-free beam with the deep inspiration breath-hold
method in left-sided breast cancer. J Med Dosim. 2020;45(4):359-362.
https://doi.org/10.1016/j.meddos2020.05.002
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surgery and radiation therapy: experience of patients treated in a Chilean radiotherapy
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https://doi.org/10.3332/ecancer.2018.819
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spoiler or photons with mixed energies. J Med Dosim. 2007;32(4):246- 253.
https://doi.org/253.10.1016/j.meddos.2007.02.002
6. Li XA, Tai A, Arthur DW, et al. Variability of target and normal structure delineation for
breast cancer radiotherapy: an rtog multi-Institutional and multiobserver study. Int J
Radiat Oncol Biol Phys. 2009;73(3):944-951.
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