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Group Outline

Sunhee Lee, Simran Rai, Janice Chuang

Effects of target volume coverage in superficial medial and lateral breast tissue using
flattening filter free beams: a case study

I. Abstract
II. Introduction
a. PI: The role of radiotherapy in breast conserving therapy and its benefits
(Reference: Wrubel et al 1)
b. PII: The problems that arise for the treatment planner when tangential separation
increases
i. The need for homogenous breast treatment. How hot spots in breast
treatment reduces overall cosmesis (Reference: Vargas et al 2)
ii. The difficulty of minimizing hot spots when tangential separation
increases (Reference: Gustafson et al 3)
iii. The loss of dose near the surface when mixed energies are used
iv. How mixed energies cannot perfectly solve the problem because although
they minimize hot spots dose near the surface is also lost due to the skin
sparing effect (Reference: Lief et al 4 )
c. PIII: Introduce the benefits of flattening filter free beams and how they can
increase dose for medial and lateral breast tissue (Reference: Kragl et al 5
,Takakura et al 6)
i. Increased dose at surface
ii. Decreased depth of Dmax
iii. How flattening filter free beams can provide advantages over mixed
energy including faster planning times and treatment times.
d. PIV: The need for increased surface dose of the breast tissue
i. Many Physicians include nearly the whole breast when delineating their
target volumes despite the typical breast evaluation structure excluding
some of this structure. (Reference: Li et al 7)
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ii. Medial and lateral superficial lumpectomy beds also create the need for
greater dose near the surface of the breast since the surgical cavity is the
most common area of recurrence.
e. PV: Summary of introduction
i. Problem: The problem is that these higher energies 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 lumpectomy cavity when receiving whole
breast radiation.
ii. Purpose: The purpose of this study is to determine if 10MV Flattening
Filter Free (FFF) beams can increase peripheral dose coverage in outer
region of breast tissue and the lumpectomy cavity compared to mixed
energy treatment techniques for patient receiving whole breast irradiation.
iii. Hypothesis: The first research hypothesis is that FFF beams for breast
radiotherapy will increase the volume of the whole breast receiving 95%
of the prescription dose. The corresponding null hypothesis is that FFF
beams for breast radiotherapy will not increase the volume of the whole
breast receiving 95% of the prescription dose. The second research
hypothesis is that FFF beams for breast radiotherapy will increase
minimum cavity dose by 5%. The corresponding null hypothesis is that
FFF beams for breast radiotherapy will not increase minimum cavity dose
by 5%.
III. Case Description
a. Patient Selection
i. PI: Inclusion criteria
1. Retrospective
2. Patients receiving whole breast radiation supine
3. Intact Breasts
4. Patients with tangential separation greater than 21 cm
5. Patients with a surgical cavity less than 1 cm from the surface
ii. PII: Simulation procedures
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b. Target Delineation
i. Targets include whole breast and cavity
1. Both drawn by physician
c. Treatment Planning
i. PI: Planning methods
1. Use of EZ fluence and electronic compensators
ii. PII: Planning details (Table 1)
1. Angles, field size and mixed energy weighting used in each plan
2. Plan normalization of 95 percent of prescription dose covering 95
percent of breast PTV.
d. Plan Analysis and Evaluation
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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
score matched comparison using the national cancer database. J Ann Surg
Oncol;2020;28(2): 914–919. https://doi.org/10.1245/s10434-020-08829-4

2. Vargas L, Solé S, Solé CV. Cosmesis after early stage breast cancer treatment with
surgery and radiation therapy: experience of patients treated in a Chilean radiotherapy
center. Ecancermedicalscience. 2018;12(1):819-826.
https://doi.org/10.3332/ecancer.2018.819

3. Gustafson NR, Burrier T, Butler B, Hunzeker A, Lenards N, Culp L. Correlation of hot

spot to breast separation in patients treated with postlumpectomy tangent 3D-CRT using
field-in-field technique and mixed photon energies. J Med Dosim.2020;45(2):134-139.
https://doi.org/10.1016/j.meddos.2019.08.004

4. Lief EP, Hunt MA, Hong LX, Amols HI. Radiation therapy of large intact breasts using a
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https://doi.org/253.10.1016/j.meddos.2007.02.002

5. 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

6. Takakura T, Koubuchi S, Uehara A, et al. Evaluation of beam-on time and number of

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.
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7. 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
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