1

Effects of target volume coverage in superficial medial and lateral breast tissue using
flattening filter-free beams.
Authors: Sunhee Lee, Simran Rai R.T.(T), Janice Chuang
Medical Dosimetry Program at the University of Wisconsin–La Crosse
Introduction

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

long term local control for early-stage breast cancer.1This approach has led to greater cosmetic
outcomes with similar long-term survival results compared to mastectomies. Following
lumpectomy, the whole breast is typically treated with 3D conformal radiation therapy (3D-
CRT) consisting of lateral and medial tangent beams. This is often followed by a boost to the
surgical cavity. The goal of this treatment is to deliver a homogenous dose to the breast and
surgical cavity while diminishing the dose to organs at risk (OAR).

The goal of homogenous dose coverage for a treatment planner is crucial but can be
difficult at times. In general, a desirable treatment plan contains a uniform dose distribution to
breast tissue without excessive hot spots. It has been shown that excessive areas of high dose
have been linked to poorer cosmetic outcomes.2 This objective becomes increasingly difficult to
balance with target coverage as a patient has an increased tangential separation. Gustafson et al3
demonstrated that the greater monitor units needed to deliver dose to the entire breast when
tangential separation is > 22 cm creates much larger high dose areas that in many cases cannot be
eliminated with lower energies. Conversely, Lief et al4 observed 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
due to the skin-sparing effect that occurs in higher energy photon beams. The availability of
energies that can provide adequate target coverage along with a low area of hot spots is one such
limitation of 3D-CRT breast planning.

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. Increased surface coverage is more likely because 6MV and 10 MV FFF beams have
a greater surface dose than their flattened counterpart.5 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
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adding to its benefits.6 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.

Despite some clinical practices, adequate dose coverage near the surface is still favorable.
Li et al7 demonstrated that although the peripheral 3 to 5 mm of the breast is often omitted when
target coverage is evaluated in a plan, many radiation oncologists do in fact include it in their
target volume. Furthermore, the area near the surface of the breast becomes of particular
importance in instances where the surgical cavity is near the medial or lateral surface 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. This leaves a need for a
more seamless planning method that maintains target volume coverage near the surface.

An investigation into the alternative options to mixed energy planning in whole breast
irradiation is needed. There is limited research on the clinical implications of using FFF beams to
increase the relative dose near the surface Whole breast tangential setups in patients with a
separation >21 cm typically requires mixed energy beams for adequate coverage of breast tissue.
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. The ability of FFF beams to provide increased superficial dose
may be able to address this issue. The purpose of this study is to determine if 10MV FFF beams
can increase peripheral dose coverage in outer region of breast tissue and the lumpectomy cavity
compared to mixed energy treatment techniques for patients receiving whole breast irradiation.
Researchers tested the hypotheses that FFF treatments would increase volume of the whole
breast receiving 95 % of the prescription dose and minimum cavity dose, for breast patients by 5
% compared to mixed energy treatment techniques.

Case Description

Patient Selection & Setup:

In this retrospective study patients that received whole breast radiotherapy in the
supine position without supraclavicular nodal involvement were selected. The inclusion criteria
included a tangential separation >21 cm and a surgical cavity that was within 1 cm from the
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surface. Tangential separation was defined as the greatest distance for the deepest point of entry
to travel outside the body on the medial and lateral beams. For the 7 patient cases, the mean
tangential separation was 23.5cm and the mean surgical cavity volume was 20.2cc.

Patients were simulated using a Philips Brilliance Big Bore CT scanner in the headfirst
supine position. A breast board was used for immobilization with the patient’s ipsilateral arm
above their heads. In order to facilitate patient comfort each patient was given a knee roll and
headrest. For setup and localization, each patient was marked with three marks, 1 mark on each
side and 1 anterior. Radiopaque markers were utilized during the scan to visualize a point of
reference. The boundaries of the breast tissue were delineated prior to the CT scan with
radiopaque wires. Patients that received radiation to the left breast were scanned in 2 instances.
Once free breathing and once with a deep inspiration breath hold. All scans were obtained with a
0.2 cm slice thickness.

Target Delineation

Upon completion of the simulation target delineation and treatment planning was
achieved with Eclipse version 15.6. treatment planning software and the calculation algorithm
was AcurosXB_15606 with dose grid size of 0.2. The surgical cavity and breast tissue was
determined by the physician. To yield a breast planning target volume (PTV) the breast structure
was cropped 5mm away from the skin surface. All OAR were contoured by the medical
dosimetrist which included the heart, bilateral lungs, and in the case of left breast patients, the
left anterior descending artery (LAD).

Treatment Planning

The field size, collimator angles, and gantry angles were set by the physician so that the
fields would cover the entirety of the ipsilateral breast tissue. The physician utilized Radiation
Therapy Oncology Group Protocol (RTOG) 0413 guidance when determining their field size.
Two tangent beams were utilized for each plan a medial and lateral. In order to facilitate the
planning process EZfluence by Radformation (New York, NY) was used in the planning of all
cases. Once the plans were exported to the EZfluence software a coverage goal of volume
receiving 95% of prescription dose equals 95 percent (V95% =95%) for the breast PTV was
input into the system for all plans. Each plan deployed the use of electronic compensators (ECs),
 4

and every patient in the study received 2 treatment plan that had the same field size, collimator
rotation and treatment angles. One plan consisted of a 10 FFF beam energy, and the other
included a mixture of 6 MV and 10 MV treatment beams. For the mixed energy plan the
weighting of the fields was kept the same as the plan in which the patient originally received
treatment. The predominant energy in the plan was modulated with ECs while the lesser used
energy was kept as an open field.

The OAR primarily of concern for the physician included the lungs, heart, and LAD.
Treatment planning objectives were specific to the clinic since RTOG 0413 does not provide any
specific dose constraints. Given a prescription dose of 50 Gy in 25 fractions, the physician
specified the mean dose to the heart could not exceed 3 Gy and the LAD must have a maximum
dose less than 3 Gy for left sided breast treatment (Table 1). The mean dose to the heart for right
sided breast treatment was limited to under 1 Gy. The volume receiving 20 Gy (V20) for the
ipsilateral lung was limited to 30%. Each plan was normalized so that 95 percent of the
prescription dose would cover 95 percent of the breast PTV.
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Tables

Table 1. Physician specified dose constraints for OAR evaluation

Structures Constraint
Heart (left breast) Mean < 3 Gy
Heart (Right breast) Mean < 1 Gy
LAD Maximum < 3 Gy
Ipsilateral Lung V20 < 30%
*Organs at risk (OAR): Volume of lung receiving 20 Gy (V20)
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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.2019.08.00488
4. Lief EP, Hunt MA, Hong LX, Amols HI. Radiation therapy of large intact breasts using a
beam spoiler or photons with mixed energies. J Med Dosim. 2007;32(4):246- 253.
https://doi.org/253.10.1016/j.meddos.2007.02.002888888888888888888888888888888
5. Kragl G, Wetterstedt S, Knäusl B, et al. Dosimetric characteristics of 6 and 10MV
unflattened photon beams. Radiat Oncol J. 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.
https://doi.org/10.1016/j.meddos2020.05.002

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 Radiat
Oncol Biol Phys. 2009;73(3):944-951. https://doi.org/10.1016/j.ijrobp.2008.10.034
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Submission Packet
You are required to submit this packet with each submission of your paper. You
will build on each draft and will also build on each submission packet so it will
represent the changes of your paper from start to finish. In this packet, you will
find:
I. Statements
II. Change Matrix
III. AMA Formatting Checklists
The instructions for each section are listed below. Copy and paste the statement
page, change matrix table and AMA formatting checklist table to the first page
of your draft submission. Remember that you should build on each submission.
 8

Statements
Remember the problem, purpose and hypotheses statements that we worked so
hard on last semester? We will be using them again! They should be stated in
your paper (just as we worked on in your research proposal) but we are also
asking you to spell them out here as a reminder of the foundational basis for your
research.
Purpose Statement: The purpose of this study is to determine if 10MV Flattening Filter Free
(FFF) beams can increase peripheral dose coverage in the outer region of breast tissue and the
lumpectomy cavity compared to mixed energy treatment techniques for patients receiving whole
breast radiation.

Problem Statement: Whole breast tangential set ups in patients with a separation > 21cm
typically require mixed energy beams for adequate coverage of breast tissue. The problem is the
higher energy beams 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 receiving whole-
breast radiation.

Hypotheses:
H1: The first research hypothesis (H1) is that FFF beams for breast radiotherapy will increase
the volume of the whole breast receiving 95% of the prescription dose.

H10: The first null hypothesis (H10) is that FFF beams for breast radiotherapy will not increase
the volume of the whole breast receiving 95% of the prescription dose.

H2: The second research hypothesis (H2) is that FFF beams for breast radiotherapy will increase
minimum cavity dose by 5%.

H20: The second null hypothesis (H20) is that FFF beams for breast radiotherapy will not
increase minimum cavity dose by 5%.
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Change Matrix
A change matrix is required with every milestone document submission.

A detailed change matrix simplifies the review process and indicates to the instructors and advisors that
the author has demonstrated a clear and thorough response to reviewer comments.

Reviewer comments are not intended as an exhaustive list. It is the Learner’s responsibility to correct
any additional errors that are not specifically noted by the reviewer and to address the requirements of
the capstone project. All instances where changes have been made should be clearly noted.

If, after discussion with the group, there are questions about a reviewer’s comments, it is the
responsibility of the group leader to reach out to the instructors and advisor via email for clarification.

If, after discussion with the instructors, the author chooses not to make a requested change, the
author must provide a brief rationale, and describe how they addressed reviewer concerns.

Failures to consider, address, and notate within the Change Matrix will result in the manuscript being
returned to the group without comment.

Copy and paste the instructor’s comment from your draft into the matrix.

You will continuously build on this change matrix so that any/all comments can be reviewed at any given
time in the projects progress.

Title of Capstone: Effects of target volume coverage in superficial medial and lateral breast tissue
using flattening filter free beams.

Group: 10
Reviewer’s recommendation How addressed Page numbers
where change
appears

Example Example p.52

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AMA Referencing Quick Guide Checklist

Correctly using AMA formatting is one of the few aspects in the Capstone project that you have
complete control of whether it is your first outline submission or the final draft. Use this AMA quick
guide checklist to avoid common AMA formatting mistakes and receive the greatest number of points
possible. Not everyone has the ability to be an exceptional scholarly writer and researcher, however,
everyone has the capability of using AMA formatting correctly. Review this guide for EVERY submission
(discussion post, outline, draft) in the research courses and ask yourself the following questions:

Task Submiss Submissio Submissio Submissio Submissio Submissio Submissio

ion n Date: n Date: n Date: n Date: n Date: n Date:
Date:
6/15/20 7/6/2022
22

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to spelled out
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defined as organS
at risk.

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common mistake, ☒ ☒ ☐ ☐ ☐ ☐ ☐
even in journal
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(Figure 1).
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Year, volume,
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are referenced
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are removed
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