Introduction

Breast cancer is still the leading malignant tumor for women, and it is no secret that
radiation therapy offers both local control and survival benefits.1 The different types of invasive
disease include infiltrating ductal carcinoma, which is the most common type, and infiltrating
lobular carcinoma.2 Although radiation therapy has shown to improve local control and survival
benefits, it is not usually used alone, it is often used in combination with surgery and/or
chemotherapy. Neoadjuvant therapy is used prior to surgery to help shrink the size of the tumor,
this can be chemo and/or radiation.2 Adjuvant therapy is used after surgery to kill any remaining
cancer cells that may have escaped the breast.2 There are several surgery options ranging from a
lumpectomy and sentinel lymph node biopsy all the way to a total mastectomy.2 Radiation
therapy follows surgery when there are 4 or more positive lymph nodes, the tumor is greater than
5 cm (about 1.97 in), and there are close/positive margins.2 The best treatment is decided based
on diagnosis, staging, and patient preference. The patient that will be discussed throughout the
paper was recently diagnosed with invasive well-differentiated ductal carcinoma with rare
microcalcifications of the right breast. After discussing with radiation oncologist and breast
surgeon she made the decision to move forwards with a bilateral mastectomy followed by
radiation therapy.

Set up

Positioning is critical when setting up breast radiotherapy.2 The position must be able to
be reproduced easily to ensure accuracy of the radiation. The most common positioning for
breast cancer treatment include supine position, arm on the affected side raised above the head,
head turned away from the treatment side, and with a breast board or vac loc in place.2 The
patient discussed above was placed in a supine position with a vac loc on a wing board under
her, both arms were raised above the head with hands holding handles of the wing board. The
vac loc was positioned and adjusted to cradle her arms to ensure comfort. Once the patient was
comfortable and the CT technician was confident in the positioning, all the air was released from
the vac loc for it to keep its shape. Finally, 3 marks were made for localization and BBs were
placed on each to visualize the CT localization on the images in the treatment planning system.
A vac loc was used to keep the patient in the same position for each treatment. The arms were
placed above the head to allow beam entry and prevent rotation. The head was turned away from
the treatment side to stretch the skin and avoid treating the neck. The position was chosen to
ensure that the patient would remain in the same position for each treatment, while allowing
optimal positioning for beams and treatment planning.

Treatment
 For chest wall irradiation the target volume is defined as operated chest wall area with
surgical scar and lobe.3 The standard dose schedule for chest wall irradiation is 45-50.4 Gy at
1.8-2 Gy per fraction.3 The pathology from the patient’s bilateral mastectomy found incidental
ductal carcinoma in situ (precancerous lesions) in the left breast, which was performed
prophylactically based on patient decision, and invasive well-differentiated ductal carcinoma
with positive margins, lymphovascular invasion, and perineural invasion of the left breast. This
led to the ultimate decision to prescribe 5,000 cGy at 200 cGy for 25 fractions. After discussing
with the physician, she decided on the dose based on the patient’s high-risk factors. Also due to
the high-risk factors she decided to include the supraclavicular nodes.

When planning it is important to define the organs at risk (OAR) to allow the treatment
planning system to track the planned dose that will be given to organs near the treatment volume.
The OAR usually have a certain tolerance that is allowed to be given. Each organ has a different
tolerance (a desired planning objective), and it is important to keep the dose as low as possible to
ensure that the organs and their function are not permanently damaged. The physician prefers to
have the spinal cord, esophagus, heart, lungs, and contralateral breast contoured to track the dose
(See figures 1 & 2 for contoured target and OAR). Below is a table of defined OAR, the
tolerance defined, and the predicted doses. All the planning objectives were able to be met,
therefore there were no contraindications.
Critical Structure Desired Planning Planning Objective Objective Met (Y or
Objective Outcome N)
Spinal Cord < 50 Gy 4
340 cGy Y
Esophagus Mean < 34 Gy 4
491 cGy Y
V35 Gy < 50%4 313 cGy
Contralateral Lung V20 Gy < 30%4 292 cGy Y
Ipsilateral Lung V20 Gy < 30% 4
1171 cGy Y
Heart V25 < 10%4 1228 cGy Y
Contralateral Breast V5% < 5Gy 3.89% Y
The supraclavicular nodes were included in the target volume (see figures 3-5 for other nodes
included). The other nodes that can be included by default are the subclavian, a small portion of
the central axillary, and the Rotter’s nodes based on the CTV drawn by the physician and the
margin created (see figure 2 for contoured target volume). The physical limits of the area treated
include first costal interspace, midline of the sternum, and about 1.5 cm (about 0.59 in) below the
inframammary fold to ensure the entire breast/chest wall is being treated.2 See figures 6-8 to
visualize the physical limits of the PTV.
 VMAT radiation technique was used to ensure target volume was entirely treated while
protecting the OAR and limiting the dose to as low as possible. Two beams were created, each 6
MV energy, the collimator and couch rotation were each 0 degrees, and the max gantry spacing
was set for 2 degrees. For VMAT 1 beam the gantry start was put at 60 degrees and the gantry
stop was put at 200 degrees to rotate counterclockwise. For VMAT 2 beam the gantry start was
set at 200 degrees and the stop was set at 60 degrees to rotate clockwise. These gantry angles
were chosen to ensure the entire PTV was covered. The MUs per fraction for VMAT 1 were
446.35, while the MUs for VMAT 2 were 459.34. See figure 9 to see the beams and their
specifications. After setting up the beams, I was able to move to the plan optimization setting in
Raystation to continue. In plan optimization, objectives and constraints were put in to create the
most optimal plan. Once all objectives and constraints were met and the physician approved the
plan it was ready to be printed and imported to the treatment machine.

Using Raystation planning system, I was able to create an optimal plan quite easily. I was
able to completely treat the PTV so the 100% isodose line covered 95% of the PTV, while
meeting all of the planning objectives for OAR. See figures 10 and 11 for final DVH and isodose
lines.

Figures
Figure 1: List of contoured target and organs at risk and their associated colors.

Figure 2: Sagittal and coronal views of contoured target and OAR.

Figure 3: An axial view of the subclavian nodes included in the PTV.

Figure 4: An axial view of supraclavicular nodes included in the PTV.
Figure 5: A coronal view of the axillary lymph nodes included in the PTV.

Figure 6: An axial view of the superior physical limit of the PTV

Figure 7: An axial view of the medial physical limits of the PTV.

Figure 8: A sagittal view of the inferior physical limit of the PTV.

Figure 9: The 2 VMAT beams and their specifications.

Figure 10: Final DVH labeled.

Figure 11: Axial, Sagittal, and coronal view of final isodose lines—including hotspot.
References

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breast cancer. Radiat Oncol 15, (2020);71. https://doi.org/10.1186/s13014-020-01501-x
2. Vann, AM. Breast Cancer. [SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry
Program; 2023.
3. Polgar C, Kahan Z, Ivanov O, et al. Radiotherapy of breast cancer- professional guideline
1st central-eastern european professional consensus statement on breast cancer. Pathol
Oncol Res. (2022); 28. Doi: 10.3389/pore.2022.1610378
4. Bentzen SM, Constine SL, Deasy JO, et al. Quantitative analyses of normal tissue effects
in the clinic (QUANTEC): an introduction to the scientific issues. Int J Radiat Oncol Biol
Phys. 2010 March 1; 76(3 Suppl). doi:10.1016/j.ijrobp.2009.09.040.