Isocenter Placement and Field Matching

The first step was to place the isocenter for my plan. I did this by looking at the

transverse view, finding the head of the clavicle and placing the isocenter between the first and

second rib, between and posterior to the the supraclavicular node and the axillary node as shown

in Figure 1. Once I placed my isocenter, I added on the supraclavicular field and made sure the

Y1 jaw was at 0. I added on the medial field and made sure that the Y1 jaw for that field was also

at 0 which allowed them to match as shown in Figure 2.

Figure 1: Isocenter placement.

Figure 2: Supraclavicular and medial field matching.

Beam Arrangements
The plan that I created consisted of 4 main fields: supraclavicular (sclav), medial, lateral

and a left posterior oblique (LPO) field. The sclav field was placed at a 345-gantry angle to

ensure that the supraclavicular nodes were being covered while also taking into consideration the

dose that the esophagus and spinal cord would be receiving as shown in Figure 3. The medial

angle was placed at 302 degrees. This gantry angle was chosen to ensure coverage on the internal

mammary nodes while also taking into consideration the dose falling onto the opposite breast

and the lung and heart dose as shown in Figure 4. The lateral beam angle was placed at an

opposing angle from the medial field of 128 degrees to eliminate the divergence between the two

beams. The LPO field was placed at 173 degrees to ensure posterior coverage of the nodes. A

collimator angle nor a table angle was used for this plan.
 Figure 3: Supraclavicular field.

Figure 4: Medial field.

Beam Weight, Monitor Units, and Energy
In order to determine the weight of the main beams that were used in my plan, I started

by setting up the supraclavicular field first. Once I had that field ready, I calculated the dose to

that field with a weight of 1. I evaluated the dose distribution of the nodal coverage and the lung

dose. The initial goal that had set was that I wanted the 90% isodose line to cover the posterior

edge of all the nodes. I was not quite reaching that goal, so I knew that I needed to add on some

sort of posterior oblique to give dose to the deeper nodes. I added an LPO field with 30 monitor

units and adjusted the monitor units on the sclav field until I was satisfied with the initial

coverage of the nodes as shown in Field 5. The sclav field and the LPO field both have an energy

of 16x. I then added on a medial and lateral field both using 6x energy and calculated the dose

and weighted those two beams accordingly to obtain a homogenous dose distribution. I did not

normalize my plan, instead I adjusted the monitor units and used field-in-field to adjust the dose

distribution. In the beginning my plan was overall very hot, but I was able to cool it down while

maintaining coverage by using field-in-field segments on the medial and lateral fields all with 6x

energy. Figure 5 displays all the fields that were used in this plan as well as the field weight.
Figure 5: Coverage of the nodes from the supraclavicular and left posterior oblique field.
Figure 6: Fields and their weight.

Multi-Leaf Collimator and Field-in-Field

The supraclavicular field has multi-leaf collimator (MLC) shaping that covers the

humeral head and a portion of the esophagus as shown in Figure 6. The MLC that is inferior of

the Y1 jaw is left open to allow a smooth transition of dose between the supraclavicular field and

the tangents. The superior MLC above the Y1 jaw on the tangents is also left open. On the

medial field, the MLCs were shaped following the posterior curve of the internal mammary

node. This helped with coverage on this node as well as decreasing the left lung and heart dose as

shown in Figure 7. The MLC’s on the lateral field followed the same formation as the medial

field as shown in Figure 8. The medial and lateral fields both have field-in-field segments that

were used to cool the plan and re-arrange the dose.

Figure 6: Multi-leaf collimator shaping on supraclavicular field.

Figure 7: Multi-leaf collimator shaping on medial field.

Figure 8: Multi-leaf collimator shaping on lateral field.

Adjustments Made to Meet Constraints

In order to meet some of the constraints and provide better coverage, there were some

adjustments that I had to make. In the beginning of the planning process, I had a gantry angle of

310 which was causing the heart and lung dose to become elevated. I had to evaluate the gantry

angle that was ideal to reduce the lung and heart dose without causing too much dose to exit onto

the right breast. Another adjustment that I needed to make was to figure out a way to reduce the

dose to the right breast. I was able to lower the dose by moving the MLC’s on the open medial
and lateral fields to cover more of the right breast. In doing this, I needed to make sure that I was

still getting coverage to the internal mammary nodes. My esophagus dose was on the higher end,

so in order to lower it I adjusted some of the MLCs on the supraclavicular field and adjusted the

gantry angle on the supraclavicular field which helped lower the dose.

Hot Spots, Cool Spots, and Dose Distribution

After my plan was completed, I had a hot spot of 116.4%. The hot spot was in the axillary

node as shown in Figure 9, which is an ideal location for a hot spot instead of in an organ at risk.

Ideally, I would have wanted to cover the entire nodes with the 95% isodose line, but I was

satisfied with 90% covering them as shown in Figure 10. The mean dose to the left anterior

descending artery (LAD) came to be 4.420 Gy. I did make sure that in all the fields, the MLC’s

were covering the LAD. In order to reduce the dose to the LAD the X1 jaw on the medial and the

X2 on the lateral could be closed more, but then it would reduce the dose that the internal

mammary nodes would be receiving. Based on the DEGRO breast cancer expert panel, the

recommended constraint for the LAD is the mean dose less than 10 Gy, V30 less than 2 %, V40

less than 1%.1 Based on the DVH in Figure 11, the plan that I created is meeting all these

constraints. If the LAD dose constraints are not met, there are complications that could occur in

the patient’s near future. The patient could experience heart damage and complications such as

inflammation, oxidative effects, and endothelial damage.1

Figure 9: Hot spot.
Figure 10: Lack of coverage.

Figure 11: DVH for the LAD

Conclusion
The plan that I created, overall displays adequate coverage on the target volumes and limited dose

to the surrounding critical structures. The hot spot is at 116.4% and it is in an acceptable location within

the axillary lymph node. Figure 12 shows the overall dose distribution in all three views. Figure 13

displays the dose volume histogram for the surrounding critical structures and target volumes. Figure 14

displays the final ProKnow scoring sheet for the plan.

Figure 12: Dose distribution in all three planes

Figure 13: Dose volume histogram
Figure 14: ProKnow scoring sheet.
 Reference
1. Piroth, M.D., Baumann, R., Budach, W. et al. Heart toxicity from breast cancer
radiotherapy. Strahlenther Onkol 195, 1–12 (2019). https://doi.org/10.1007/s00066-018-
1378-z