Breast Plan Write Up

Milica Ilic
• How did you match the supraclavicular field to the tangent fields? Include Visuals
To begin, I attempted to keep this plan set up similar to how we currently set up
for monoisocentric breast plans in my clinic. Upon initial evaluation of target volumes,
the isocenter is typically placed between the supraclavicular and inframammary nodes.
This can vary slightly. I placed my isocenter at the bottom of the supraclavicular nodes
and at the edge of the lung and chest wall interface. The isocenter point was also placed
at about mid-depth of the patient. Figure 1 shows my supraclavicular half-beam block
with isocenter and all the PTV target volumes outlined. I blocked the bottom half of the
beam up to the same point as isocenter. This was then used for my match line. I angled by
supraclavicular field at 353-degree gantry angle. This was done to help push the beam off
the esophagus, trachea, and spinal cord as much as possible. Figure 2 shows the beam
edges of the SCF beam avoiding the spinal cord, trachea, and partial esophagus. For my
tangent beams, the medial beam used an angle of 294-degrees, and the lateral beam used
an angle of 115- degrees. Figure 3 shows the medial half beam tangent block. The top of
the beam only goes to the point of isocenter, blocking the top portion of the beam
creating the match line between the tangent fields and the supraclavicular field. Figure 4
shows my lateral half beam block as well. The top of the beam was brought down to the
isocenter to create the match line. Figure 5 shows a sagittal slice where all the beams are
visualized along with the match line location. I did not use any couch kicks as I did not
deem it necessary as I was able to block out the humeral head in by supraclavicular field.
Figure 1. Block for supraclavicular field and isocenter placement.
Figure 2. SCF Beam Edge Showing Avoidance of Trachea, Spinal Cord, and Partial
Esophagus
Figure 3. Medial Tangent Half Beam Block
Figure 4. Lateral Tangent Half Beam Block
 Figure 5. Sagittal Slice Representing Match Line

• How did you reach the coverage required (energy and technique) for the axillary nodes?
For all my beams, I used an energy of 18 MeV. Before choosing this energy, I
began with the smallest energy at my clinic of 6 MeV first and gradually increased in
energy to increase my coverage. Typically, at my clinical site, 18 MeV is the energy of
choice for the supraclavicular fields. The axillary node PTV volume is split in half at the
match line with my plan. This could be seen referencing back to Figure. 1. The axillary
node volume is in the teal color. I brought the block edge out a little further laterally to
help get adequate coverage and so the volume was not at the edge of the block. To help
even out how hot the plan was due to the AP supraclavicular field I added a posterior
axillary boost field. The PAB field was matched to the SCF to be coplanar on the medial
aspect. Figure 6 shows the beam and block for my PAB field. The final beam weighting
between these two fields was 57.0% for the PAB and 43.0 % for my SCF field. Figure 7
shows how adding the PAB field made the dose distribution homogenous between the
two fields. I also used an energy of 18 MeV for my tangent fields to help with coverage
of the axillary nodes in those fields.

Figure 6. PAB Field

 Figure 7. Isodose Distribution Between SCF and PAB fields

• What technique did you use to treat the internal mammary nodes?
The IMN volume was the most difficult to meet coverage objectives. I used deep
tangents to be able to reach the IMN volume. Figure 8 provides a screen capture of the
beam path and how much into the right breast the beams traveled to reach the IMN
volume. The IMN volume is shown in orange. I also used beam energies of 18 MeV for
the tangent beams. As previously mentioned, the angles used for tangent beams were 294
for the medial beams and 294 for the lateral beams. I was not able to get adequate
coverage with gantry angles that went into the right breast tissue.
 Figure 8. Deep Tangent View

• Identify any cold spots (dose less than prescription), where are they located, and explain
if its location was acceptable.
The area that is receiving dose less than the prescription is near the IMN PTV volume at
the match line. Figure 9 shows the IMN PTV in orange. It is clear to see that portions of
the volume are not receiving 100% of the prescribed dose. It is present at the match line
between the tangent fields and the supraclavicular fields. It is common to see cold spot
areas near the match line of the plan. The match line is where the 50% isodose line meets
for each field, which is why often there are cold spots here. Readjusting where the
normalization point and prescribing to an isodose line can sometimes help with this
problem.
 Figure 9. IMN PTV Cold Spots

• Identify the maximum dose location and explain if its location was acceptable.
The maximum dose value was 6,149 cGy. The location of the hotspot is within
the Chest Wall Eval structure. It is more anterior and in the inferior portion of the
volume. I would deem this location of the hotspot acceptable as it is one of the major
tumor volumes that needs to be covered. Figure 10 shows the location of the hotspot
within all three planes.
 Figure 10. Hot Spot Location

• What was the dose to the LAD (left anterior descending artery)? Were you able to
spare it? Is there any way to decrease dose to it? What are the possible long-term effects
based on the dose that is given? Is there a LAD constraint that you can find in literature
when treating left sided breasts?
The mean dose to the LAD was 21.31 cGy and the maximum dose was 49.29
cGy. I added additional fields within each medial and lateral field to help with volume
coverage and block more of the heart. Figure 11 shows the block for the additional
medial and block and Figure 12 shows the additional lateral field. The LAD is in orange.
I did sacrifice coverage of the chest wall PTV in order to limit the dose to the heart and
LAD. There are currently no QUANTEC recommended constraints for any coronary
vessels to use as objectives. There have also been various study ranges for the mean LAD
value. These ranges could be attributed to the variances in heart and breast size.1As with
any OAR when creating a plan, its dose should be limited as much as possible. One study
completed by Zureick et al. Found that there were increased amounts of cardiac events in
patients who had increased exposure to the LAD.2 One study evaluated heart toxicity
from breast cancer irradiation and concluded that the following constraints are a good
frame of reference: DmeanLAD < 10 Gy; V30LAD < 2%; V40LAD < 1%. It was also found
that it can cause radiation-induced cardiovascular disease. This includes direct damage to
the coronary arteries, fibrosis of the pericardium and myocardium, microvascular
damage, and valve stenosis.3

Figure 11. Medial Tangent Blocked Field 2

 Figure 12. Lateral Tangent Blocked Field 2

• Explain how your plan was normalized or explain why no normalization was required.
This plan had to be normalized because it was a monoisocentric plan. You cannot
prescribe to the isocenter for any of the fields. This is because the isocenter is located
near the block edge for every field. Prescribing to this point would cause the plan to
become too hot because the treatment planning system would use too many monitor units
to deliver the prescription to that point. It would be asking the planning system to
accomplish something that is not reasonable. For this reason, I had a normalization point
for the SCF and PAB fields and a separate point for all the tangent fields. Additionally, I
 normalized to an isodose line for each of the fields. The prescription for the SCF and
PAB fields were normalized to the 96% isodose line. The tangent field prescription is
normalized to the 85% isodose line. I had to normalize to isodose lines because my plan
was too cold, and I was not getting adequate coverage for the tumor volumes.

• Embed your ProKnow plan score card within your assignment

Figure 13. ProKnow Score Card

• Was there a metric you were unable to meet, and if so, how did you try to fix it?
The only metric that I had an unacceptable marking in was for the right breast. All
other criteria were acceptable, good, and ideal. I initially created a plan that did not have
as deep tangents, but it did not provide adequate coverage for the IMN PTV volume. I
attempted to block out the right breast in additional segmented beams for the tangent
beams, but I would lose coverage in other more critical PTV volumes. Thus, I thought it
was reasonable to not meet this metric to provide adequate coverage in the tumor
volumes.

• Did you sacrifice points on a specific metric to improve your plan in other areas? What
was your rationale?
I sacrificed points on the right breast metric. I believed it to be more critical to get
coverage on the IMN PTV volume. In most clinical cases I have participated in, this has
typically been the case. Physicians will often sacrifice planning objectives for other OAR
to maintain PTV coverage. I also sacrificed some points on the esophagus metric. I
originally tried to block out the esophagus on the original SCF beam set up, but it was not
 possible to do so without clipping other parts of the supraclavicular nodes. Referring to
Figure 1, that is why the medial aspect of the supraclavicular nodes is so close to the
block edge. I tried to block out the esophagus as much as possible. With this, I was able
to still receive an “Acceptable” score on the metric for the esophagus.

• Provide a DVH with the target volume(s) and important surrounding critical structures
with clear labels.

Cartig_Thyroid

L Lung

Breast_R
External Skin

Lungs

Spinal Cord
R Lung

Figure 14. DVH For Surrounding OAR

 Trachea

A_LAD

Heart

Esophagus

Figure 15. DVH For Surrounding OAR

 PTVn_SCL_L
PTVn_IMN_L
PTV_CW_EVAL

PTV_CW_L

PTVn_Ax_L

Figure 16. DVH For PTV Volumes

 CTVnSCL_L
CTV_CW_L

CTV_CW_L

CTVn_AX_L

Figure 17. DVH For CTV Volumes.

• Outcome and Isodose Line Coverage

Overall, I am satisfied with the coverage of the plan. However, I am aware that it
may not be able to be treated clinically. The plan has adequate coverage, but it is very hot
with areas receiving 110% of the prescribed dose. Physician's standards can vary
depending on what they deem to be treatable or not. Since everything but the right breast
constraint was met on the score card, some physicians may deem this plan treatable, and
others may not. The figures below show isodose line coverage of all PTV volumes.
Figure 18. shows the isodose distribution at the level of between the axillary lymph node
PTV volume and the supraclavicular lymph node volume. The axillary lymph nodes are
in blue and the supraclavicular PTV volume is in red. Figure 19 shows the inframammary
nodes in orange as well on the axial slices. The plan overall is very homogenous, and the
dose is evenly distributed. Additionally, the chest wall evaluation PTV structure is shown
in teal blue. Figure 20 shows the isodose distribution at mid-depth of the chest wall PTV.
Figure 21 shows the isodose distribution at the inferior level of the chest wall volume.
Figures 22 and 23 provide the complete isodose distribution for many of the slices on the
axial views.
Figure 18. Isodose Distibution At Level of Axillary and Supraclavicular Lymph Node
PTV Volume
Figure 19. Isodose Distibution At Level of Inframammary Node PTV, Supraclavicular Lymph
Node PTV, and Chest Wall PTV.
Figure 20. Isodose Distibution At Level of Mid-Depth Chest Wall PTV.
Figure 21. Isodose Distibution At Level of Inferior Chest wall PTV.
Figure 22. Axial Slices Isodose Distibution.
Figure 23. Axial Slices Isodose Distibution Continued.
 References
1. Garg A, Kumar P. Dosimetric Comparison of the Heart and Left Anterior Descending
Artery in Patients With Left Breast Cancer Treated With Three-Dimensional Conformal
and Intensity-Modulated Radiotherapy. Cureus. 2022;14(1): e21108. Published 2022 Jan
11. doi:10.7759/cureus.21108
2. Zureick AH, Grzywacz VP, Almahariq MF, et al. Dose to the Left Anterior Descending
Artery Correlates With Cardiac Events After Irradiation for Breast Cancer. Int J Radiat
Oncol Biol Phys. 2022;114(1):130-139. doi:10.1016/j.ijrobp.2022.04.019
3. Piroth MD, Baumann R, Budach W, et al. Heart toxicity from breast cancer radiotherapy:
Current findings, assessment, and prevention. Kardiale Toxizität durch Strahlentherapie
bei Brustkrebs : Aktuelle Ergebnisse, Bewertung und Prävention. Strahlenther Onkol.
2019;195(1):1-12. doi:10.1007/s00066-018-1378-z