Plan Setup: When planning breast or chest wall cases, the first step I take in assessing

my plan of action is to look at all of the contours. Before being able to choose an isocenter or
beam arrangement you need to fully understand the way the PTVs coincide with the patient’s
organs at risk and other volumes. While scrolling through the dataset, I was able to notice why
this case would prove to be so difficult to plan. The Internal Mammary (IM) nodes are very deep
within the patient superiorly. The Axilla target volume was also more lateral than I expected
based on the NSABP protocol B-511. Once I had assessed the volumes, I added structures I
needed within contouring such as my couch insert. Because I knew the target volumes location
and the clinical metrics for the plan, I understood that placing isocenter was very important to the
success of my plan. Breast plans, especially total nodal cases, are complex top to bottom. When
you make a mistake early on, like a suboptimal isocenter location or poor weighting on tangent
fields for example, you will run into more issues down the line. I ended up planning this case
multiple times, figuring out what mistakes I made previously and how to improve them.

I knew that the superior portion of the IM nodal volume was deeper than the inferior IM
volume by over 2 cm. This meant that it would be difficult to plan this case covering all of these
nodes with a single energy electron field. Because the nodes are so posterior, it would be very
difficult to plan the patient with only photons as well and meet any sort of lung metrics. My
original idea was to use multiple different electron energies to treat the IM nodes alone. As I got
further along in the plan, I decided that in order to limit dose to the heart and central lung it
would be more advantageous to try a different option. So, I went back to the drawing board and
tried new isocenter placements for another approach.
I knew that I wanted to end up with a single isocenter location for all photon fields. That
meant I could include the chest wall (CW) eval PTV below isocenter and the supraclavicular and
portions of the axilla volumes superiorly. This technique requires a half beam block to limit
spilling dose from the abutting fields. To use a half beam block, a primary jaw (which one
depends on the collimator rotation) is brought to 0 on the fields. This technique provides a match
line for the superior and inferior sets of fields.
 As you can see from the images above, I did not use the tangent fields to treat the entire
CW eval volume. I elected to treat the flatter surface anteriorly with an electron field and have
that field encompass the inferior portion of the IM nodes PTV. That came from my failed
previous attempts to limit ipsilateral lung and contralateral breast dose. A lot of these more
difficult breast cases rely on trial and error. There is no way to tell what method will be optimal
until you try different beam arrangements and calculate preliminary dose.
These are all things that I think about and discuss when placing my isocenter. What
technique will I use to treat all the volumes, am I encompassing the entirety of the PTVs, etc. I
know that for a clinically treatable case at our hospital, we need a tabletop measurement of less
than 20cm. This is another aspect I keep in mind when selecting isocenter. My isocenter was
only 7.5cm from the couch. From working with dosimetrists here, I have noticed that for
clearance concerns we try to keep our x value less than 10cm (laterally) in order to limit any
issues with the patient’s body. My isocenter ended up being fairly deep within the patient’s lung,
not something I typically want. The reason behind this was that the superior IM nodes were
going to be included within the photon field. With an isocenter closer to the anterior region of the
patient’s body, I would have had to use a significantly flatter tangent field medially. This would
then limit my ability to match with an electron field and also increase dose to the contralateral
breast. Thus, I found an isocenter placement that allowed me to treat the superior IM nodes with
the tangent photon fields, and the angle was steep enough to get a decent medial region treated
with the electron field I wanted to use. Because of this, there was a large region of the ipsilateral
lung in the tangent field. Typically, I would want to use the primary jaws posteriorly to limit
dose to the lung. This case was very unique and required that I rely on MLCs to block the lung
and heart tissue that I wanted to. Below is an image of the isocenter placement and how it
appears in regard to the lung. It seems suboptimal, but due to the planning strategy I will soon
explain it worked well.

After placing my isocenter I had to create my field arrangements. I knew that I had to use
the half beam block technique as mentioned before and made sure that I had enough field length
below isocenter to cover the entire length of the tangent field. The length was 19.5 cm medially
and 17 cm laterally, both are under the 20 cm limit. Following the guidelines taught to me from
our primary breast dosimetrist Ruth Ann Good, I created the tangent fields. I gave the skin
surface at least 2cm flash for swelling, rotation, and patient movement. I brought the inferior
border to roughly .7 cm below the field as required for 3D plans. Superiorly, I included the top
portion of the CW eval PTV and a .5cm margin. Posteriorly, I blocked the heart, as much lung as
possible, and inferior IM nodes. This was because that portion of the PTV was going to be
included in the electron field. I used the axial view to see where my MLCs were falling in
respect to the slope of the patient’s chest wall. The lateral tangents follow basically the same set
up as the medial, except for the posterior MLCs. Below is a visual for the medial tangents set up
design.
 This is where I started to stray further away from the normal set up process. Typically,
for a breast tangent set up, the medial and lateral are parallel opposed fields. For my beam
arrangement I elected to change the lateral tangent angle slightly to match the slope of the lateral
chest wall. I did this because I wanted to be as parallel as I could within the region of the chest
wall that was only being treated by the photon fields. This angle subsequently also helped give
the posterior border of my superior IM nodes more margin on this field. The angles I ended up
selecting for my plan were; Med Tangent 325 degrees gantry and 0 collimator, Lat Tangent 140
degrees gantry and 0 collimator. The collimator was left at 0 degrees in order to use the half
beam block as the match line of the supraclavicular and posterior axillary boost fields meeting
the tangents. The energy I used for my tangent fields was 6 MV. I did not use mixed energies for
the tangents because of the patients thickness through the treatment fields in the arrangement I
decided to set up. The greatest separation was only roughly 17.5 cm for my tangent fields. The
SSD was 87.1 cm for the medial tangent and 92.9 cm for the lateral tangent. No fields utilized a
couch kick in order to keep my match line simple.
The next step I took in setting up my plan was trying to get the lateral MLCs to match the
medial fields 50% isodose line on the skin surface. I did this because I know that the electron
field would match with the medial field at the skin surface. Thus, because I know the light field
corresponds with the 50% isodose line, and in order to have limited hot spots at the electron
photon junction, I created a structure of the 50% isodose line from the medial tangent dose cloud.
I knew that this was where the lateral tangents MLCs should match. That made sure that the
photons dose from both tangents meets the electron field at the same place of the skin surface. I
know that you can also match the electron field border by using the field entrance shape on skin
surfaces but using the 50% isodose line method ended up working out nicely. Below are images
to help further my explanation of this method for my lateral tangent MLC placement. I had to
pull the leaves as I watched the axial view below.

Beginning of the MLCs blocking the IM nodes and medial CW for electron field
matching
 Once I created the tangent fields and was happy with the way my MLCs were
positioned on the primary fields, I began to plan the tangents. From my initial impression of this
case, and knowledge prior, I decided to include a .3cm bolus for my tangent fields. I decided on
.3 cm by following our clinical guidelines here at VCU Health (since the PTV was pulled away
from the surface I knew there was not skin involvement). With the bolus placed and fields
designed I began to calculate my plan. I originally had the fields weighted 50:50 since I was only
using 6 MV beams. I ended up needing slightly more posterior weighting for my initial fields.
From there on, I planned the tangents with a field in field technique. Working my way until I was
satisfied with the coverage I had achieved. It was difficult to know if the coverage was ideal
since a large portion of the CW and IM PTVs were going to be included in the electron plan. A
large portion of my Axillary PTV was included within the tangent fields since I chose steep
tangent angles. The superior portion received dose from the supraclavicular and PAB fields.
The next step I took was to create my supraclav and PAB fields. Following the half
beam block in the images at the beginning of this write up, I used the same isocenter and
adjusted my jaws to fit the necessary volumes. Using the information and skills that I have
gathered from past experiences I knew that picking the correct angles for my fields here are
crucial in order to avoid certain OARs such as the spinal cord, trachea, and esophagus. I like to
choose a supraclavicular field that is 10 to 15 degrees off of AP. I ended up using 350 degrees
and a 0-degree collimator rotation for my RAO field. To select the PAB gantry angle, I used the
divergence of the RAO and tried to find an angle that did not enter into the esophagus or trachea.
The PAB field ended up being at 175 degrees and I did utilize a collimator angle of 90 degrees.
Using a full 90-degree rotation allowed me to continue to use the half beam block, just a
different jaw was closed to isocenter. The purpose of the collimator rotation was to be able to
cover any potential hotspots that occur centrally within the superior fields without blocking
major portions of the PTVs. I read from our assignment material that often the match line for
photons at a half beam block can be cold. In order to combat this, I pulled the MLCs beyond the
lower primary jaw to allow for some additional scatter radiation. There are images below
showing my PAB and supraclav fields.
 The final field that I needed to set up was my inferior IM nodes and medial CW electron
field. I measured the depth of the PTVs and based on the average depth of 2.5cm I decided to
utilize 9 MeV. I did end up linking my .3cm bolus to this field as well. This helped me reach
desired coverage and reach less depth of the lung. Setting up the electron field I had to assess
again the MLCs for my tangent fields. I have learned that electron fields tend to bow out,
especially at depth where there are lower isodose lines. Unlike the photon match line, this would
prove to be hot in some areas once I started planning. In order to create my electron field, I
followed Ruth Ann’s presentation linked within this assignment. In her electron IM field
matching document, there are suggested angles to use. I used my medial tangent angle of 325
and went steeper to 335 degrees. This helps for limiting hot spot spillage into the photon field
match line area. For clearance, the SSD is set to 105 cm. My electron isocenter is not the same as
the photon fields. I placed isocenter towards the middle of the untreated CW volume. I drew the
block freehanded. My cone size was 15 cm to encompass the entire volume needed superior to
inferiorly. Following the document, I used a 2mm overlap of the field onto the medial tangent at
the skin surface. It was roughly where the 50% isodose structure I created was. Around the
inferior and posterior margins, I left around .75cm and superiorly I used a .5cm margin from the
tangent fields.
Plan Evaluation: Once all my fields were set up, I calculated dose to the photon fields. As I
mentioned, I used field in field techniques to push dose medially on the tangents. The dose for
my supraclavicular and PAB fields was added after the fact. To do this, I added field weight to
the plan. Originally, the superior fields had a locked field weighting of 0. When the tangents
were completed, I normalized the tangents to the 93% line. We use Body Maximum as our
normalization mode here at VCU Health. Because we do this, we have to do some calculations in
order to add weighting to the other locked fields. We have a guide for this method, and this is as
it follows. Keeping 0 weighting on the Supraclav and PAB fields, make sure the tangents equal
1. I saved an image of the weighting and MUs so that we have them saved. In the dose tab, I
wrote down my plan normalization value in percent. The next step is to change the normalization
mode to Plan Normalization value and set it at the percent (mine was 90.2). Going to the fields
page, I did a calculation to see what field weighting to give the LPO and RAO. The weighting
begins with 55% for the LAO and 45% for the RPO. Thus, we multiply .55 by the normalization
value recorded. This plan ended up having large hot spots with the recommended weighting, so I
scaled back the weighting until the hot spots were limited in the fields. Assessing these fields is
interesting because you do not want to have much prescription dose, if possible, in the posterior
portion of the patient since there is no PTV there. The next step is to change plan to absolute
dose and cool the plan off with field in fields. I only used the LPO as that was the field that I
turned the collimator to 90 degrees so I could block hot spots without covering much PTV.
Images below show the field weightings for my photon fields.
 Once I was finished with the photon fields, I began to work on the electron field. I
created a plan sum at this point. The purpose of the plan sum was to show the total dose to the
patient while being able to manipulate the electron field or tangent control points to optimize the
coverage. Within the plan sum I decided to manipulate the electron normalization. This is
another benefit of the plan sum; I can adjust the isodose prescription line through normalization
of the electron field without causing issues to the photon fields. I ended up using the 85%
isodose line as my treatment percentage (normalizing to body max). This provided the most
coverage without spilling too far into the patient’s lung. I am glad that I included the bolus to
reduce that dose further. There are some areas that ended up cold in my plan. From the electron
field there were a few areas that ended up hot and I tried to fix that that by adjusting my electron
block at first. It fixed the majority of the issues, but when I was adjusting the block, I noticed that
the prescription line was starting to get colder in certain regions of the IM/CW PTV. I know that
the way I set up the electron field was to help minimize the spillage at depth into the photon
field, but it cannot be avoided completely. Instead, I minimized the hot regions and tried to
compromise by limiting where the prescription dose would be cold at the junction. There are also
areas of prescription cold at the deeper portion of the tangent fields. This comes from our MLC
margin on the heart and lung to limit dose to those structures. I decided to not compromise on
heart dose in order to protect the patient. Something instilled in me was that a lot of breast
patient are younger. Their chances of living through a secondary complication can be higher than
that of an older patient. Images below show the regions of interest mentioned here.
 The maximum dose for my plan was located within the electron field. This was destined
to happen due to my planning technique. Because I had to normalize down for the electron field,
there are areas of increased hot spots in this field. Below is my max hot spot of 6021.5 cGy
shown below. The .03 max was 6000cGy. I think that this is a reasonable location for the hotspot
because it is not in any folds of skin, it is away from any OAR, and it is near bone. Overall, that
is a safe location for the hotspot. There were several metrics that were difficult for me to meet
the ideal constraint on. The PTV coverages were very high and in order to meet those metrics
would have meant sacrificing my OAR in many situations. I chose to create a plan that I believe
is treatable. This meant trying to meet acceptable PTV coverages and keep other healthy
structures as low as possible. I tried to fix certain metrics along the way such as the lung
V1000cGy and the heart V3000cGy. I wanted to create a plan that could be clinically used and
selected by our physicians. The physicians at my clinical site tend to be conservative with PTV
coverage if it means better OAR dose totals. This influences my thought process on planning.
Below are images of my hotspot and location as well as my overall plan coverage. I also
included my DVH with labeling to show the plan dose distribution.
 From my DVH, you can gather some information regarding my plan’s effectiveness. The
left lung still received considerable dose, but that is to be expected. My PTV coverage tails with
the IMN/CW volumes because of the electron inclusion. Our write up expectations mention the
Left Anterior Descending Artery (LAD). This is a topic I am studying in lung patients for my
research project. I saw that it was contoured and tried to keep the LAD contour below the clinical
goals I have studied are. I was able to spare the LAD considerably, as well as the heart. This was
something that I tried to not compromise on during planning. According to my research, there
are no left sided breast LAD constraint goals published. The clinical goals according to my lung
research state that LAD doses should be V15Gy < 10% of the structure.2 This is the metric I used
in my evaluation. My V15Gy covered .424% of the LAD. The complications that may occur
with LAD dose exposure exceeding this clinical metric are increased non-cancerous death from
coronary disease or coronary events.2 Below is a DVH showing my LAD dose.

ProKnow: After completing my plan and evaluating the coverage as well as hotspot/cold spots I
input my plan into ProKnow. The following is my plan score card that contains my metrics
achieved and score attained. It is visible within this goal sheet that my PTV coverage was
mostly acceptable, but not ideal. I was comfortable with this sacrifice to maintain the ideal scores
in more of my OAR, as would have been instructed of me if this was a live case at my site. I was
very proud of the heart constraints!
References:
1. Mamounas EP, White JR, Bandos H, et al. NSABP B-51/RTOG 1304: Randomized phase III
clinical trial evaluating the role of postmastectomy chest wall and regional nodal XRT
(CWRNRT) and post-lumpectomy RNRT in patients (pts) with documented positive axillary
(Ax) nodes before neoadjuvant chemotherapy (NC) who convert to pathologically negative Ax
nodes after NC. Journal of Clinical Oncology. 2014;32(15_suppl):TPS1141-TPS1141.
doi:https://doi.org/10.1200/jco.2014.32.15_suppl.tps1141
2. Atkins KM, Chaunzwa TL, Lamba N, et al. Association of Left Anterior Descending
Coronary Artery Radiation Dose with Major Adverse Cardiac Events and Mortality in Patients
with Non–Small Cell Lung Cancer. JAMA Oncol. 2021;7(2):206–219.
doi:10.1001/jamaoncol.2020.6332