ProKnow Left Chest Wall Discussion

This case was a left chest wall with supraclavicular, internal mammary, & axillary nodes
included in the treatment fields. We prescribed 50 Gy total, giving 200 cGy per fraction for 25
fractions to the chest wall and lymph nodes. I used a 3D technique, using four beam portals with
one isocenter in a half-beam block setup. This is considered standard practice for a four-field
breast at my clinic. The treatment portals included a medial tangential field, lateral tangential
field, supraclavicular (SCV) field, and a posterior axillary boost (PAB) field. I used mixed
energies of 6 MV for the tangential fields and 15 MV for the nodal fields. The gantry angles
were as follows: Left medial tangent - 310°, Left lateral tangent - 125°, SCV - 345°, and PAB -
165°. I did not use any collimation as I used the collimator jaws to create a half-beam block. I
also did not include any couch angles for this plan. I was able to match the supraclavicular and
posterior axillary fields to the tangent fields by using one isocenter and closing the jaws to create
a half-beam block setup. I have each field shown below with the isocenter marked in green
showing its location in relation to each field.

SCV Medial

ISO

PAB Lateral
 Below is a 3D rendering showing the field borders of the SCV & tangential fields on the
patient and how they match. To note is the medial field extends slightly over onto the right
breast, this was done to ensure adequate coverage of the internal mammary nodes.

The X1 and Y2 jaws were closed for the medial tangent, while the X2 and Y2 jaws were
closed for the lateral tangent. To match the supraclavicular and posterior axillary fields to the
tangent fields, I closed the Y1 jaw for these fields. I have attached screenshots showing the
couch angle, gantry angles, and collimation along with the specific field borders.
 I had to be aware of where I placed the isocenter as I included the internal mammary
nodes in the tangent fields because I felt this setup best allowed me to get adequate coverage.
Therefore, my axillary and supraclavicular fields targeted the supraclavicular and axillary nodes.
I specifically used 15 MV for these fields because the nodes were at varying levels which
allowed me to contribute dose deeper into the affected nodes. I also used slightly oblique angles
of 345° and 165° to avoid the esophagus and spinal cord. The axillary nodes for this patient
tracked down into the tangent fields, which helped with achieving adequate coverage to them
too. I was able to use 6 MV for the tangential fields due to the patient’s thinner chest wall and
the patient’s separation was 21 cm. I tried using 10 MV alone, then mixed energies of 6 & 15
MV and then 6 & 10 MV for the tangential fields to see if that gave me better coverage but after
trial-and-error, I decided that my coverage was best just using 6 MV only for the tangential
fields. I have attached screenshots showing how each nodal volume is covered by the treatment
fields along with the volumes in colorwash with the isodose lines to show the actual coverage of
each PTV. Please use the key delineating the color of each structure.

Color Structure
Yellow IMN
Dark Blue Axillary
Red SCV
Light Blue Chest wall

SCV PAB
Medial Lateral

SCV

SCV & AX
SCV, AX & CW

AX & CW

CW
 Below is the labeled DVH including the target volumes & surrounding critical structures.

At the level of the isocenter, where all the fields converge, I had a cold spot. Due to the
half-beam block setup, this junction level is cooler since there is no divergence at the central
axis. This spot only occurs at this level and shows that at least 70% of the dose is covering the
axillary & chest wall planning target volumes at this level so I think it is acceptable. I have
attached a screenshot showing the cold spot in the plan. The hot spot for this case was located
anteriorly in the chest wall tissue, which is an acceptable location since it was within the chest
wall planning target volume. I think the hot spot is in this location because I was trying to ensure
adequate IMN coverage, therefore leaving this area unblocked when adding the segments. I
would say this is not an ideal location because of the skin irritation that may occur on the patient
in that area after 25 fractions. I would have preferred to see the hot spot in the lateral tissue of the
patient, but knowing that my medial tangent was heavily weighted, I think this hot spot location
is acceptable. I have attached a screenshot showing the maximum dose point in the plan.
Cold Spot Hot Spot

The left anterior descending artery (LAD) is within the heart and irradiation of this
structure has been associated with increased risk of cardiac events in patients. In a study
conducted by Zureick et al1, it was determined that dose to the left anterior descending artery
correlated with adverse cardiac events and suggested minimizing dose to the LAD when patients
are receiving left-sided breast irradiation. The results of this study reported that the risks of any
cardiac event increased by 9% per 1 Gy of LAD mean dose.1 At my clinic, our breast physician
uses mean dose and volume constraints to limit dose to the left anterior descending artery. Her
constraints are mean dose less than 330 cGy and .03 cc of the volume to receive less than 5000
cGy. The dose to 0.03 cc of the LAD was 2903 cGy, which was within the constraint used by my
physician but I would not have met her mean dose constraint. The aforementioned study
considered LAD mean dose of 2.8 Gy & LAD max dose of 6.7 Gy as thresholds of when an
cardiac event could occur, suggesting these as clinical guidelines when assessing dose to the left
anterior descending artery.1 In this plan the mean dose to the LAD was 677 cGy and the
maximum dose was 3585 cGy. I would think this patient could experience an adverse cardiac
event after receiving radiation treatment with these doses. This could include myocardial
infarction, angina, heart failure, arrhythmia, cardiovascular death, and/or pericarditis.1 I used the
multileaf collimators to block the heart and lung on my tangential fields, which included the
LAD, but noticed it is still receiving a significant amount of dose. I could not avoid irradiating
the LAD entirely, but I think a change in my gantry angles could have helped alleviate some
dose to this structure. I would just need to be mindful of my IMN coverage when I make this
gantry angle adjustment.
The plan was normalized at 95% for both prescriptions. I used two prescriptions because
I had two calculation points, one for the tangential fields (which included the IMN nodes) and
another for the SCV & PAB fields. I was able to use only two calculation points as my tangents
and SCV & PAB fields were opposed. I normalized at this percentage to be able to best achieve
adequate coverage of each PTV without compromising coverage to my axillary and internal
mammary nodes. I also adjusted the weighting of the beams and used segments on my tangents
to provide better coverage and decrease hot spots. The specific prescriptions are listed below.
 After I was satisfied with my coverage and plan quality, I submitted to ProKnow to see
where I scored within the metrics. I was then able to fine tune my plan to achieve the most ideal,
which required me to adjust my segments and normalization. In particular, I had too much dose
extending over to the right breast, which I was able to decrease by adjusting my segments on my
tangent fields. I was excited to meet this goal without compromising coverage of the IMNs.
One metric that I wanted to meet but was not able to achieve ideal, was the V20 for the lung,
which was quite challenging. I was compromising chest wall and axillary coverage when I tried
to block more of the left lung and decided to settle with what I had as it was acceptable. I
decided to rather have PTV coverage with a little more lung dose, than lacking PTV coverage. I
also feel that I sacrificed points on meeting the metric for the esophagus (dose (Gy) covering
0.03 cc of the esophagus) due to the fact that it was very close to the supraclavicular nodes. I
tried to block the esophagus entirely, but was not able to do so as my axillary coverage was then
less than 70%. I even tried adjusting my gantry angle to see if that helped but it did not.
Therefore, I have more of the esophagus being irradiated than I would ideally like too.

My ProKnow scorecard is attached below.

 References

1. 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