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Joseph Spencer
Clinical Internship II
ProKnow Left Chest Wall Plan Write Up

For this assignment, I downloaded the ProKnow left chest wall data set and the first thing
I did was look at the treatment volumes. This gave me an idea of the fields I was going to use
and if I needed to use one or two isocenters (ISO). I could see that the location of the internal
mammary nodes (IMN) was going to make this planning assignment difficult, but I wanted to
keep things very simple to see if I could create a good plan to build from. I decided that I would
start by using two tangent fields and two AP/PA supraclavicular fields. The length of the
treatment area allowed me to attempt a monoisocentric technique. I placed the user origin based
on the BB placement during the simulation scan. Next, I chose a location for the treatment ISO. I
wanted to place the ISO in a location that allows all fields to use the same isocenter and enables
a half-beam block technique for matching the tangent fields with the supraclavicular fields. This
makes it easier to field match because it blocks out half the beam at the central ray where there is
no beam divergence which makes for better field matching. I wanted to place the treatment ISO
near the ribcage but in tissue while avoiding the left lung and rib bones. For the depth, I wanted
to shoot for an SSD in the range of 95-97 cm while avoiding being too close to the left lung and
anterior skin line. For this case I settled at 95.5 cm SSD. I used the level of the left clavicular
head and the superior border of the chest wall PTV to decide where to place the ISO in the
superior and inferior direction. Figure 1 shows the location I chose for my ISO placement.
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Figure 1. ISO placement in axial, coronal, and sagittal views with reference to treatment
volumes (PTVs).

Now that I had an ISO placed, I created a plan for the tangent fields. Starting with the
medial tangent, I angled the gantry to 305° and opened the field size to include the IMN and
chest wall PTV. Normally, I wouldn’t want my tangent fields to cross midline but, in this case, I
had to include the IMNs which then includes some of the contralateral right breast tissue. In a
tangent only plan I would angle the collimator to match the angle of the chest wall so that I could
use the jaws to block the lung and heart. I left the collimator at 0° in this case because I needed to
match the tangent fields with the supraclavicular fields. I also closed the superior jaw through the
isocenter to establish the half-beam block technique. To finish creating my field edges, I opened
the inferior edge to include my chest wall PTV and the lateral edge to create 3 cm of flash. With
the field edges established, I added multileaf collimators (MLC) and followed the medial side of
my PTVs while blocking as much lung and heart as possible. Originally, I blocked out the entire
heart like I would do in clinic but instead, I had to open the MLCs to get better PTV coverage.
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Once my medial tangent field was created, I opposed it to create the lateral tangent field with the
same parameters. To match the medial edge of both fields and to account for beam divergence, I
had to angle the lateral tangent field to 128°. The technique of matching diverging fields is like
that of the half-beam block technique if you want to create a straight isodose distribution. In this
case, matching tangent breast fields helps to spare more healthy tissue from unnecessary dose.
Figure 2 shows how I matched the tangent fields, and the beam borders I established.

Figure 2. The tangent fields for my left chest wall plan assignment including MLC blocking.
Figure (A) demonstrates an axial view of the matched medial edge of the tangent fields and
Figure (B) displays a beams-eye view of the medial tangent field I created.

Once my fields were created, I copied the plan and calculated dose with 6 MeV and 10
MeV beam energies. From my perspective, there wasn’t much difference between the two
energies, so I chose to use 6 MeV to maintain better superficial dose. I adjusted the beam
weighting very slightly to get more uniformity in the isodose lines. I also created an identical
plan with 1 cm of bolus which didn’t make any significant changes. I chose not to pursue the
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bolus plan because this added unnecessary and potential complexity to a plan with matched
supraclavicular fields.
At this point, I wasn’t getting the target coverages that I was after, but I knew that I’d be
adjusting once I combined all the fields, so I started to create the supraclavicular plan and
associated fields. I started with the AP field. I angled the gantry to 350° to avoid delivering dose
to the spinal cord, trachea, and esophagus. I matched the half-beam blocking with the tangent
fields for the inferior border at the isocenter. I then used the supraclavicular and axillary PTVs to
create my jaw borders making sure that all targets would get coverage. Using the MLCs, I
sculpted around the targets, attempting to give them a 0.8 cm margin from the MLCs and made
sure to block the humeral head. Through trial and error, I figured out that I had to create a tight
border to better block the esophagus because it was receiving too much dose. Once the AP
supraclavicular field was defined, I opposed it and created a PA field with the same borders. This
field is also known as a posterior axillary boost field (PAB) which is how I was able to get
needed dose the axillary nodes. Just like with the tangent fields, I matched the AP and PA
supraclavicular fields along the medial side, and this can be seen in Figure 3. Once again, I
created two supraclavicular plans using 6 MeV and 10 MeV. This time, I did see a difference in
the dose distribution and chose to use 10 MeV. I also adjusted the plan to use more weighting in
the AP field.
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Figure 3. The supraclavicular fields for my left chest wall plan assignment including MLC
blocking. Figure (A) demonstrates an axial view of the matched medial edge of the AP and PA
fields, and Figure (B) displays a beams-eye view of the AP supraclavicular field.

Now that I had both plans built, I normalized each plan individually (using the Plan
Normalization Value function in Eclipse) to get 100% prescription coverage to the respective
PTV targets on both plans. Normalizing the plans made extreme hotspots of around 115-120%
but I knew that as I worked with field-and-field techniques, the max hotspots would come down.
At this point, I created a plan sum to give me an idea of what I was working with. The plan sum
showed low dose where the two plans abutted at ISO. To increase the dose between these
abutting fields, I pulled back a couple of MLCs on all fields along the abutting border over the
jaw blocking. This increased the dose slightly but not enough to make a nice even dose
distribution. I then moved the jaw for both plans to overlap slightly. This had greater effect to
warm-up the abutting fields and made it too hot. I went back and forth making small adjustments
until I got the dose where I wanted it. I ended up moving the superior tangent field jaw (Y2) 0.1
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cm to create the overlap I needed, and I left the supraclavicular jaw at ISO. Both plans still
retained the pulled back MLCs.

Figure 4. A zoomed in view of the abutting fields to show placement of the MLCs and
collimator jaw. (A) The medial tangent field with 0.1 cm jaw overlap and (B) the AP
supraclavicular field with no jaw overlap.

Figure 5. Chest wall plan with an arrow showing the location of abutting tangent fields with the
supraclavicular fields. Figure A showing original plan with cool spot at the field junction. Figure
B showing my final plan with better homogenous dose distribution at the field junction due to the
0.1 cm field overlap.

Now that I have made my fields, I used the ProKnow “Plan Study Instructions” to create
a ClearCheck tool using the ProKnow constraints in the “Good” category. Having established
constraints allowed me to adjust the plan while getting quick feedback of the effect of those
adjustments. Figure 6 below is a snapshot of my final plan represented on the ClearCheck I
made.
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Figure 6. Snapshot of the ClearCheck for my final plan using constraints obtained from the
ProKnow activity.

My next step was to start applying a field-in-field technique. First, I used the medial
tangent field to create a new subfield to block out the max dose areas with some of the MLCs.
Then I weighted that new field until the max dose disappeared. I then did the same with the
lateral tangent but instead lowered the visual max dose by 3-4%, blocked and weighted it like I
did with the first subfield. I continued this pattern, alternating fields until I got the max dose to
below 110%. I applied this same technique to the supraclavicular plan. In total, the tangent plan
had five subfields and the supraclavicular plan only needed two to get the max dose down below
110%. Figure 7 shows all my field and subfield parameters including energy, weighting, gantry,
couch, and collimator angles.

Figure 7. Final chest wall plan parameters including energy, weighting, gantry, couch, and
collimator angles. The tangent plan is above and the supraclavicular plan is below.
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Once all my subfields were done, I created a new Plan Sum of the new field-in-field
plans and using the ClearCheck constraint document, I fine-tuned the MLCs in the Plan Sum
until I met my constraint goals (see Figure 6). I noticed that moving the MLCs at this stage
pushed the hotspot around considerably. In the end, my final plan had a max dose of 111% but I
was able to keep most of it within the PTVs, so I was happy with it. Below you will find images
of the isodose coverage for my final plan and a dose volume histogram (DVH).

Figure 8. Axial, coronal, and sagittal views of the supraclavicular field dose distribution of my
chest wall plan.
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Figure 9. Axial, coronal, and sagittal views of the target dose distribution of my chest wall plan.
The axial image shows the dose at the level of field matching at the half-beam block.
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Figure 10. Axial, coronal, and sagittal views of the tangent field dose distribution of my chest
wall plan.

Figure 11. DVH for my chest wall plan including PTVs and OAR.
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I couldn’t meet one of my goals for the left lung constraints without sacrificing coverage
to the PTV volumes. It was still acceptable, but this would normally be a discussion with the
physician. I chose to maintain target coverage for the best ProKnow score possible. A more
compelling argument against my plan would be made with the dose going to the left anterior
descending artery (LAD). According to Danish Breast Cancer Group (DBCG) HYPO Trial1, the
dose to the LAD should be D0.1cc ≤ 20 Gy where my plan is delivering 48 Gy. I was not able to
spare the LAD, but I could decrease dose to it by sacrificing PTV coverage and blocking it out of
the treatment field. Other techniques for lowering LAD dose would include treating with
intensity-modulated radiotherapy (IMRT), respiratory gated radiotherapy, breath holding
techniques, and prone patient positioning.2 Poitevin-Chacón et al2 suggests that improvements in
LAD contouring and using smaller 2.5 mm CT cuts can also improve efforts for lowering dose to
the LAD. I found another study that encourages placing the edge of the tangents to at least 2.5
mm from the closet point of the contoured LAD to assure lowering the max dose to the LAD.3
Long term effects to the LAD include radiation induced heart disease, myocardial fibrosis, and
coronary artery disease.2
Considering the difficulty of covering all targets, I was happy with the plan I designed for
this project. See Figure 12 for my ProKnow score card. I was able to keep it simple and straight
forward which would hopefully minimize complications on the treatment floor. However, the
dose to the LAD would need to be addressed if this plan were to treat an actual patient.
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Figure 12. ProKnow score card for my chest wall plan.

References:

1. Thomsen MS, Berg M, Zimmermann S, et al. Dose constraints for whole breast radiation
therapy based on the quality assessment of treatment plans in the randomised Danish
breast cancer group (DBCG) HYPO trial. Clin Transl Radiat Oncol. 2021;28:118-123.
Published 2021 Apr 6. doi:10.1016/j.ctro.2021.03.009

2. Poitevin-Chacón A, Chávez-Nogueda J, Prudencio RR, et al. Dosimetry of the left

anterior descending coronary artery in left breast cancer patients treated with
postoperative external radiotherapy. Rep Pract Oncol Radiother. 2018;23(2):91-96.
doi:10.1016/j.rpor.2018.01.003

3. Cooper BT, Li X, Shin SM, et al. Preplanning prediction of the left anterior descending
artery maximum dose based on patient, dosimetric, and treatment planning
parameters. Adv Radiat Oncol. 2016;1(4):373-381. Published 2016 Aug 9.
doi:10.1016/j.adro.2016.08.001