Hi everyone!

I used 6 beams for this plan, 2 were for the supraclavicular nodal region, and 4 were used with 0.5cm
bolus for the chestwall. I used a mixture of 18MeV and 6MeV to even out the dose in the deeper and
more superficial parts of the chestwall. I did not have to use wedges for this plan, but I did use field in
fields to cool the dose down. For the nodal fields I used gantry angles 350 and 170 (this is considered a
PAB). For the tangen�al fields I used 2 beams at gantry angle 305, and 2 beams at gantry angle 129. All of
the collimator angles were set to 0 in order to have the MLCs come in horizontally and allow me to spare
more lung �ssue. I also kept the couch rota�on at 0, since this is the standard for le� sided
breast/chestwall at UC Health. The ra�onale behind using couch angle 0 for these treatments is that we
always do DIBH for le� sided breasts or chestwalls, and some of our satellites use the RPM ga�ng box.
The ga�ng box has a difficult �me accurately seeing the movement of the box when the couch is kicked.
Although the structure set did not directly say that the pa�ent was being treated DIBH, I assumed this
would be the case if I was planning this pa�ent here at UC Health.

Matching the supraclavicular field to the tangent field is very important because it is what will set the
planner up to have adequate coverage for both the chestwall and the nodes. When star�ng a chestwall
plus nodal plan, I will locate where the clavicular heads ar�culate with the sternum. Of course, this is just
a star�ng point and can be moved a�er it is placed if needed. It’s also important to place isocenter at a
height that will ensure that the gantry will not collide with the treatment table. At UC Health, we have a
standard that we will always put the isocenter less than or equal to 28cm from the tabletop, this ensure
clearance for the therapists.
Choosing energies is also very important. For the axillary nodes, I used a higher energy to reach
coverage. This is because the axillary nodes are deep, so if the planner used a lower energy beam, the
dmax would not be deep enough in the pa�ent. I used a mix of 6MeV and 18MeV to meet this coverage
constraint. I included the axillary nodes in the tangen�al fields of the chestwall fields, and the wedged
pair of the nodal fields. To reach coverage constraints for the internal mammary nodes, I included them
in the tangen�al fields for the chestwall and made sure that I did not cover them when using field-in-
fields. I had to adjust the weigh�ng to be further weighted towards the anterior beam since the anterior
part of the IMNs was what was ge�ng cold and having a hard �me mee�ng coverage.

The cold spots were mainly located near the ribs in this plan, which is acceptable because we do not
need excessive dose to the ribs. This can be shown by the blue areas around the perimeter of the
volumes.
The maximum dose to the le� anterior descending artery was 95.2% or 4759cGy. This is close to
prescrip�on dose, and ideally, we would want it to be lower. However, since the LAD is so close to the
chest wall volume, the only way to spare it was to individually pull MLCs to cover the LAD. This is a great
way to decrease dose to the LAD, however we would be sacrificing coverage to the chest wall, since we
would also be covering part of the volume with the MLC that is covering the LAD. Possible long term
effects of irradia�ng the LAD is deteriora�on of the artery and arterial disease. At UC Health, the
constraint we use for LAD is ALARA, we aim to keep the dose as low as reasonably achievable, but it is
accepted by our physics staff that we are to keep the pa�ent’s total dose to the LAD over their life�me
under 15Gy.

I did not normalize this plan, because the plan was already a bit hoter than I would have liked it to be,
but the coverage was acceptable. If the coverage was suffering or the max dose was lower, I could have
normalized to get beter coverage to the target.

The biggest metric that I did not meet in order to make my plan beter, was avoiding the right breast. At
UC Health, our rule of thumb is that we need to completely avoid all entry dose to the opposite breast.
However, since this chestwall PTV was so close to the pa�ent’s skin surface, it was impossible to get
reasonable coverage without having minimal dose to the opposite breast. If I did not do this, the beam
would have not been steep enough to reach the IMNs and the medial por�on of the chestwall PTV.

Thank you!
Margaret, UC Health – Denver, CO