ProKnow Left Chest Wall Plan

Katie Williams
Upon opening the patient, I noted that there were four planning target volume (PTV) structures:
supraclavicular PTV, axillary PTV, an internal mammary nodes (IMN) PTV, and a large chest wall PTV. The
plan was prescribed 50Gy in 25 fractions. I was able to utilize a monoisocentric technique for this plan and use
one isocenter. Before adding in any beams, I created a PTV_Total volume which combined all four PTV
structures into one structure, so I was able to plan to the PTV_Total volume. Next, isocenter was determined by
assessing the Beam’s Eye View (BEV) in the treatment planning system. The most superior margin of the field
would be the supraclavicular PTV and the chest wall PTV would be the most inferior margin of the field. The
axillary PTV and chest wall PTV extend the farthest laterally, while the supraclavicular PTV and chest wall
PTV extend the farthest medially. In the image below, the supraclavicular PTV is the peach color superiorly, the
axillary PTV is the blue structure laterally, the IMN PTV is the green structure medially, and the chest wall
PTV is the red structure inferiorly.

Figure 1 Demonstrates each Individual PTV that Helped to Establish Isocenter and Properly Match Fields.

Isocenter was setup to split the total field into two smaller regions: the superior nodal region and the
inferior chest wall region. Within the treatment planning system, the Z-coordinate was set about 0.5 centimeter
(cm) below the supraclavicular PTV, the X-coordinate was set by finding the most central location between the
supraclavicular PTV and the axillary PTV structures, and the Y-coordinate was set by utilizing the axial plane
and placing isocenter close to the chest wall. At the James Cancer Center with The Ohio State Wexner Medical
Center, the goal is to keep the X-coordinate shift below 7 cm due to clearance. The dosimetrists in the department
have found if the X-coordinate shift is above 7 cm, the patient’s opposing elbow will not clear during treatment
when the elbows are raised and placed in immobilization. Isocenter is seen in the image above as the red circular
dot on Y1. By utilizing the monoisocentric technique, this ensured proper field matching. For the nodal superior
region, I was able to set Y1 to zero and bring the jaw in to half beam block the inferior chest wall region using
the monoisocentric technique. In contrast, the inferior chest wall fields were set with Y2 to be zero to complete
the half beam block to create two separate plans with one isocenter. In the image below, fields 1, 1A, 2, and 3
were part of the superior nodal region, and fields 4 and 5 were part of the inferior chest wall region.

Figure 2 A Visualization of Shifts and Adjustments to Use a Monoisocentric Technique for the Plan.

Upon assessing the volumes, the chest wall PTV was located extremely close to the patient’s external.
The chest wall PTV was cropped back by the physician 0.3 cm from the patient’s external. In attempt to ensure
coverage superficially, a 0.5cm of bolus was added to every field on the patient’s body. At the James, the bolus
is used routinely on chest wall plans and shaped to the patient's prior scar. The physician marks the scar during
the Computed Tomography (CT) simulation with wire and then contours a 2cm margin around the scar. In the
image below, the chest wall PTV is the red color, the scar with a 2cm margin in all directions is the peach color,
and the bolus added in the treatment planning system is the blue structure.

Figure 3 Demonstrates the Bolus Placed Near the Chest Wall PTV. The 2cm Margin Around the Scar Assisted in Bolus Placement. Bolus on Chest Wall
Plans are used Routinely at the James Cancer Center.

I began setup of the superior nodal field first. Before I started adding beams, I created a Nodal
Optimization (Nodal_Opti) structure. I combined all the PTV structures that were above isocenter
(supraclavicular, IMN, and axillary) into one structure so I could optimize the shape of my Multileaf Collimator's
(MLC’s). I wanted to approach the nodal volumes utilizing two opposed beams in the anterior and posterior
planes. By doing so, I would be able to spare Organs at Risk (OAR) on the patient’s right side because the PTV’s
were all located on the patient’s left side. The OAR structures that I tried to spare were the esophagus and the
spinal cord. I was able to look in the BEV and select an angle of 350 degrees in order to spare the spinal cord and
esophagus and much as possible. Then, I set my MLC’s to be within a 0.3cm margin of the medial border of the
Nodal_Opti structure. A 0.5cm margin was given in all other directions, but a smaller margin was used medially
in an attempt to spare the esophagus and spinal cord as much as possible. Below in the image, the esophagus is
light purple color and the spinal cord is the hot pink color.
 Figure 4 Demonstrates the Superior Nodal Region and how MLC’s were fit to the Structure to Spare the Esophagus and Spinal Cord.

Next, I opposed the 350-degree beam to create a 178-degree beam and divergence was matched. The
MLC’s were shaped to match the anterior field. The weighting was adjusted until there were no areas of high
dose or hot spots that fell posteriorly because the PTV structures were all anterior. A 130-degree arc was added
with a 0.3cm margin in all directions to assist with conformality. The arc was weighted just enough to pull the
high isodose lines anterior, by taking some of the weight from the posterior 178-degree beam. In the image
below, the peach color supraclavicular PTV and blue axillary PTV are encompassed by the yellow 100%
isodose line, the green 95% isodose line, the dark blue 90% isodose line, and the light blue 80% isodose line.

Figure 5 Demonstrates the Isodose Line Color Representation and the Superior Nodal Region with Isodose Line Distribution after Weighting
Adjustments.
 The energies I chose for the superior nodal field were 10X for the 350-degree anterior field, 10X for the
130-degree anterior arc, and 15X for the posterior 178-degree field. I chose 10X for the anterior field and
anterior arc because I wanted to make sure there was enough energy to penetrate deep enough to reach the
supraclavicular PTV. The 10X beam also helped with coverage of the axillary node that extended fairly deep
towards the lung and patient’s axilla. The posterior beam was set to 15X because it had a lot of lung and soft
tissue to traverse through before reaching the PTV structures. By utilizing the higher energies with the anterior
and posterior beams, it helped cover the axillary nodes. However, my coverage of the axillary nodes increased
even more when I added the 10X anterior arc.

Figure 6 Demonstrates the Isodose Line Color Representation and the Superior Nodal Region with Isodose Line Distribution after Weighting
Adjustments with High Energy fields.

Once I was satisfied with coverage of the superior nodal region, I moved down to the inferior chest wall
region. The BEV was once again utilized to spare as many OAR structures as possible. The OAR structures I
tried to spare included the heart, the left lung and the contralateral (right) breast. At the James Cancer Center,
our strictest restriction is on the heart, followed by the contralateral breast. For this inferior chest wall field, the
PTV structures did not extend too far into the chest cavity, so my plan was to utilize tangent fields to cover the
PTV structures and avoid OAR structures. Looking at the BEV, I turned on the OAR contours and the PTV
contours. I chose an angle of 292 degrees coming in from the medial side. I felt this angle helped best to spare
the heart and left lung, however it did enter through quite a bit of the contralateral breast. As mentioned earlier,
at the James Cancer Center, we prioritize the heart above the contralateral breast and typically the physicians do
not extend the PTV past midline in most cases. Although with this 292-degree angle I enter though part of the
contralateral breast, I was able to spare more of the heart. Below is an image of the BEV for the 292-degree
field. The chest wall PTV structure is the red color, the IMN PTV is the green color, the axillary PTV is the
light blue color, the left lung is the dark blue color, the heart is the light pink color, and the contralateral breast
is the white color.
 Figure 7 Demonstrates the MLC placement for the Inferior Chest Wall Region to Spare the OAR Structures.

Two centimeters of flash was added in the X2 direction to account for any changes in set up or changes
to the tumor volume throughout treatment. Very tight margins were used (0.1cm) medially to try to spare the
OAR structures along X1. In addition, MLC’s along the X1 axis that were around the heart utilized a 0cm
margin against the PTV. An opposing tangent beam was added to the plan and I matched beam divergence once
again to produce a 117 degree beam. Similar MLC margins were used again. As mentioned earlier, it is protocol
at the James Cancer Center to spare the heart and left lung, even if it means exiting through the contralateral
breast. I chose 10X beams for both fields. Although the chest wall PTV structure was superficial by the
patient’s external, the bolus helped me to successfully utilize 10X and maintain coverage of the PTV while
simultaneously cooling the overall hot spot down.
 Figure 8 Demonstrates the Axial Plane View of the Isodose Distribution to the Chest Wall PTV.

Figure 9 Demonstrates the Sagittal Plane View of the Isodose Distribution to the Chest Wall PTV.
 Figure 10 Demonstrates the Coronal Plane View of the Isodose Distribution to the Chest Wall PTV.

In the above images, the red PTV volume is covered well by the yellow 100% isodose line, the green
95% isodose line, and the blue 90% isodose line. By utilizing tangent beams, I was able to minize dose to the
heart and left lung. The bolus helped maintain coverage of the PTV towards the patient’s external surface.

Figure 11 Demonstrates the Isodose Line Color Representation and a Green Arrow Pointing at the IMN PTV. The Image Demonstrates Sufficient IMN
and Chest Wall PTV coverage in the Plan.

In the image above, the dark green arrow points to the green PTV structure that is the IMN PTV. It was
challenging to cover the IMN PTV structure while also sparing the heart because they are so close together. The
angle of the tangent had to be carefully chosen in the BEV to spare the heart as much as possible, while still
covering the IMN PTV structure. In this case, it unfortunately meant sacrificing the contralateral breast by
coming in with a shallower medial beam angle of 292 degrees. After the tangent beams were aligned properly, I
adjusted the weighting because the majority of the hot spots fell in the superior nodal region. I took weight from
the superior nodal beams and added weight to the inferior chest wall fields to help cool the plan down. Lastly, a
reduced field was added to the anterior 350-degree field in the superior nodal region to help cool off the overall
hot spot as well. I noted that I was overcovering the axillary PTV and most of the hot spots were still falling
around the isocenter where there was overlap with the superior nodal region and the inferior chest wall region.
The anterior 350-degree field was weighted the most, so I chose to use a reduced field on that beam. I weighted
this reduced field only 3% until the overall hot spot decreased to 117% which is acceptable for our department’s
palliative planning at the James Cancer Center (less than 120% hot). As I added weight to the reduced field, I
continuously watched the Dose-Volume Histogram (DVH) to ensure I was not losing too much coverage to the
PTV structures. Below is an image from the BEV of the 350-degree reduced field.

Figure 12 Demonstrates the Reduced Field Utilized to Decrease the Overall Hot Spot in the Plan. The Reduced Field was Placed on the 350-Degree
Field.

In order to properly treat the internal mammary nodes, I set my fields how I described above and
continuously watched coverage on the DVH. Finally, to try to give them as much coverage as possible, I pulled
out individual MLC’s around the IMN PTV shown in green above so the margin was not as tight around the
IMN PTV. At the James Cancer Center, acceptable coverage for the IMN PTV is 80% of the dose covering
80% of the volume because it is challenging to cover this volume without exposing the heart or other OAR
structures to high prescription dose. The green line on the DVH below is the IMN PTV structure demonstrating
that 80% of the IMN PTV is receiving 46.75Gy, which is above 80% of the prescribed dose (40Gy).
 Figure 13 Demonstrates the IMN PTV Coverage on the DVH.

The area that struggled to get full prescription dose was the medial part of the chest wall and the IMN
PTV volume. In the image below, the yellow isodose line represents the 100% isodose line, the green line
represents the 95% isodose line, and the dark blue line represents the 90% isodose line and the decrease in dose
continues until the last dark blue line which represents the 20% isodose line. The arrow is pointing to the green
IMN PTV structure.

Figure 14 Demonstrates the Isodose Line Color Representation and a Green Arrow Pointing at the IMN PTV. The Image Demonstrates Sufficient IMN
and Chest Wall PTV coverage in the Plan.

It is noted that the yellow 100% isodose line does not fully cover the red chest wall PTV structure or the
green IMN PTV structure. However, the green 95% isodose line is covering both structures and at the James
Cancer Center, our goal is to have 95% of the dose cover 95% of the target structure for breast and chest wall
studies. Therefore, this area of “cold spot” is acceptable because it is still covered by the 95% isodose line
indicating it is receiving 95% of the dose.
 The maximum dose location is in between the superior nodal region and the inferior chest wall region
where they overlap. This is to be expected as we essentially have two plans meeting and coming together in this
region.

Figure 15 Demonstrates a Coronal View of the Overall Hot Spot in the Plan.

Figure 16 Demonstrates an Oblique View of the Overall Hot Spot in the Plan.
 The superior nodal region and the inferior chest wall region both meet at isocenter. I set this plan up in a
monoisocentric fashion and, although I half beam blocked with Y1 in the nodal region and Y2 in the chest wall
region, there is still dose contamination and divergence from the two separate plans that cause hot spots to
develop in the areas of overlap. The hot spot is located within the supraclavicular PTV and the chest wall PTV
and is 117% which is acceptable at the James Cancer Center.
The dose to the left anterior descending artery (LAD) was fairly significant in my plan. The maximum
dose the LAD received was 54.65Gy and the mean dose was 18.91Gy. It was challenging to try to spare the
LAD because of how close it is located to the chest wall PTV. One method I could’ve done to reduce the dose
to the LAD would have been to make the medial tangent field shallower and try to just skim the chest wall PTV
structure. However, then I would have been entering through more of the contralateral breast and potentially
struggling for IMN PTV and chest wall PTV coverage. I also could have utilized a reduced field of the LAD,
but that may have reduced coverage to the PTV structures, which take priority because the LAD is not a serial
organ.

Figure 17 Demonstrates the Portion of the LAD that can be Spared in the Plan.
 Figure 18 Demonstrates the Portion of the LAD that cannot be Spared in the Plan.

According to Stowe et al,1 utilizing deep inspiration breath hold (DIBH) is a technique that can help
reduce the dose to the heart during treatment. Having patients hold their breath during radiation administration
helps separate the heart from the chest wall, thus reducing dose to the heart. The study found that using DIBH
techniques help reduce the mean heart and LAD doses by 20-70%.1 In addition, treating the patient prone, if
they are able to tolerate it, can also pull the heart away from the chest wall more than if the patient lays supine.
If the heart and the LAD cannot be spared, it can lead to radiation induced cardiovascular diseases and cardiac
mortality.1 A study completed by Atkins et al2 discovered that major adverse cardiac events are more likely to
occur when the LAD V15Gy is greater than or equal to 10%. However, the dose restrictions for the LAD are
mentioned to be under researched.2 According to the V15Gy is less than 10% restriction, my plan failed to meet
that restriction.

Figure 19 Demonstrates the LAD V15Gy on the DVH.

At the James Cancer Center, our breast and chest wall plans are normalized to 97% of the dose covers
95% of the target structure, which I set to the chest wall or the largest PTV structure. By doing so, I hope to
achieve the overall goal which is to have each at least 95% of each PTV structure receive 95% of the dose. As
mentioned earlier, the physicians are a little more lenient with the IMN PTV and require 80% of the dose to
cover 80% of that target structure due to the difficulty of coverage while sparing OAR structures around it.
Below on the DVH, the red line represents the chest wall PTV, the blue line represents the axillary PTV, and
the peach color represents the supraclavicular PTV and each structure meets the 95% of the dose covering 95%
of the volume goal.

Figure 20 Demonstrates the Coverage to the IMN PTV, Chest Wall PTV, Axillary PTV, and Supraclavicular PTV. The Goal at the James Cancer Center is
for 95% of each PTV to Receive 95% of the Prescription Dose. The Acceptable Coverage for the IMN PTV is 80% of the IMN PTV is covered by 80% of
the Prescription Dose.

The metric I sacrificed in my plan and ultimately was unable to meet was the contralateral breast
restriction. Due to how far past midline the chest wall PTV traversed, I had to enter through more of the
contralateral breast in order to spare the heart while still covering the chest wall PTV. At the James Cancer
Center, our protocol is to cover the PTV above all else, unless a serial organ is involved, followed closely by the
restriction that spares the heart. In order to meet those two goals at my facility, it meant sacrificing the
contralateral breast. In the image below, some of the higher isodose lines are demonstrated entering the
contralateral breast in order to spare the heart while also maintaining coverage to the chest wall PTV.
 Figure 21 the Isodose Line Color Representation and the Higher Level Isodose Lines Entering Through the Contralateral Breast.

Overall, this plan was able to meet many of the department standards at the James Cancer Center. I
attached the goals in our department that utilizes a software program that is used, called ClearCheck, that
analyzes the goals compared to our plan specifically. In our department, I would not have met the overall hot
spot to the heart or the dose to the contralateral breast.

Figure 22 Demonstrates the ClearCheck Model at the James Cancer Center with the Goals Attached to the Plan.

In the ProKnow model, all the metrics were able to be met with at minimum “Good” rating except the
contralateral breast. As mentioned previously, the contralateral breast was sacrificed in order to meet PTV
coverage and spare the heart.
 Figure 23 Demonstrates the ProKnow Results with the Goals Listed and Performance Evaluation for the Plan.

Finally, a copy of the final DVH is attached with each structure labeled. The most challenging structure
to properly cover was the IMN PTV and the metric I sacrificed was the contralateral breast. As I went through
the plan, I tried to balance how hot the overall plan was, with coverage to each PTV. By using the
monoisocentric technique, I was able to get more than sufficient coverage to the superior nodal region, so I
ended up taking weight for that region to give to the inferior chest wall region to help with coverage.

Figure 24 Demonstrates the Final DVH for the Plan.

 References

1. Stowe HB, Andruska ND, Reynoso F, Thomas M, Bergom C. Heart sparing radiotherapy techniques in
breast cancer: a focus on Deep inspiration breath hold. Breast Cance: Dov Med Press. 2022;Volume
14:175-186. doi:10.2147/bctt.s282799
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 Onc. 2021;7(2):206. doi:10.1001/jamaoncol.2020.6332