Left Chest Wall Treatment Plan

Meshan C. Curry

Before beginning this treatment plan, my clinical preceptor had me find the RTOG 1304
Protocol study this treatment plan was designed on so I could clearly see all the criteria and
acceptable variations allowed in the study. Then after discussing the protocol, it was suggested
that I combine the four volumes into two treatment volumes. The four treatment volumes that
needed coverage were the chest wall planning tumor volume (PTV), axillary nodes PTV, internal
mammary nodes PTV, and the supraclavicular PTV. I merged the supraclavicular PTV and
axillary nodes PTV to make one supraclavicular volume by using the boolean union operation. I
also did the same with the chest wall PTV and the internal mammary nodes PTV since these can
be difficult to obtain adequate coverage on. I then took a few slices off the top and bottom
borders of each field. I also made my new volumes smaller by making sure that they were inside
the treatment wire borders placed on the patient’s skin, decreasing the volume of my new
planning tumor volume at the suggestion of my preceptor.
 After completing these tasks in contouring, I then went into external beam in eclipse and
made sure the gantry angles encompassed my new volumes and my PTV’s that came pre-
contoured on this test patient. I separated the supraclavicular fields into one plan and my tangent
fields in another plan. I used the multi-leaf collimators to block out the humeral head and
esophagus in the supraclavicular fields. I also did the same to the tangent fields to block out the
heart and LAD as much as possible while still maintaining coverage to my overall planning
tumor volume, which proved to be difficult to cover in the end. The gantry angles, fields, and
energy I used were a 10 MV RAO left supraclavicular field at 345 degrees with 70% weight
from this field and a 15 MV LPO left supraclavicular field at 165 degrees with 30% weight from
this field. After many experiments, I decided to use a mixed energy approach so the deeper
supraclavicular nodes could have adequate coverage. This was also done to decrease the dose to
the patient’s esophagus. Due to this a cold spot was found in the supraclavicular area, however
the esophagus dose was found to be in the acceptable range. On the left medial tangent 10 MV
energy was utilized with a gantry angle of 300 degrees, and a 49% weight from this field. The
left lateral tangent was also a 10 MV energy beam, but at 120 degrees with 51% weight from this
field. I also made sure that my SSD’s for my tangent fields were close in proximity. The
collimator and couch were at zero for all the fields. I then normalized to the Rad Calc point for
each field at 100%. I calculated my dose and began to add segments on each field and various
weights of no more than 3% block out my 110% hot spots. In total I had 4 segments on each
tangent field and 3 segments on each supraclavicular field.

After getting my hot spots down the best that I could for the supraclavicular fields and tangent
fields, I merged my subfields and then normalized to the prescription volumes that I created and
then changed my normalization value until I reached the desired dose coverage to my contoured
PTV volumes.

Target Coverage

Due to combining PTV volumes, the coverage to my nodal volumes were not hard to
meet. The most difficult part of my treatment plan was covering 95% of the planning tumor
volume. To meet this volume, I sacrificed not meeting the acceptable dose to the contralateral
breast and left anterior descending artery. 70% of my left anterior descending artery received
greater than 500 cGy. At this dose the patient could potentially experience a major cardiac event,
which is not ideal. With new treatment technology, the patient could be treated with a deep
inspiration breath hold technique or done IMRT to spare the left anterior descending artery and
right breast. My maximum dose location was also in the medial left tangent due to not being able
to spare the right breast and LAD. The final hotspot dose was 52.5 Gy. This location would not
be acceptable due to the implications for the right breast. Overall to meet my planning tumor
volume coverage, I decided to sacrifice the right breast even though this would not be an
acceptable plan to implement at my clinical site.