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Clinical Oncology Assignment

Rachelle Jacobs
In Partial Fulfillment of DOS 531
University of Wisconsin – La Crosse, Medical Dosimetry Program
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Introduction

This patient is a 60-year-old female who was diagnosed with invasive ductal carcinoma
(IDC) of the right breast after presenting with a 4 cm palpable mass. IDC is the most common
type of breast cancer, accounting for about 8 in 10 of invasive breast cancers.1 It originates in the
milk ducts and then spreads to the surrounding breast tissue.1 IDC can metastasize through the
lymphatics and bloodstream if not caught early.1 This patient’s clinical staging was IIIC
(cT2N3aM0) IDC, G3, ER+/PR+/HER2-. This signifies that the TNM staging system was used.
T indicates the size of the tumor, N indicates whether the cancer has spread to lymph nodes and
how many, and M indicates if the cancer has metastasized to distant sites.2 In this case, the tumor
was more than 2 cm but not more than 5 cm across (T2), it had spread to 10 or more axillary
lymph nodes or to infraclavicular nodes (N3a), and no distant spread was found (M0).2 The grade
of the tumor was G3, which means that the cells appear abnormal and poorly differentiated. 2 The
cancer was also found to be estrogen receptor positive (ER+), progesterone receptor positive
(PR+), and human epidermal growth factor receptor 2 negative (HER2-).2 This implies that the
cancer was growing due to an overexpression of estrogen and progesterone.2

The patient underwent a lumpectomy and axillary dissection prior to being seen in our
department. She will be doing post-op radiation therapy to the right whole breast and
supraclavicular and axillary lymph nodes, followed by a lumpectomy boost. The initial dose to
the breast and nodes will be 4005 cGy in 15 fractions and the boost will be 1335 cGy in 5
fractions and will focus on the lumpectomy site. It is typical for our physicians to do a
lumpectomy boost for patients who have had surgery. This focuses the dose on the area where
the tumor was taken out and the aim is to kill any cancer cells that may be remaining in the area.

Simulation

At simulation, the patient was positioned head first supine on our Orfit AIO breast board
with her arms above her head and resting on the large arm rest. Her hands were holding on to the
T-bar attachment which was adjusted to a height that was comfortable for her. Breast patients’
arms are typically raised above their head so that the dosimetrists don’t have to avoid their arms
in planning. This also creates a more stable, reproducible setup as it reduces folds in the breast
tissue and the arm rest settings will be documented in the setup notes and reproduced each day
for treatment. The Orfit system that we use has many different attachments to allow
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customization of patient setup. The 5-degree wedge was added to the Orfit board to angle the
superior portion of the patient’s body up which helps compensate for the slope of the chest and
reduce the collimator tilt that will be used in planning. This gives a better dose distribution and
helps reduce potential underdosing where the breast and axillary fields meet. Since we are
treating the right side, the patient was also instructed to turn her head to the left. This moves the
chin and more of the throat away from the supraclavicular area that will be treated. One side
effect of treating supraclavicular nodes is a sore throat, so care should be taken to move as much
of the throat away from the field as possible. Finally, the patient was given a cushion under her
knees for comfort.

Target Doses

The doctor prescribed 4005 cGy in 15 fractions to the breast and lymph node volumes.
Nodal volumes that will be treated include supraclavicular, axillary, and internal mammary
(IMN) lymph nodes. This will be followed by a boost of 1335 cGy in 5 fractions to the
lumpectomy site. This dose regimen is based on guidelines from the American Society for
Radiation Oncology (ASTRO).3 These recommendations are the result of evidence-based
practice and literature reviews which show that this is an appropriate dose regimen to lower the
risk of recurrence while minimizing toxicity.3 Also in accordance with the guidelines from
ASTRO, the physician has asked for 100% of the prescribed dose to cover at least 90% of the
breast (CTV_WB_R), supraclavicular (CTVn_SCL_R), axillary (CTVn_Ax_R), and IMN
(CTVn_IMN_R) volumes. Additionally, the doctor wants 100% of the prescribed dose to cover
at least 95% of the lumpectomy PTV volume (PTV_Lump_EVA_R). These contoured targets
are shown in Figures 1 and 2. These are our standard departmental constraints for breast and
lymph node treatments.

Organs At Risk

One very important aspect of treatment planning is contouring surrounding organs at risk
(OARs) and making sure the dose they’re receiving is under the acceptable limit and as low as
possible. The OARs that were of interest with this plan were the esophagus, heart, lungs, and
spinal cord, as shown in Figure 3. Table 1 lists the QUANTEC dose tolerance values for these
organs. If the dose tolerance is exceeded for any of the OARs, the patient would experience
radiation-induced toxicities. If dose limits are exceeded for the esophagus, acute esophagitis or
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perforation of the esophagus could occur.4 If dose limits are exceeded for the heart, pericarditis
or long-term cardiac mortality could occur.4 The heart dose is especially critical with breast
treatments since it can be located very close to the target volume and has a low dose tolerance.
Damage to the heart can be fatal, so this is something to be very mindful of when creating breast
plans. If dose limits are exceeded for the lung, symptomatic pneumonitis could occur.4 Finally, if
dose limits are exceeded for the spinal cord, myelopathy, or in severe cases, paralysis, could
occur.4 At our clinic, we use the ClearCheck program along with the dose volume histogram
(DVH) to evaluate if target doses and OAR constraints are being met. Any constraints that are
unable to be met are signed off on by the doctor. Table 2 shows the constraints for this plan after
being run through ClearCheck.

Lymph Node Involvement

This patient’s cancer had spread to 10 or more surrounding lymph nodes, so she has
multiple nodal target volumes that will be included in the treatment fields. These consist of
axillary, supraclavicular, and IMN nodes. Figure 4 displays a diagram of these lymph node
chains in relation to the breast. It was important to shape the treatment fields to include all of
these volumes with enough margin to account for respiratory motion. The goal was to adequately
cover the targets while blocking the nearby OARs like the spinal cord and esophagus. Figures 5
and 6 show how the treatment ports were shaped to achieve this with nodal regions labeled.

Treatment Boundaries

The treatment boundaries were primarily based on the volumes drawn by the physician
but there are also some general rules we follow when designing the fields. For breast tangents,
medially, we do not want to go past midline. This is because we do not want dose in the
contralateral breast because the patient would be at risk of developing a secondary radiation-
induced cancer in the other breast. Keeping the field border at midline also reduces lung dose,
which should be kept as low as possible. Laterally, we want to include all of the affected breast
tissue and about 2 cm beyond that for margin. Superiorly, the fields will go right up to isocenter
which will be placed in between the nodal and breast volumes using a half-beam blocking
technique, which is explained in the treatment planning section. Isocenter is usually placed
around the level where the clavicles can start to be seen axially near the sternum. Inferiorly, we
also want to make sure we’re including the entire breast with some margin, so usually place the
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field edge about 1.5 cm below the bottom of the breast. Anteriorly, there should be enough flash
to include the entire breast and to account for the possibility of breast swelling, so the field edge
will be 2-3 cm past the anterior portion of the breast. Figure 7 shows the treatment borders for
one of the tangential breast fields.

For the nodal fields, medially, the treatment borders will go to the edge of the spinal cord.
We want to make sure the spinal cord is blocked with the jaws, if possible, to reduce dose.
Superiorly, the field should include the entire supraclavicular space with about 1 cm of margin.
Laterally, the field should encompass the axillary volume with about 1 cm of margin and it will
usually extend into or past the humeral head. At my clinic, we use the MLCs to block the
humeral head so it does not receive dose. Inferiorly, the field will extend to isocenter where it
will abut the tangent fields with half-beam blocking. This is around the first costal space. Figure
8 shows the treatment borders for one of the nodal fields.

Treatment Planning

This patient is going to be treated with a 3D conformal technique. This was specified by
the doctor in the prescription. Additionally, 3D conformal planning is standard for most breast
treatments because IMRT is usually not necessary to achieve adequate target coverage while
keeping OAR dose low. There are two treatment plans for this patient, a tangential plan for the
whole breast, which will incorporate the IMN volume, and a wedged pair with anterior fields for
the supraclavicular and axillary lymph nodes. Two plans are necessary because the shape of all
the combined volumes is long and irregular so it would be difficult to get conformal coverage on
the entire treatment area. These plans will have the same isocenter and a half-beam blocking
technique will be used. The isocenter will be placed in between the nodal and whole breast
regions and then the jaws will be closed on one side of the isocenter to prevent any overlap or
hot spots between the two plans. Figure 9 shows the isocenter placement for this patient. We
typically place isocenter around the level where the clavicles first show up axially by the
sternum, but this is dependent on individual patient volumes. The monoisocentric technique
makes the treatment quicker and may reduce treatment errors since there is no shift required in
between the two plans. If they had separate isocenters, the therapists would have to go in the
room to manually shift the table in between the whole breast and nodal plans. They would draw a
match line on the patient’s skin and match the treatment field borders each day to prevent
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overlap. The caveat with this monoisocentric technique is that if the patient’s volumes are too
large and half-beam blocking is not possible because the jaw limits would be exceeded, then
plans with separate isocenters would be necessary.

First, I started with the whole breast and IMN plan. I added two opposing beams, a
medial and a lateral tangent. I chose angles that were parallel with the whole breast volume and
did not cross midline into the contralateral breast tissue. I also adjusted the angles so that the
posterior field edges near the lung were non-divergent. This ended up being a difficult case to get
coverage on the IMN volumes with the original angles I had chosen, so after consulting with my
preceptor and the doctor, we adjusted them to cross midline a bit to achieve coverage on the IMN
nodes and to lower the right lung dose. As shown in Figure 10, the IMN volumes are located
very medially and the patient was also slightly rolled on her affected side at simulation. In a
situation like this, the physician would have to make the call on whether they would be willing to
accept lower coverage on the IMN volumes to avoid crossing into the other breast or if they
would like to try to switch to IMRT. The gantry angles that we decided on were 57 degrees for
the medial tangent and 234 degrees for the lateral.

The collimator rotation chosen for the medial field was 80 degrees and the lateral field
was 10 degrees. Initially, I started with rotating to 90 degrees for both because I knew that I
would want to add dynamic wedges to be used in the anterior/posterior direction and then I
adjusted the collimators from there to align parallel with the chest wall. This technique helps
reduce lung dose. After setting the collimators, I added MLCs to my fields, shaping them with
about 1 cm margin around the volumes, but blocking out the lung and heart. With the half-beam
blocking technique, I drew the superior edge of my MLCs along the match line slice that we had
created in contouring in order to keep the superior jaw closed at isocenter. Due to how close the
IMN volume was to the lung tissue, I couldn’t open the MLCs as much as I wanted to posteriorly
without increasing the lung dose. Looking at the DVH, I could see that the lung dose was over
the tolerance limit at this point. Again, I consulted with my preceptor, and we decided to
prioritize the lung dose over the IMN coverage and to verify this with the doctor. Figure 11
demonstrates our final choice for the MLC shaping.

Next, I adjusted the energies and decided on 10 MV for the medial field and 15 MV for
the lateral field. Using mixed energies gave the most conformal dose distribution because
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medially there was less tissue to go through than there was laterally so I did not need as high of
an energy on the medial field. Wedges were added to both fields to push the dose more
posteriorly towards the chest wall to help cover the entire breast volume. The axillary volume
also extends quite posteriorly and laterally, so I had to wedge heavily to make sure dose was
being pushed enough to cover the axillary volume. On the medial tangent, I used a 45 OUT
wedge and on the lateral a 45 IN wedge. The wedge orientation for both was with the heels at the
anterior surface of the breast and the toes pointing posteriorly towards the chest wall. At this
point, I also normalized so that 100% of the dose was covering 90% of the whole breast target
volume, which is our desired coverage. I adjusted the weighting of the fields and weighted the
lateral more heavily than the medial since there was more tissue to go through laterally. When
the fields were equally weighted, it was causing a hot spot medially.

When I felt like I got to an ideal place with wedging and field weighting, my final step
was to add field-in-fields (FIFs) to both the medial and the lateral fields to remove hot spots and
cool the plan down. For the medial FIF, I copy and pasted my medial field, removed the wedge,
and took the FIF weighting down to 0 to start. Then I looked at where the most heat was located
on my beam’s eye view and pulled MLCs to cover the hot spots. I slowly added some weighting
to my FIF, but I locked the lateral field so that I was only taking weight off the medial. I repeated
the same process for the lateral FIF. The final weighting choices were 0.250 for the medial
tangent, 0.082 for the medial FIF, 0.474 for the lateral tangent, and 0.078 for the lateral FIF. The
couch rotation was kept at 0 for all fields in this plan to prevent beam divergence. Figures 12-15
show the beam’s eye view for the final field designs.

For the supraclavicular and axillary nodal plan, an anterior wedged pair technique was
used. I created left anterior oblique (LAO) and right anterior oblique (RAO) fields and put FIFs
on both, following the same process as the tangential plan. The energy used was 15 MV on all
fields except the RAO FIF which used 10 MV. Using higher energies for the supraclavicular plan
helped achieve coverage on all of the nodal volumes. The LAO fields were angled at 15 degrees
and the RAO fields were angled at 350 degrees. Angling the fields 10-15 degrees helps to avoid
the esophagus and spinal cord. Both the LAO and RAO fields had a wedge where the heels were
placed together, as shown in Figure 16. This helped spread out the isodose distribution in both
directions to cover the axillary and supraclavicular targets which were both very lateral on
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opposite sides of the field. The LAO field had a 60 OUT dynamic wedge with the heel towards
the lateral side of the patient and the toe pointing medially and the RAO field had a 60 IN
dynamic wedge where the heel was towards the medial side of the patient and the toe was
pointed laterally. The collimator was turned to 90 for all fields so that the wedges could be
placed in these orientations. The couch rotation was kept at 0 for all fields to prevent beam
divergence. The final weighting was 0.520 for the LAO, 0.032 for the LAO FIF, 0.518 for the
RAO, and 0.046 for the RAO FIF. With this plan, the two main fields were weighted more
evenly than they were with the whole breast plan because there is not a huge difference in tissue
thickness where the beams are entering. The purpose of the FIFs was to help cool the plan down
so they were weighted very lightly. Like the breast tangential plan, the MLCs were drawn so that
they would cover the volumes with about 1 cm of margin, but then block out the spinal cord,
esophagus, and humeral heads. The final field designs are show in Figures 17-20.

Plan Evaluation

To accurately evaluate the total dose distribution for the combined plans, a plan sum was
created which combines the dose from the whole breast and axillary plans. Figure 21 shows the
dose distribution for the plan sum. The dosimetrist and doctor also use the DVH and the
ClearCheck application to make sure that the target volumes are being adequately covered and
doses to the OARs are within tolerance. Figure 22 shows the final DVH for the combined plans.

As previously discussed, the fact that this patient was slightly rolled at simulation
combined with how the IMN volume was drawn made it difficult to meet our standard coverage
constraints, which would be V100%  90% on the target volumes. In this case, the doctor
decided to reduce the IMN coverage to V90%  90% in order to meet other constraints and
communicated with us that she wanted V95%  95% for coverage on all the other target
volumes. The goal for the PTV_Lump_EVA_R (lumpectomy) volume was V95%  95% and we
are getting V95% = 98.112% so that constraint is being met. The goal for the CTV_WB_R
(whole breast) volume was V95%  95% and we are getting V95% = 98.47% so that constraint
is also being met. The goal for the CTVn_SCL_R (supraclavicular) volume was V95%  95%
and we are getting V95% = 97.035% so that constraint is being met. The goal for the
CTVn_Ax_R (axillary) volume was V95%  95% and that is being met at V95% = 96.899%.
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The goal for the CTVn_IMN_R (IMN) volume was V90%  90% and we are getting V90% =
91.9% so that constraint is being met. Given these modified constraints from the doctor, we were
able to meet all of her target coverage goals.

The constraints for the OARs were all passing as well. The goal for the right lung was
V2000cGy  30-35% and the right lung is receiving V2000cGy = 28.5%. The goal for the heart
was Mean  200-400 cGy and the actual dose to the heart is Mean = 54.3 cGy so that is well
below tolerance. The goal for the esophagus was Mean < 3400 cGy and the actual dose to the
esophagus is Mean = 166.9 cGy which is also well below tolerance. Finally, the goal for the
spinal cord was Max < 5000 cGy and the actual max dose to the spinal cord is 4016 cGy.

Conclusion

Breast cancer is the most common cancer that occurs in women in the United States.1
Radiation therapy is a standard treatment for breast cancer and is often prescribed post-
operatively, so it is a common plan that dosimetrists will encounter. Since breast cancer can
spread to the lymph nodes surrounding the breast, these nodal areas are frequently included in
the radiation treatment fields. Using monoisocentric 3D conformal planning with a whole breast
tangential plan and a wedged pair axillary plan is one technique to adequately treat the breast and
surrounding lymph nodes. This patient’s plan was created using this technique and was approved
by the physician for treatment after a plan evaluation showed that all constraints were being met.
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References

1. Invasive Breast Cancer (IDC/ILC). American Cancer Society. Revised November 19, 2021.
Accessed April 20, 2024. https://www.cancer.org/cancer/types/breast-cancer/about/types-of-
breast-cancer/invasive-breast-cancer.html
2. Stages of breast cancer | Understand breast Cancer staging. American Cancer Society. Revised
November 8, 2021. Accessed April 20, 2024. https://www.cancer.org/cancer/types/breast-
cancer/understanding-a-breast-cancer-diagnosis/stages-of-breast-cancer.html
3. Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: Executive
summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline.
Practical Radiation Oncology. 2018;8(3):145-152. https://doi:10.1016/j.prro.2018.01.012
4. Marks LB, Yorke E, Jackson A, et al. Use of normal tissue complication probability models in
the clinic. International Journal of Radiation Oncology, Biology, Physics. 2010;76(3):S10-S19.
https://doi:10.1016/j.ijrobp.2009.07.1754
5. Lymph nodes of breast & Arm | SEER training. Accessed April 20, 2024.
https://training.seer.cancer.gov/lymphoma/anatomy/chains/lymph-upper.html
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Figures

Figure 1. Contoured Axillary And Supraclavicular Lymph Node Targets

Figure 2. Contoured Breast, Lumpectomy, and Lymph Node Targets

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Figure 3. Contoured OARs

Figure 4. Diagram Of Lymph Nodes Of The Breast5

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Figure 5. Beam’s Eye View Of LAO Field With Nodal Regions

Figure 6. Beam’s Eye View of RAO Field With Nodal Regions

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Figure 7. Treatment Borders For Tangential Breast Fields

Figure 8. Treatment Borders For Supraclavicular and Axillary Nodal Breast Fields
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Figure 9. Isocenter Placement

Figure 10. Tangential Beams For The Whole Breast Plan

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Figure 11. Medial Field MLCs With IMN Volume Not Fully Covered

Figure 12. Medial Field

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Figure 13. Medial Field In Field

Figure 14. Lateral Field

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Figure 15. Lateral Field In Field

Figure 16. LAO And RAO Nodal Fields With Wedges

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Figure 17. LAO Field

Figure 18. LAO Field In Field

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Figure 19. RAO Field

Figure 20. RAO Field In Field

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Figure 21. Dose Distribution For Plan Sum

Figure 22. Final DVH For Plan Sum

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Tables

Table 1. QUANTEC Normal Tissue Constraint Guidelines.4

Organ at Risk Constraints

Esophagus Mean < 34 Gy
V35 Gy < 50%
V50 Gy < 40%
Heart Mean < 26 Gy
V30 Gy < 46%
V25 Gy < 10%
Ipsilateral Lung V25 Gy < 10%
Spinal Cord Max = 50 Gy

Table 2. ClearCheck Constraints For The Plan Sum