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Derek Smith
February Case Study
02/23/2014
Forward Planning IMRT of the Chestwall
History of Present Illness: Patient MH is a 63 year old Caucasian female who noticed a non-
healing lesion of the skin of the nipple on the right breast. She attributed this to an injury
sustained from her dog jumping on her. The lesion did not heal and she underwent a
mammogram in July of 2013. This indicated a 20 mm retroareolar lesion involving the right
breast and no abnormality of the left breast. An ultrasound study confirmed a hypoechoic lesion.
Stereotactic biopsy was recommended. Pathology from showed a grade 3 infiltrating ductal
carcinoma of the skin around the right nipple and breast region. MH underwent surgery in
August that consisted of lumpectomy with removal of tissue around the nipple. This confirmed
the impression of involvement of the skin and dermal lymphatics with Pagets disease, or
inflammation of the nipple associated with breast carcinoma. Axillary sentinel lymph node
procedure was done and 1 of 2 nodes was positive and 10 non-sentinel lymph nodes were all
negative. In the middle of August, MH was referred to the Radiation Oncology department for
consultation for post-operative radiation therapy to the right chest wall.
Past Medical History: MH has a past medical history of degenerative disc disease, depression,
fibromyalgia, gastroesophageal reflux, hypercholesterolemia, hypertension, obesity, and sleep
apnea. MHs past surgical history includes a knee replacement, ganglion cyst removal, gastric
band surgery, hernia repair, lumpectomy and total thyroidectomy. This patient was also receiving
chemotherapy at the time of evaluation on January of 2014.
Social History: MH does not have any remarkable family history. MH is married and lives in
her own house with her spouse. She has had total disability since 1956. She doesnt drink and
has never smoked and is also sedentary.
Medications: MH uses the following medications: anti-diarrheal, Arixtra, Coumadin, Crestor,
Cyanocobalamin, Demadex, Herceptin, Hydrochlorothiazide, Indomethacin, Levothroid,
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Nucynta, Nuvigil, Potassium Chloride, PriLosec, Prochloroperazine Maleate, Provigil, Questran
Light, Spironolactone, Toprol XL, Uloric, Vitamin D, and Zofran.
Diagnostic Imaging: In September of 2013, MH underwent a mammogram screening for nipple
abnormality of the right breast. The mammogram findings showed an irregular mass measuring
20 mm and associated fine pleomorphic calcifications seen in the retroareolar region of the right
breast. In the left breast no abnormalities were seen.
Radiation Oncologist Recommendations: After review of MH past surgical and family history
along with pathology reports, the Radiation Oncologist recommended that he would discuss her
case at the multidisciplinary breast oncology conference, with concern in regards to breast
conservation therapy and the dermal lymphatic and skin involvement which puts her at a higher
risk category in terms of local recurrence. Due to the high grade of disease and the nodal
involvement and the hormone receptor negativity, MH required chemotherapy. After MHs case
was presented the radiation oncologist recommended MH undergo post-operative radiation
therapy to the right chest wall using a 3D/IMRT technique plan that includes a medial and lateral
beam. Early to current studies have shown that forward planned IMRT shows superior coverage
to the chestwall for larger chestwall separation.
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The Plan (prescription): The prescription dose for the entire right chest wall was 50.4 Gray
(Gy) at 1.8 Gy per fraction for 28 fractions. Due to the separation of the mastectomy scar and
extent of patient anatomy, the entire treatment was split in two plans at 1.8 Gy per fraction for 14
fractions each for a composite dose of 50.4 Gy with the initial covering the entire chest wall and
the second with steeper beam angles to spare dose in the right lung. In regards to this case study,
only the initial plan will be discussed in detail.
Patient Setup/Immobilization: MH was simulated for the treatment to her right chestwall. The
patient was placed in the supine position on a Civco breast board with right arm up, wedge under
knees, and feet banded (figure1). Wires were placed at the superior, inferior, medial, lateral
borders, and mastectomy scar. A computed tomography (CT) scan was performed. After the
images were reviewed, a user origin was selected, and medial and lateral tattoos were given by
the radiation therapist.
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Anatomical Contouring: After the patient simulation was completed, the CT images were
imported into the Varian Eclipse v.11 treatment planning system (TPS). In this case the
Radiation Oncologist approved the wire placement of the superior, inferior, medial, lateral
borders, and the mastectomy scar to reproduce the field he wanted treated rather than contouring
the entire chest wall. The mastectomy scar (Figure 1) was quite large and encompassed the entire
chest wall. The Medical Dosimetrist contoured the wires listed previously and the organs at risk
(OR). The OR included the right lung and the heart. The lung dose was a particular concern due
to the length of chest wall separation which included a large portion of the lung. The radiation
oncologist reviewed and approved the contours to allow the dosimetrist to begin treatment
planning.
Beam Isocenter/Arrangement: MHs treatment plan was based on the capabilities of the Varian
21 EX linear accelerator that she will be treated on. The Medical Dosimetrist placed an isocenter
in tissue at approximately 1.5cm anterior of the right lung (Figure 2). The isocenter was placed
accordingly in reference to the superior, inferior, medial, lateral border wires. (Figures 3-5). The
gantry angles for the medial photon beam was set at 138.1 and the lateral photon beam was set
at 321.3. Each beam utilized a 6 Megavoltage (MV) beam to cover dose at the chestwall depth.
Within these two beams the Medical Dosimetrist utilized 18 MV field-in-field beams with an
MLC, or multi-leaf collimator, drawn to spare the right lung (Figure 6) . This mixed energy
technique assisted to gain coverage all the way through the chest wall separation as well as
lowering the plans hotspots. No fields had collimator rotation. The field sizes were based on the
superior, inferior, medial, lateral border wires initially and the medical dosimetrist performed a
dose optimization through the TPS to then have defined medial and lateral field sizes of
11.9x18.0 cm.
Treatment Planning: The plan was completed on Varian Eclipse v.11 treatment planning
system. The planning objective from the Radiation Oncologist was to utilize a 3D/IMRT
treatment technique via medial and lateral tangential fields while sparing dose to the right lung
and heart. The plan intent was to gain sufficient coverage that utilizes the Varian analytical
anisotropic algorithm (AAA) for heterogeneity correction factors throughout the right chest wall
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. The prescribed dose of 1.8Gy/Fraction was calculated to the calc pt tang set by the medical
dosimetrist (Figure 7). The medial and lateral beams were equally weighted and assigned to the
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set calculation point. The medical dosimetrist was having trouble getting coverage to the entire
mastectomy scar without getting hotspots of 114.9% due to the length of coverage (~32cm) and
the difficult external anatomy of the patient (Figure 8). The medical dosimetrist consulted with
the radiation oncologist and they both agreed to only give half of the dose with the initial plan
and the other half of the dose with medial and lateral tangential beams consisting of steeper
angles. The second plan was comprised of an MLC block and steeper angles that spared dose to
the lung tissue. Studies have shown that tangential beam IMRT can significantly reduce dose to
the ipsilateral lung.
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The only problem with the second plan was the fact that the area near the
medial wire was not receiving enough treatment dose. To counteract this problem the Medical
dosimetrist placed a 9 MeV electron beam with the gantry rotation at 165 to give a full dose to
the area near the medial wire (Figure 9). The dosimetrist performed a plan sum within the TPS to
ensure the entire chest wall was receiving the dose requirements as well as ensuring the organs at
risk (OR) fell within the OR dose constraints which were less than 5 Gy for the mean dose of the
heart. The maximum dose to the ipsilateral lung was less than 25% the total lung volume at 5Gy
(V5) and less than 10% the total lung volume at 20 Gy (V20). The Dose Volume Histogram
(DVH) shows the plan fell within the OR constraints while also achieving greater than the
required dose coverage of 95% to the left chestwall as prescribed by the Radiation Oncologist
(figures 10 and 11). The plan sum performed on the TPS that combined the split photon plans
and the electron plan were reviewed by the radiation oncologist, approved, checked in RadCalc,
double checked by the Physicists, and scheduled.
Quality Assurance/Physics Check: To ensure the Varian Eclipse v.11 treatment planning
system made correct monitor unit (MUs) calculations, the Medical Dosimetrist exported the
treatment plan to RadCalc. The percent difference between the RadCalc MUs and the TPSs
MUs fell below the required 5% acceptance. A QA diode second check was performed and
approved by the Physicists. The Actual diode value, read on a Sun Nuclear Corporation diode
system, fell within the expected diode range that was also calculated in RadCalc by the Medical
Dosimetrist.
Conclusion: This case was a very interesting case because it started out as a challenge when the
Medical Dosimetrist saw the size of the mastectomy scar. The Radiation Oncologist and Medical
Dosimetrist worked together to attain a treatment plan that was prescribed as a 3D/IMRT right
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chestwall with a medial and lateral photon beam that progressed into the intricate plan that
summed up to cover the entire right chestwall and mastectomy scar while still sparing dose to the
heart and the right lung. The plan was intriguing due to how much the external anatomy affected
the dose distribution. This plan covered field in field (FIF), MLC block, gantry angling, and
electron beam techniques. It also showed how crucial communication is amongst the Medical
Dosimetry team and the Radiation Oncologist. The Medical Dosimetrist showed a lot of
dedication by trying numerous treatment techniques until a plan that was best for the patients
wellbeing was established.





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References
1. Holloway C, Thompson H, Robinson D, et al. A pilot study of intensity modulate
radiation therapy (IMRT) in breast cancer patients. Radiotherapy and Oncology.
2004;72(1):s31.
2. Breitman k, Rathee S, Newcomb C, et al. Experimental validation of the Eclipse AAA
algorithm. J of Appl Clin Med Phys. 2007;8(2)76-93.
3. Rudat V, Alaradi AA, Mohamed A, Ai-Yahya K, Altuwaijri S: Tangential beam IMRT
versus tangential beam 3D-CRT of the chest wall in postmastectomy breast cancer
patients: a dosimetric comparison. Radiat Oncol 2011, 6:26.









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Figure 1: patient CT simulation setup and treatment setup













Figure 2: Isocenter placement


Mastectomy
Scar -------->

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Figure 3: Isocenter placement at medial beams eye view













Figure 4: Isocenter placement at lateral beams eye view


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Figure 5: Isocenter placement from transversal, frontal, and sagittal view














Figure 6: MLC block placement medial and lateral beams eye view












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Figure 7: Calculation point placement from transversal view












Figure 8: Challenging external anatomy outlined by green lines














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Figure 9: 9 MeV electron beam










Figure 10: plan sum displaying all treatment beams (95% coverage lime green isodose line)

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Figure 11: plan sum dose volume historgram