PII S0958-3947(97)00116-7

TANGENTIAL IRRADIATION OF THE INTACT BREAST: THE ABC OF

THE TECHNIQUE
AMR AREF, M.D.,
1
GARY EZZELL, PH.D.,
1
PAUL CHUBA, M.D., PH.D.,
1
DALE THORNTON, R.T.T., C.M.D.,
1
and IBRAHIM AREF, M.D.
2
1
Department of Radiation Oncology, Wayne State University School of Medicine, and the Barbara Ann Karmanos
Cancer Institute, Detroit, MI;
2
Department of Radiation Oncology, Ottawa Regional Cancer Center, Ottawa, Canada
AbstractThis paper describes in detail the setup of breast irradiation using an isocentric tangential technique.
This setup method does not require any special devices or calculations beyond simple arithmetic. We will discuss
some of the practical problems and pitfalls that result from the oblique incidence of the radiation beams and the
slope of the chest wall and provide possible solutions. 1998 American Association of Medical Dosimetrists.
Key Words: Tangential irradiation, Radiotherapy Technique, Breast irradiation.
INTRODUCTION
Early breast cancer is commonly treated by lumpectomy
and whole breast irradiation using an opposed tangential
beam arrangement. As tangential breast irradiation is one
of the most commonly used techniques in radiation ther-
apy departments, it deserves a description in full detail.
We describe the technique used at Wayne State Univer-
sity with special emphasis on practical problems often
encountered. This technique can be easily installed clin-
ically without the need for special devices or mathemat-
ical calculations beyond simple subtraction. Patients are
treated using an isocentric technique wherein the central
axis of the beam lies in the plane of the posterior borders
of the tangential elds. One-half of the used eld is
blocked at the primary collimator and only one-half of
the eld is actually used for treatment.
METHODS
Accurate body immobilization is achieved using a
commercially available sloping board. We prefer to ele-
vate the upper part of the patients body so that the
anterior chest wall becomes parallel to the horizontal
plane. Practically, this cannot be achieved in many pa-
tients as the degree of the required slope may be large
enough to force the patient to slide down the board, and
most patients will be simulated with the superior part of
the anterior chest wall sloping to varying degrees poste-
riorly. The ipsilateral arm is abducted and exed. Fol-
lowing axillary dissection, many patients nd this posi-
tion initially uncomfortable, but adherence to a regular
physiotherapy program before simulation alleviates this
problem to a great extent.
The upper border of the radiation elds is deter-
mined clinically. The exact position of the upper bor-
der varies according to the degree of the board eleva-
tion used, breast size and shape, and position of the
lumpectomy site. Although the upper border is often
dened by the angle of Louis, we have found this
denition unsatisfactory in many women with moder-
ate to large sized breasts, as the plane of this angle
may actually lie only a few centimeters superior to the
nipple. Similarly, we are unable to describe the upper
border in relation to palpable breast tissue, as this is
hard to dene in many postmenopausal patients with
slight obesity. We commonly position the upper bor-
der at the level of the inferior border of the clavicular
head. The inferior border is set 2 cm below the infra-
mammary fold in the midclavicular line. The mid-
transverse plane between these two borders is dened
by setting the upper and lower borders of the collima-
tor opening at the dened points. The transverse laser
beam is then placed equidistant from the upper and
lower borders. A medial setup point is dened at the
intersection of the transverse laser beam with the
patient sagittal midline. The sagittal midline is dened
clinically, not on uoroscopy. Because of the abduc-
tion and exion of the arm, the sagittal midline of the
anterior chest wall will often not coincide with the
sagittal plane passing through the middle of the dorsal
vertebrae as seen on uoroscopy. The medial setup
point is marked with a small radiopaque marker. A
lateral setup point is dened at the intersection of the
transverse laser beam with the mid axillary line. For a
lateral lesion, the lateral border is moved posteriorly
to avoid geographic miss at the lumpectomy site.
1,2
This point is also marked by another radiopaque
marker.
The isocenter of the simulator is placed at the
medial setup point (Fig. 1). The gantry is rotated
Reprint requests to: Amr Aref, M.D., Gershenson Radiation
Oncology Center, Wayne State University School of Medicine, and the
Barbara Ann Karmanos Cancer Institute, 3990 John R, Detroit, MI
48201
Medical Dosimetry, Vol. 23, No. 1, pp. 1519, 1998
Copyright 1998 American Association of Medical Dosimetrists
Printed in the USA. All rights reserved
0958-3947/98 $19.00 .00
15
clockwise for right breast lesions or counterclockwise
for left breast lesions until, under uoroscopy, both
the medial and lateral markers are superimposed.
Since the isocenter of the machine is placed on the
medial setup point, these two points must overlap
during the gantry rotation. The gantry angle with the
vertical plane, , is recorded. For the majority of
patients, this angle will be in the range of 5058. At
this point, the amount of lung tissue included between
the chest wall and the central axis is assessed. We
typically aim for about 23 cm of lung tissue to be
included in the tangential eld. Moving the medial
setup point laterally or moving the lateral setup point
anteriorly and adjusting the gantry angle will decrease
the amount of lung tissue included in the tangential
elds. The reader will note that, at this position, we
have identied a central ray that passes through the
source of radiation, the isocenter of the machine, the
medial setup point, and the lateral setup point. To
achieve an isocentric setup, we desire to move the
isocenter of the machine along this line so that it will
be equidistant from the both the medial and lateral
setup point (Fig. 2).
To move to the true isocenter, the table is moved
in upward and medial directions until a position satisfy-
ing the following two conditions is met: a) the central
axis passes through the medial setup point and, b) the
distance between the source of radiation and the medial
setup point equals 100 cm minus one-half the separation
between the medial and lateral setup point. In other
words, this will mean that the isocenter of the machine is
placed equidistant from the medial and lateral setup
points. This position may be conrmed by rotating the
gantry 180. The central axis will pass through the lateral
setup point as expected and can be veried under uo-
roscopy.
Next, the gantry is returned to the initial zero posi-
tion. It will now be noticed that the central axis is
projected between the medial and lateral setup points.
The lateral position of the table is recorded and the table
is moved laterally until the central axis passes through
the medial setup point and the new lateral position of the
table is recorded. The difference between these two table
readings represents the lateral shift. The distance be-
tween the radiation source and the medial setup point is
recorded as the setup depth (Fig. 3).
In an actual treatment setup, with the gantry in
degree position, the isocenter of the machine is posi-
tioned over the medial setup point and the table is moved
vertically until the distance between the radiation source
and the medial setup point equals the setup depth. The
eld is moved horizontally towards the ipsilateral breast
to a distance equal to the lateral shift.
The gantry is rotated by degrees and treatment is
given through the medial tangential eld (Fig. 4). The
gantry is rotated to the opposing angle for the lateral
tangential eld.
Fig. 1. The isocenter of the simulator is placed at the medial
setup point (M). The source-to-skin distance is 100 cm. L
lateral setup point, Ub upper border, Lb lower border.
Fig. 2. A central ray is identied that passes through the source
of radiation (S), the medial setup point (M), which also over-
laps the isocenter of the machine, and the lateral set up point
(L). The desired position of the isocenter is at I where IMIL.
The distance SM 100 cm.
Medical Dosimetry Volume 23, Number 1, 1998 16
DISCUSSION
The tangential technique is a parallel opposed-
pair technique. The plane of the radiation source and
the central axis, which in our technique also forms the
posterior border of both the medial and lateral tangen-
tial elds, does not have a perpendicular incidence to
the skin surface as in other conventional parallel op-
posed-pair techniques (anterior/posterior and lateral
arrangements) used often in radiation therapy. This
difference accounts for the following observations: the
projection of the central axis on a sloping surface will
not be a straight line, as in the cases of conventional
parallel opposed- pair techniques, but will be curved.
In most patients, the superior part of the chest wall
slopes posteriorly and, to some extent laterally as well,
and therefore, the light projection of the central axis
will not be a straight line coinciding with the sagittal
plane of the patient, but rather curved and concave
laterally (Fig. 5). This may result in missing the upper
medial part of the treated breast from the radiation
eld. This problem, if small in magnitude, can be
corrected by rotating the collimator clockwise for the
right breast and counterclockwise for the left breast;
however, care should be exercised as rotating the
collimator may also result in excluding the lower
medial part of the treated breast from the radiation
eld. Another approach to this problem is to mark the
sagittal midline with a radiopaque wire and design a
block that matches this wire from a simulator lm
(Fig. 6). Such a block should not be designed directly
from the simulation lm without the aid of skin mark-
ings as it is difcult to predict the position of this
block on the patients skin and part of the medial
aspect of the contralateral breast may be unintention-
ally included in the treatment eld. In obese patients,
the inferior part of the anterior chest wall slopes
anteriorly and the inferior part of the light eld den-
ing the medial border of the tangent will be projected
away from the midline towards (and may include) the
Fig. 3. The central axis is projected between the medial and
lateral setup points. MI lateral shift.
Fig. 4. Actual treatment position. MS 100 - MI and MI
IL, ML patient separation, S source of radiation, M
medial setup point, I isocenter of the machine, L lateral
set point.
Fig. 5. The projection of the central axis in the treatment
position will be curved and is not a straight line.
Tangential irradiation of the intact breast G A. AREF et al. 17
lower inner quadrant of the contralateral breast. Again,
placing a radiopaque wire over the midline would
facilitate constructing a block that alleviates this prob-
lem (Fig. 7). Adequate coverage of an extremely me-
dial lesion may prove difcult to achieve without
including the medial aspect of the contralateral breast
in the radiation eld. The contralateral breast, because
of its thickness, may obstruct the path of the medial
tangential eld before it covers the lower lying skin
over the manubrium. This problem can be solved
either by taping down the contralateral breast or
changing the gantry angle and accept a more posterior
exit point with increased amount of lung tissue in the
radiation eld. Alternatively, a separate electron eld
may be used to treat the medial part of the ipsilateral
breast. The posterior border of the lateral tangential
eld is commonly dened as passing through the mid-
axillary line, implying that it intersects the patients
lateral chest wall along a line that lies in the coronal
plane of the patient. Again, this is not an accurate
description, as the posterior border of the lateral tan-
gent often projects as an oblique line with the lower
part anterior to and the upper part posterior to the
mid-axillary line. The posterior border of the lateral
tangent will meet the mid-axillary line only along the
transverse midline plane of the eld. Attempts at col-
limator rotation, beyond a few degrees, during the
setup of the medial tangential eld will cause the beam
to exit at an even more posterior level superiorly and
more anterior level inferiorly. This may result in treat-
ing a large area of the upper posterior chest wall and
distal axilla, which may cause excessive dry or moist
desquamation especially in obese patients, and under-
dosing the lower outer quadrant of the ipsilateral
breast. One should always appreciate that the medial
and lateral tangential elds are mirror images of each
other and any change in one eld will also result in
changes in the other eld if all points in the radiation
volume are to be treated by both elds (Fig. 8). This
interaction between both elds is best examined clin-
ically as it is difcult to appreciate it during uoros-
copy or from review of the simulation lms.
Fig. 6. A wire is placed over the patient sagittal midline and a
cerobend block is designed from the simulator lm along this
wire.
Fig. 7. Projection of the central axis in the treatment position
when treating an obese patient. The upper part of the central
axis is deviated towards the ipsilateral breast and the lower part
is deviated away from the midline towards the contralateral
breast. W radiopaque wire placed along the patient sagittal
midline, M projection of the posterior border of the medial
tangential eld.
Fig. 8. The interaction between the medial tangential and lateral
tangential elds. M the projection of the posterior border of
the medial tangential eld, CM the projection of the medial
tangential eld after collimator rotation, L the exit of the
posterior border of the medial tangential eld, CL the exit of
the posterior border of the medial tangential eld after colli-
mator rotation.
Medical Dosimetry Volume 23, Number 1, 1998 18
CONCLUSION
We have described in detail an easy way to clin-
ically set-up a tangential isocentric technique and dis-
cussed some clinically relevant observations. The tan-
gential eld technique is a special type of a parallel
opposed pair technique and has all of its characteris-
tics. Because of the oblique incidence of the radiation
beam on the skin and the sloping shape of the breast
and chest wall careful clinical evaluation of the setup
is important, as potential pitfalls cannot be readily
recognized using uoroscopy, simulation, or port
lms.
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Tangential irradiation of the intact breast G A. AREF et al. 19