[Type here] [Type here] Bianca Tester

Clinical Trial Treatment for a Left breast

I. History of Present Illness

a. 44 y.o. female
b. Presented with a palpable mass in left breast in February 2016
i. Mass would come and go with her periods
ii. By March 2017 mass was consistent and she sought medical attention
c. Diagnostic mammogram 04/13/17
i. 3 cm mass in 1:00 position of left breast
ii. 2.6 cm enlarged left axillary lymph node suspicious for metastatic
disease
d. Ultrasound-guided needle biopsy
i. Pathology revealed grade 3 invasive ductal carcinoma. ER/PR and
HER-2/neu were all positive.
ii. Ki-67 was 38%
e. Fine-needle aspiration of left axillary lymph node
i. Confirmed metastatic breast cancer
f. PET/CT
i. Showed hypermetabolic activity in left breast and left axilla
ii. Showed no metastatic disease
g. MRI
i. Notable for the same as the PET/CT
ii. Indeterminate 9 X 5 mm enhancing breast mass on the right side
h. Pt elected to do TCHP chemotherapy starting in June 2017
i. Last cycle on 9/18/17
1. Pt noticed dramatic response
2. This was confirmed by both ultrasound and subsequent MRI.
3. Both studies showed no definitive persistent disease
i. Genetic testing was negative on 28 gene panel
i. Given pts mother’s breast cancer at early age pt elected for bilateral
mastectomies
1. Pt underwent bilat mastectomies on 10/17/17
2. Was notable for complete pathologic response in both primary
site and in pt’s axillary nodes (0 of 11 nodes)

j. Pt’s case was discussed at Multidisciplinary Breast Conference

i. Dr.’s made recommendation for pt to look into adjuvant radiation
[Type here] [Type here] Bianca Tester

II. Past Medical History

a. ADHD
b. Depression
c. Left breast invasive cancer

III. Social History

a. Married
i. 1 child
b. Medical Assistant
c. ½ pack per day smoking history
i. Quit 2009 (smoked 3-4 years)
d. Mother
i. Deceased at 59 y/o
1. Metastatic breast cancer
e. Father
i. Deceased at 73 y/o

IV. Medications
a. Citalopram
b. Methylphenidate HCI
c. Hydrocodone-acetaminophen
d. Percocet
e. Keflex
f. Tums
g. Melatonin

V. Diagnostic Imaging
a. Diagnostic mammogram 4/13/17
i. 3 cm mass in left breast
ii. 2.6 cm enlarged left axillary lymph node
b. FNA of left axillary node
i. Confirmed metastatic breast cancer
c. PET/CT
i. Showed hypermetabolic activity in left breast but no metastatic
disease

VI. Radiation Oncologist Recommendations

a. Recommended NSABP B-51 clinical trial
b. Pt was randomized to Arm 2B of B-51 trial
i. Consented to treatment
ii. Regional nodal XRT and chestwall XRT
[Type here] [Type here] Bianca Tester

VII. The Plan (prescription)

a. 50 Gy in 2.0 Gy fx
b. VMAT plan
c. Simulated 1/4/18
d. Started course 1/22/18 and ended 2/26/18

VIII. Patient Setup/Immobilization

a. 3D treatment planning CT on breath hold
i. breath hold done to bring chest wall away from heart as much as
possible
b. Supine, wing board, “B” head holder
c. Vac-lock on top of wing board
d. Memory foam under pt’s right side of vac-lock (for comfort)
e. Knee sponge
f. Reference marks placed during CT sim and shifts were made on first day during
(Vsim)

IX. Anatomical Contouring

a. Pinnacle treatment planning system
b. Dr. Structures
i. CTV nodes Level 1, CTV nodes Level 2, CTV nodes Level 3, CTV
IMN nodes, CTV axilla nodes
c. Dosimetrist Contours
i. PTV, lungs, carina, spinal cord, heart, thyroid, larynx, skin, right
breast, esophagus

X. Beam Isocenter/Arrangement
a. Varian Trilogy machine
i. 6 MV VMAT plan
b. Isocenter placed roughly towards the center of the area being treated, but was
placed in air (iso placed more posterior than typical tangent field) since the plan
was done with arc’s instead of tangent fields and the fields had to go more
laterally to cover the IMN’s and axilla.
c. Field 1: Gantry 230-114 arc; Field 2: Gantry 114-2 arc; Field 3: Gantry 2-114
arc; Field 4: Gantry 114-230 arc.
i. 6 MV dynamic arc
1. Concerned about sparing dose to ipsilateral lung and heart
without sacrificing coverage to IMN and axilla
2. Partial arcs used to avoid dose to contralateral lung
[Type here] [Type here] Bianca Tester

XI. Treatment Planning

a. Varian Pinnacle v16.0
b. Radiation Oncologist put in prescription according to protocol, and dosimetrist
instructed to plan according to planning objectives in protocol.
c. Dosimetrist printed out 67-page protocol to ensure protocol constraints would
be met during the planning process

XII. Quality Assurance/Physics Check

a. Plan was exported to a Sun Nuclear Arc Check model 1220 cylindrical diode
array.
i. Diode array and beam fluence measured using EPID
b. VMAT QA performed and approved by physicist

XIII. Conclusion
a. Guidelines for B-51 clinical trial and how constraints effect treatment
planning
b. Things I struggled with
c. Things I learned/how this enhanced my understanding of dosimetry