1

Dan Frieling

April Case Study

April 2, 2018

Electron Treatment for Male Breast Bud

History of Present Illness: The patient is a pleasant 59 year old male who in early 2017
presented with an elevated PSA. On 5/25 of the same year, an urologist noted a firm nodule in
the patients prostate. A subsequent prostate biopsy performed on 6/22/17 revealed more
regarding the patient’s condition. Pathology showed the nodule to be an adenocarcinoma with a
Gleason score of, 3 + 4 = 7. On 8/1, a CT of the pelvis displayed no pelvic lymphadenopathy. A
bone scan on the same day showed no evidence of bone metastasis. Later that month on 8/26, a
MRI of the prostate revealed a 1.8 cm lesion in the right aspect of the prostate with no evidence
of seminal vesicle invasion.

On 9/1/17, the patient started a Casodex regimen which continued for one month. Later that
month on 9/27, the patient began receiving what would be the first in a series of Eligard
administrations. This drug is given to patients with advanced prostate cancer to aid in the
management of systems. Eligard overstimulates the body’s production of hormones to cause a
temporary shutdown. In men, this leads to a reduction in the amount testosterone created.1 The
patient received Eligard on the following three dates; 9/27 (7.5 mg), 11/1/17 (22.5 mg), and
2/15/18 (7.5 mg). The patient was referred to the Cleveland clinic to receive SBRT treatments of
the prostate from 11/6 to 11/15. He was prescribed 36.25 Gy in five fractions. 10 MV photon
beams were utilized with a SBRT coplanar VMAT technique. A SpaceOAR rectal balloon was
inserted on 10/24 and was employed for the duration of the treatment.

On February 2018, the patient experienced bilateral breast bud enlargement. He reported pain
and sensitivity in the same areas. The patient also complained of hot flashes, decreased sex drive,
muscle aches, and a weight gain of nine pounds. This led the physician to deduce that the patient
required radiation treatment to the breast bud area.
 2

Past Medical History: In 1968, the patient fractured his left ankle. Three years later in 1971, the
patient also fractured his left wrist. The patient has a history and ongoing struggle with chronic
back pain, high blood cholesterol and hypertension.

Social History: The patient is married with two grown children. He is a former smoker who
smoked one pack of cigarettes a day for fifteen years. He quit on 4/3/1988. The patient drinks
alcohol regularly and reports consuming six standard drinks or an equivalent per week. The
patient’s paternal grandfather died of cancer. His maternal grandfather had an early death due to
medical reasons the patient cannot recall. The patient’s father had heart disease. His son has no
known medical problems while his daughter struggles with obesity. The patient is disabled due
to back pain.

Medications: The patient is currently using the following medications: Gabapentin (300 mg
capsule), Tamsulosin (0.4 mg capsule), Lisinopril (20 mg tablet), Aspirin (91 mg tablet), and
Acetaminophen.

Diagnostic Imaging: After presenting with a prostate nodule, the patient underwent a CT of the
pelvis on 8/1/17. This displayed no significant pelvic lymphadenopathy, borderline prostatic size,
and asymmetric heterogeneous attenuation of the right lateral prostate. A bone scan on the same
day showed no evidence of bone metastasis. The patient received a prostate MRI on 8/26. A 1.8
cm lesion was found in the right aspect of the prostate. No evidence of invasion of the ipsilateral
seminal vesicle was identified. However, there were mildly prominent bilateral external iliac
lymph nodes detected.

Radiation Oncologist Recommendations: For the patient’s prostate disease, external beam
radiation therapy (EBRT) was recommended to the patient followed by potential high-dose rate
(HDR) brachytherapy. However, the patient expressed interest in stereotactic body radiation
therapy (SBRT) which is not performed at the University of Rochester (UR). The patient was
eventually referred to the Cleveland Clinic. While he was there, the patient received SBRT
treatments to the prostate. He was prescribed a dose of 36.25 Gy over five fractions. This
resulted in a daily dose of 7.25 Gy per fraction. A rectal balloon placement was necessary to
ensure a proper treatment. Hence, the patient underwent a rectal balloon insertion procedure
prior to the start of treatment.
 3

Upon completion of his prostate radiation treatments, the patient presented with bilateral breast
discomfort. The physician recommended radiation therapy to the bilateral breast buds. This
would be done to reduce the patient’s pain and prevent his gynecomastia from getting worse. The
patient was amenable and agreed to undergo EBRT treatments. He was prescribed 12 Gy over
two fractions. Electrons were used with a .5 centimeter bolus covering the treatment field.

The Plan (prescription): Upon agreement with the physician’s recommendations, the patient
began the aforementioned treatment plan. He received 12 Gy over two fractions to both the right
and left breasts. The plan utilized electrons and a .5 centimeter bolus. The patient was simulated
with a GE CT Simulator. He started his treatment course on 2/26/18 and finished on 2/27/18.

Patient Setup/Immobilization: The patient was positioned supine with his head first towards
the gantry. A wingboard was used with the patient’s hands extended to the “A5” position. This
was done to ensure that the arms were removed from the treatment area. A clear “B” head rest
was used. Due to the patient’s chronic back pain, a large triangle cushion was placed under his
knees. This was done to relieve the pressure on the back due to the flat, hard simulator table.
During simulation, the physician outlined the treatment area with radiopaque wiring. The wiring
was visible on the subsequent CT and aided the dosimetrists in locating the treatment area.

Anatomical Contouring: At the end of the CT simulation, the patient’s treatment planning CT
was imported into the Eclipse planning software. From there, the dosimetrists began contouring
the necessary critical structures. These organs at risk (OAR) included the heart, lungs, spinal
cord, trachea/carina, and external body. The wiring used to outline the treatment area was also
contoured to further highlight the region. Dmax was located for each treatment field and
contoured as a structure. This was done to aid in the planning process which will be discussed
later.

Beam Isocenter/Arrangement: The patient was treated on a Varian linear accelerator. Single 12
MeV beams were used to treat both breasts. Isocenter was placed in the center of the wired area
that was determined at simulation at the depth of dmax. In total, two fields were used to treat the
patient. One field had a static gantry angle of 325 degrees with a 90 degree collimator angle. The
other field contained a static gantry angle of 35 degrees with a 90 degree collimator angle as
well. A .5 centimeter bolus covered the treatment fields for both breasts.
 4

Treatment Planning: From the beginning, the physician decided that the patient needed to be
treated with electrons. Electron planning at The Wilmot Cancer Center is done using treatment
planning software. Varian Eclipse software was utilized to plan this patient’s treatment. The
physician was present for the simulation. He outlined isocenter himself by placing the
radiopaque wiring where it needed to be. Upon completion of the simulation, the radiation
oncologist submitted the prescription into the computer. From there, the dosimetrist entered the
dose intent into the treatment planning software. The field angles were chosen due to their ability
to cover the treatment area sufficiently. Once the plan was finished, the physician reviewed it
with the dosimetrist. The plan was then approved prior to the beginning of treatment.

Quality Assurance/Physics Check: The Wilmot Cancer Center uses the RadCalc software to
perform quality assurance calculations. The treatment plan was exported to this software to
perform a double check of the treatment planning software’s monitor unit (MU) calculations.
After this, the patients chart was given to the medical physicist. In order to treat the patient, the
chart must be approved by both the physician and the medical physicist. He then reviewed the
chart before giving it to the treatment machine. Once at the machine, the chart was checked by
the radiation therapists. They verified that the gantry angles would work with the machine. The
therapists also check the electron cutouts that were made for this patient. They verified that they
were cut correctly and matched the field shape in the treatment plan. Once everything has been
verified, the plan is ready for patient treatment.

Conclusion: This particular treatment had a fairly short duration. With only two treatments, the
patient did not demonstrate any acute radiation symptoms. The patient finished the course
without any issues and handled the procedure well. It was later reported that the sensitivity in his
breasts was reduced and there was no noticeable increase in the patient’s gynecomastia.

Planning this patient’s treatment was not overly difficult. It was a simple electron plan with a
clearly defined treatment area. The physician instructed the use of 12 MeV electrons for the
beam and also provided the prescription dose. The only area of potential concern was the fact
that the patient was being treated in two areas concurrently. Proper communication was
necessary to ensure the treatment was delivered accurately.
 5

The main reason that this patient’s treatment peaked my interest was the somewhat controversial
nature of the treatment method. Before the start of my time here at The Wilmot Cancer Center, I
had never heard of treating breast buds with electrons. After planning this patient, I began to
research the method. There have been documented cases where patients who receive
prophylactic radiation treatments for gynecomastia develop a secondary malignancy.1 This is
typically a greater concern when treating younger patients. However, studies have also shown
that there may not be a significant correlation between the two. In a study involving Norwegian
patients, over 59,000 patients with prostate cancer were analyzed. Of these, 7,864 of them had
received prophylactic radiation therapy. After a follow-up time of four years, twelve men had a
diagnosis of breast cancer. Only three of these men had received prophylactic radiation therapy.
Of these three, two had phyllodes tumors. In the researcher’s mind, this demonstrated that there
wasn’t a significant link between prophylactic radiation therapy and secondary breast cancer.
However, they did mention that the incidence of secondary breast cancer could increase with a
longer follow-up time. 2

In the end, the situation must be analyzed by the physician. Each patient is different along with
the set of circumstances they are going through. Gynecomastia is an issue that can be very
sensitive for men. The radiation oncologist needs to take into account the patient’s age,
condition, and long-term prognosis in deciding whether or not they are a candidate for
prophylactic radiation therapy to the breast buds.
 6

References

1. Lewis R, Cassoni A, Payne H. Prophylactic Breast Bud Radiotherapy for Patients Taking
Bicalutamide: Should This Still Be Practised for Patients with Prostate Cancer?. Case
Reports in Oncological Medicine. 2012; 2012. http://dx.doi.org/10.1155/2012/239269
2. Aksnessaether B, Solberg A, Klepp O, et al. Does Prophylactic Radiation Therapy to
Avoid Gynecomastia in Patients With Prostate Cancer Increase the Risk of Breast
Cancer?. International Journal of Radiation Oncology Biology Physics. 2018; 101(1):
211-216. https://doi.org/10.1016/j.ijrobp.2018.01.096
 7

Figures

Figure 1. A collage showing how the patient was setup during simulation. The top row images
show the patient supine with arms extended above his head. The middle right image shows the
outlined treatment areas.
 8

Figure 2. Axial image demonstrating the isocenter placement of both treatment areas. The
treatment fields and dose distribution can be seen as well.
 9

Figure 3. Sagittal view of the right breast isocenter.

Figure 4. Sagittal view of the left breast isocenter.

 10

Figure 5. Coronal view of the right breast isocenter

Figure 6. Coronal view of the left breast isocenter.

 11

Figure 7. Beam’s Eye View of the patient’s RAO field which treats the patient’s right breast.
The field cutout can be seen on this image.

Figure 8. Beam’s Eye view of the patient’s LAO field which treats the patient’s left breast. The
field cutout can be seen on this image.
 12

Figure 9. A 3D rendering of the patient’s body showing the treatment fields and treatment areas.
 13

Figure 10. DVH of the right breast bud plan.

Figure 11. DVH of the left breast bud plan.