Prone vs Spine

Breast EBRT
BY B R E N N A D E N E H E R
 Treatment Advantages
• Prone Setup
• Reduces dose to heart, lungs, & contra-lateral breast
• Eliminates skin fold under breast
• Planning can be less complex
• i.e. smaller separation & higher energies not always needed

• Supine Setup
• Easier setup & reproducibility
• Able to see field borders on patient skin
• Allows for boost treatment with electrons
 Treatment Disadvantages
• Prone Setup
• Setup & reproducibility can be challenging
• Patients can be on the table longer
• Getting on the table can be difficult for patients
• Unable to see field entrance on the medial breast
• Boosts must be with photons

• Supine Setup
• Heart and lungs are closer to breast volume
• Skin folds are present for larger breasted women
• Worse skin reaction
• Larger portion of humeral head is inside treatment field
 Patient Info
D IAGN O SIS T IM E LI N E

• Invasive Ductal • 11/18/16—initial diagnosis

Carcinoma of the left
• 1/23/17—lumpectomy and
breast
breast reduction surgery
• Pathologic Stage: 1A • Negative borders
(pT1a pN0 M0)
• 3/29/17 to 4/26/26—RT
• Grade 2 • 4256 cGy

• ER/PR+ & HER2 Neg • 4/7/17—Endocrine therapy

• Tamoxifen
 Immobilization & Setup
PRONE SUPINE
• Positioning Devices • Positioning Devices
• Q-Fix Board • Breast Board
• Upper vacbag
• Chin Strap
• Sponge under head
• Arms up
• Face turned away
• Knee Sponge
• Arms up holding hand bar
• Sternal Sponge • Setup
• Optional pad under opposite breast
• Mid-sag tattoo at CT zero ( mid-nipple for
• Foot sponge whole breast & at match line for nodal)
• Setup • 3 pt setup tattoos inferiorly
• 3 pt setup tattoos at CT zero w/ lasers shifted • Daily shifts
posteriorly
• Superior & inferior mid-sag tattoos
• Daily Shifts
 Field in Field vs Wedge Treatment
FIF
• Open fields with additional
reduced field
• Used to block out dose
• Dose can be boosted in the
lumpectomy site
• Reduce dose to normal tissue/
structures
W E D GE S
• Wedge shaped absorber which
decreases intensity across the
beam
• Heel pushes dose toward the toe
of the wedge
• Hard wedges can increase
scatter
• Only used on the lateral field to
reduce scatter to contralateral breast
Dose Distribution Comparison
W E D GE N O W E DG E
 Plan Objectives

• 105% dose to the lumpectomy PTV

• All hot spots kept in the lumpectomy PTV
• Hot spots to be <110% dose

• 100% dose to the PTV

• Reduce dose to normal tissue with full coverage of the
PTV
Prone Obliques Dose Distribution
RAO LPO

• 124.2% of the dose to

the PTV
• Dose pulling anteriorly
• Losing coverage to
the chest wall and
lumpectomy site
DVH—Prone Obliques
Prone FIF Dose Distribution
Beam Arrangement & Parameters

• RAO
• LAO
• LAO 1a
• LAO 1b
Prone FIF Dose Volume Histogram
Dose Distribution—Supine
Tangent Fields
Beam Orientation & Parameters

• RAO
• Gantry: 305 deg
• Collimator: 6 deg

• LPO
• Gantry: 131 deg
• Collimator: 354 deg
DVH—Supine Tangent Fields
Dose Distribution—Supine FIF
Tangents
 Beam Orientation & Parameters
OP E N F IE L D RE D U C E D F IE L D

• LPO
• LPO RF
• RAO
• RAO RF
DVH—Supine FIF Tangents
Supine FIF vs Prone FIF
Critical Structures & Tolerance Doses (Gy)

STRUCTURE TD 5/5 TD 5/5

(1/3) (3/3)
Heart 6000 4000

Lung 4500 1750

Humeral Head 5200

Spinal Cord 5000 (5cm) 4700 (20cm)

 Mean Dose Comparison (cGy)
Structures Prone Prone FIF Supine Supine FIF Prone FIF
Tangents Tangents Tangents Tangents Tangents +
Boost
Heart 233 210.9 227.3 208.3 215.3
Left Lung 121.1 113.8 946.5 892.4 120.2
Right Lung 18.2 16.8 24.5 22 17.4
Contra- 42.2 38.7 39.4 36.3 41.3
lateral Breast
PTV 4706 4348.8 4523.2 4332.7 4768.3
Lumpectomy 4748.6 4479.8 4557.5 4445.6 5483.9
PTV
 Final Plan—Prone FIF Tangents + Boost
BOOS T T O LUM P E C T OM Y
P RO N E FIF TAN GE N TS
C AVIT Y

• 42.56 Gy to whole breast • 10 Gy to lumpectomy PTV

• 6MV • 15MV
• 266 cGy/ fxn • 200 cGy/ fxn
• 16 fxns • 5 fxns
• RAO • LPO
• LAO
• RAO
• LAO RF 1a
• LAO RF 1b
Prone FIF + Boost DVH