Spencer Arnould February Case Study 2/16/2013 Ductal Carcinoma In Situ of Right Breast (DCIS) History of Present Illness:

Patient P is a 72 year-old female who has a history of benign cysts on her right breast and who has undergone yearly mammography screenings. She recently had a new area of abnormality identified on her recent screening on November 6, 2012. This mammography revealed a 6-millimeter (mm) cluster of amorphous calcifications in the right breast tissue approximately 3.5 centimeters (cm) from the nipple. With her nature of calcifications, a recommended biopsy was performed on November 28, 2012. Pathology from this biopsy indicated a high-grade ductal carcinoma in situ with comedonecrosis and micro calcifications. The patient was then evaluated and referred to get a right breast lumpectomy, which was performed on December 20, 2012. The patient was then seen in follow-up where a post lumpectomy mammogram was performed on January 16, 2013, which showed a postoperative seroma in the right breast with no residual calcifications present. Past Medical History: Patient P has a past medical history that includes hypertension, gastroesophageal reflux disease, and arthritis. She also had a hysterectomy and bilateral salpingo-oophorectomy in 1992 for heavy menstrual bleeding. As indicated, she had three cysts removed from her right breast which all showed signs of benign fibroadenoma. Social History: Patient P is retired and is a lifetime nonsmoker. She drinks alcohol occasionally and does not use illicit drugs. Her family history indicates that her mother was diagnosed with breast cancer at age 59, and she also has a brother with melanoma at age 70. Her father was diagnosed with colon cancer at age 78. Medications: Patient P uses the following medications: Xanex and Aspirin. Patient P is also allergic to Lisinopril, which causes cough and gastrointestinal stress. Diagnostic Imaging: The patients mammography images were reviewed including the right digital mammogram from November 6, 2012, which showed a 6mm area of calcifications 3.5 cm from the nipple. After her lumpectomy, another mammogram was performed on January 16, 2013, which showed no calcifications present. Radiation Oncologist Recommendations: Patient Ps Staging: DCIS (Tis, N0, M0) stage 0. Tumor in situ, no regional lymph node metastasis, and no clinical or radiological evidence of

2 distant metastasis.1 After review of Patient Ps high-grade ductal carcinoma in situ, the physician reviewed the micro invasive disease, as well as her sentinel node biopsy showing negative surgical margins. The physician also discussed the prognosis and natural history of DCIS, as well as possibility of local recurrence. After a complete discussion about the risks and side effects associated with this cancer, the physician recommended that she move forward and be treated with radiation therapy to her right breast. The Plan (Prescription): The radiation oncologists treatment recommendation to Patient P was having her right breast treated with opposed tangential fields to a total dose of 50 Gray (Gy) in 2 Gy fractions daily with a 10 Gy boost to the lumpectomy cavity. This treatment will be performed over the course of six weeks. Since there is no indication of regional nodal involvement, they will not pursue treatment of the supraclavicular or posterior axillary regions. Patient Immobilization: On February 6, 2013, Patient P underwent a computed tomography (CT) simulation scan for radiation therapy. She was placed on a standard Civco breast board with specified arm, bottom, and head placement to ensure daily treatment set-up accuracy (Figure 1). The patient was also given a knee cushion underneath her legs to give additional support while lying at 10 degree angle on her back (Figure 1). After Patient P had the CT scan completed, her radiation fields were then created. A set-up mark was then placed on the patient at midline 10cm superior of the xiphoid process (Figure 2). The mark was then tattooed onto the patient, along with two other tattoos given on each of her sides (for daily set-up rotation) (Figure 3). Although this type of immobilization is not the most comfortable for patients, it suggests the best positioning with the area we are treating. Anatomical Contour: After the scan has been completed, the resident and physician will both approve the scan while also setting the intended fields from treatment. Depending whether or not this treatment is set-fields or planning, the physician will normally draw the lumpectomy cavity so the dosimetrist can make sure that they cover it. Once this has been completed, the physician will fill out a planning directive (including boost), and the scan will be sent to UMPlanning system for dosimetry to plan. Once pulled into dosimetry, the dosimetrist will then start to contour both the normal anatomy as well as organs at risk (OR). Depending on the side, location, and depth, the dosimetrists will contour the lungs, heart, esophagus, and bronchus. The main organ that is considered in this type of treatment is the heart, and how much dose its allowed to receive.

3 Beam Isocenter / Arrangement: Since the physician has already set an isocenter in simulation, both the beams and isocenter information have been loaded into the UM-Planning system. The beam isocenter was placed about 1.5 cm outside of the chest wall for adequate coverage around the entire breast, and specified lung coverage (Figure 4). As for the different beam angles and arrangement, since this was a set-fields right breast case, the physician decided on two opposed co-planar tangential angles for treatment. The angles included the medial angle of 53.8 degrees, and the lateral angle of 229.6 degrees. This beam arrangement was important because the medial angle light field matches to the set-up tattoo on the patients skin. Treatment Plan: Since the radiation oncologist has already outlined the dose prescription and objectives in the planning directive, it is up to the dosimetrist to follow through and achieve an adequate treatment plan. The planning system that was used to both contour and calculate the treatment plan was UMPlan. When starting to plan breast cases, the dosimetrist usually starts out with 6 megavoltage beams (MV), and evaluates the necessity for anything higher. Since this patient was relatively thin and small, the 6MV beam energy was adequate for all fields. As figure 5 indicates, there were 4 fields total for this plan including 2 segments. These in-field segments boost specific areas that need dose and also push this dose around the entire breast (Figure 5). The medial fields include an open field with a segment that treats the upper-medial portion of the breast (Figure 5). The lateral fields included an open field with a segment that treats the inside medial portion of the beast. Both lateral fields include a 15-degree wedge. This wedge was used because it attenuated the beam across the field resulting in a tilted isodose curve that accounted for the patients anatomy.2 Overall the dose to the treatment volume (lumpectomy cavity) received 51.4 Gy and the entire breast received 95 percent coverage (Figure 6). Quality Assurance: The monitor unit calculation and monitor check were done in both the download (through UMPlan) as well as the second check through a medical physicist (usually hand checked). The monitor units on the two-field breast plan (including all 4 fields) were within tolerance and fell within the back-up time that is associated with our departments tolerance. Conclusion: Although many of our breast patients (other than the active breath control system) go through this same type of treatment planning, every situation can be different. This specific type of breast treatment included more than just two open fields. It included both in-field segments and wedging. One of the things about this case that I enjoyed the most was learning

4 more about breast treatments. I think that although I struggled a bit in attempting to add additional segments to the plan, I learned many different things about the necessity and value of beam modifiers. I learned about when and why its a good time to add in these types of modifiers to adjust in treatment planning. In doing this type of plan (two fields with wedges and segments), it has shown me many things that I will do differently on the next patient. Overall, this case was a great learning opportunity and gave me a lot of experience in contouring, planning, and adding compensators when necessary.

Figures

Figure 1: Patient on Civco Breast Board with knee cushion.

Figure 2: Patient with set-up tattoo and straightener.

Figure 3: Patient with side tattoos and levels.

Figure 4: Beam isocenter placement about 1.5 cm outside of chest wall.

Figure 5: Upper two images are the medial fields and the lower two images are the lateral fields with both segments. Lateral fields have 15-degree wedges.

Figure 6: Dose Volume Histogram (DVH) for the target volume/lumpectomy cavity.

9 References 1. Gielda B, Griem K, Dickler A. Breast Cancer. In: Khan F, Gerbi B. eds. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2012:609-610. 2. Bentel, G. Treatment Planning Head and Neck Region. In: Wonsiewicz M, Navrozov M. Radiation Therapy Planning 2nd ed. New York, NY: McGraw Hill; 1996:50.