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A.J. Kressin
Clinical Practicum I
March 8, 2014
Tangential Fields for Respiratory Gated Left Breast
History of Present Illness: Patient NS is a 64 year-old female who underwent a screening
mammogram in December 2013, in which a density in the left breast at the 8 oclock position
was discovered. A diagnostic mammogram was performed in January 2014 revealing a 1.3 cm
lesion. An ultrasound on the same day showed an irregular mass at the left 7 oclock position
near the inframammary fold. An ultrasound-guided biopsy of the lesion revealed ductal, grade 3,
invasive mammary carcinoma. Estrogen and progesterone receptors were both positive and Her-
2/neu was negative. Patient NS underwent a computed tomography (CT) scan of the chest,
abdomen, and pelvis in January 2014 which revealed the presumed left breast cancer. A cystic
lesion in the left kidney was also discovered. On the same day NS underwent a bone scan, but it
was determined that there was no clear evidence of metastatic disease. Patient proceeded with
breast conservation surgery in January 2014, in which a left axillary deep sentinel lymph node
biopsy and a left breast lumpectomy were performed. Margins for the invasive carcinoma in the
main specimen were all negative. The patient had 8 sentinel lymph nodes evaluated, all of which
were negative. Final pathology showed T1C, N0 disease. In February 2014, the patient was
referred to radiation oncology to discuss the potential for post-operative radiation therapy to left
breast to help with local control of disease. The radiation oncologist reviewed the patients
records and discussed the various treatment options with her. Radiation treatment to the entire
left breast was recommended with a boost to the lumpectomy cavity to follow. After a long and
thorough discussion about the risks and benefits of treatment with NS, she elected to proceed
with radiation treatment.
Past Medical History: Patient has a past medical history of allergy to chlorhexidine towlette,
asthma, gastroesophageal reflux disease, diabetes mellitus type 2, hypertension, deafness in the
left ear, fibrocystic breast, hyperlipidemia, migraine headache, and elevated liver enzymes. NS
reports a surgical history that includes a total abdominal hysterectomy with bilateral
salpingoophorectomy, and a left breast lumpectomy.
Social History: NS is retired and married with 2 children. Patient has reported never smoking or
using tobacco. Patient also does not claim to consume alcohol and has no drug use on file. NS
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reports she has a mother who is deceased with a history of myocardial infarction and
hyperlipidemia, a maternal grandmother who died in her 80s with a history of cerebrovascular
accident (CVA), a maternal grandfather who died in his 80s with a history of CVA, a father who
died at the age of 78 with a history of alcoholism and malignant lung cancer, a paternal
grandmother who died in her 70s, a paternal grandfather who died in his 70s, and two deceased
brothers with histories of cystic fibrosis.
Medications: The patient uses the following medications: acetaminophen, albuterol, aspirin,
atorvastatin, blood sugar diagnostic strip, calcium citrate-vitamin D3, cinnamon bark, Centrum
Silver, fluticasone-salmeterol, lancets, lisinopril-hydrochlorothiazide, metformin, omega-3 fatty
acids, omeprazole, oxycodone-acetaminophen, propranolol, and sumatriptan.
Diagnostic Imaging: In December 24, 2013, NS underwent a mammogram screening that
revealed a density in the left breast. An ultrasound-guided biopsy of the lesion was performed in
January 2014. The pathology from this biopsy revealed a ductal, grade 3, invasive carcinoma of
no special type. Estrogen and progesterone receptors were both positive and Her-2/neu was
negative. NS also underwent a CT scan of the chest, abdomen, and pelvis in January 2014. This
scan revealed the presumed breast cancer along with a cystic lesion in the left kidney. A bone
scan was performed that same day and returned negative for metastatic disease. In January 2014
NS underwent a left axillary deep sentinel lymph node biopsy and a left breast localized
lumpectomy. Pathology of the tumor revealed invasive ductal carcinoma, grade 2, with the
greatest dimension of the tumor measured at 1.4cm with no positive margins. The patient had 8
sentinel lymph nodes evaluated, all of which were negative. NS was said to have pathologic
T1C, N0 disease.
Radiation Oncologist Recommendations: After reviewing the patients surgical and
pathological history, the radiation oncologist recommended NS undergo post-operative radiation
treatment to the left breast using traditional medial and lateral tangential beam arrangements.
Following breast conservation surgery up with whole breast radiation therapy has been a
common practice for years in order to help with local control.
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There is also some evidence that
shows the risk of developing second cancer after breast conserving therapy may be lower when
3-dimensional conformal radiation therapy (3D-CRT) or tangent intensity-modulated radiation
therapy (t-IMRT) is used as opposed to multi-beam intensity-modulated radiation therapy (m-
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IMRT) or volumetric-modulated arc therapy.
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The radiation oncologist also recommended that
NS follow up initial breast treatment with a 3D conformal boost to the lumpectomy cavity.
The Plan (prescription): The radiation oncologists recommendation to the patient was a 3D
breast plan that consisted of traditional medial and lateral tangential beam arrangements. The
physician also recommended NS undergo a 3D boost to the lumpectomy cavity following initial
whole breast irradiation. The prescription plan for the initial whole left breast irradiation was
5040 cGy at 180 cGy per fraction for 28 fractions. The boost prescription was 1000 cGy at 200
cGy per fraction for 5 fractions. Daily Exac-Trac imaging was prescribed to assist with daily
reproducibility. For the purposes of this case study, only the initial whole breast plan will be
discussed.
Patient Setup/Immobilization: In February 2014, the patient underwent a CT simulation scan
to aid in radiation treatment planning. The patient was placed in the supine position on the CT
simulation couch with a wing board and Vac-Lok bag and arms raised above her head (Figures
1-2). The radiation oncologist outlined the breast field and lumpectomy scar with wire for
identification on the CT scan. The patient also had foam under her knees for support. Prior to
scanning, NS was aligned and straightened with in-room lasers.
Anatomical Contouring: After the CT simulation scan was completed, the data set was sent to
the Philips Pinnacle 9.0 treatment planning system (TPS). The physician contoured the
lumpectomy cavity and heart. The medical dosimetrist contoured the lungs and carina. The
medical dosimetrist was given a prescription objective sheet to begin treatment planning.
Beam Isocenter/Arrangement: The physician placed the isocenter in the left lung
approximately 1.5 cm from the chest wall (Figures 3-4). The isocenter is also approximately at
the mid-plane depth of the medial and lateral tangential beams and at the center of the inferior
and superior wires placed during simulation (Figures 5-7). Because of the lumpectomy cavity
location and patient size, 6 MV and 10 MV energies were used in both the medial and lateral
tangential fields. Beam weights of 27, 25, 23, and 25% were used in the 6MV medial tangent,
10MV medial tangent, 6MV lateral tangent, and 10MV lateral tangent beams respectively. The
medial tangential beams were set at 304 degree angles, while the lateral tangential beams were
set at 124 degrees. The field size apertures were defined by the physician and include the whole
left breast and a margin for flash (Figures 8-9). Each field aperture utilized multi-leaf collimators
(MLCs) to define the field size and block out the heart. The medical dosimetrist assigned the
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prescription to all 4 fields and added control points to the 6 MV beams in both the medial and
lateral tangential fields. The medical dosimetrist then adjusted control point weights in order to
acquire an adequate dose distribution around the lumpectomy cavity and eliminating hot spots.
Treatment Planning: The radiation oncologist outlined the dose prescription and treatment plan
objectives. The objective was to avoid any unnecessary radiation to the heart and lungs while
delivering an adequate and homogenous dose distribution to the tumor volume throughout the
entire left breast (Figures 10-11). The prescription for the initial tangential fields was prescribed
to a calculation point placed in the left breast by the medical dosimetrist. All 4 beams were
assigned to this calculation point and computed. The prescription was a total of 5040cGy
delivering 180 cGy per fraction for 28 fractions. The 6 and 10 MV medial tangential beams
delivered 48.6 and 45 cGy respectively per fraction. The 6 and 10 MV lateral tangential beams
delivered 41.4 and 45 cGy respectively per fraction. The medical dosimetrist assigned a
normalization of 97% to the prescription. The heart and lung doses were to be kept as low as
reasonably achievable (ALARA). The DVH showed a maximum heart dose of 3878.7 cGy and a
mean dose of 154.3 cGy (Figure 12). The maximum total lung dose was 5230.1 cGy with a mean
of 179.4 cGy. The radiation oncologist reviewed and approved the plan.
Quality Assurance/Physics Checks: The monitor units (MUs) were double checked using the
MUcheck program. The department tolerance between MUcheck and the TPS is 5% for MUs
of each field. This plan fell within the 5% tolerance. The blocks for each segmented field were
verified using the Dose Lab program. The department requirement is that 95% of the motor
counts be within 2 mm from the TPS MLC positions to the delivered MLC positions. The
completed plan was reviewed by a medical physicist for a final check before treatment began.
Conclusion: The breast plan presented the medical dosimetrist with a few minor challenges.
After playing with weights using only 6 MV beams, and considering the patients size, it was
determined that dual energy needed to be used in order to get adequate dose coverage to portions
of the lumpectomy cavity adjacent to the chest wall. Using nearly 25% beam weights for all 4
beams seemed to help with dose coverage. The dosimetrist also needed to prescribe to 97% in
order to ensure adequate dose coverage of the lumpectomy cavity. While adding control points,
the dosimetrist had to compromise between coverage and hot spots. It was determined that 10%
hot spots medially and laterally were acceptable to allow for the best coverage of the
lumpectomy cavity adjacent to the chest wall. Through the planning of this patients treatment I
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learned that ending up with 10% hot spots medially and laterally is not uncommon, especially for
thicker patients.

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References
1. Mozsa E, Meszaros N, Major T, et al. Accelerated partial breast irradiation with external beam
three-dimensional conformal radiotherapy: five-year results of a prospective phase II clinical
study. Strahlentherapie und Onkologie. 2014. http://dx.doi.org/10.1007/s00066-014-0633-1
2. Abo-Madyan Y, Aziz MH, Aly MMOM, et al. Second cancer risk after 3D-CRT, IMRT and
VMAT for breast cancer. Radiotherapy and Oncol. 2014.
http://dx.doi.org/10.1016/j.radonc.2013.12.002

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Figures

Figure 1. Patient position on a wing board on CT simulation couch.

Figure 2. Patient position on a wing board on CT simulation couch.
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Figure 3. Anterior view of isocenter placement on a digitally reconstructed radiograph (DRR).
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Figure 4. Lateral view of isocenter placemen on a DRR.
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Figure 5. Isocenter placement in axial view.
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Figure 6. Isocenter placement in the sagittal view.
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Figure 7. Isocenter view in coronal view.
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Figure 8. Medial tangent treatment field with MLC blocking.
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Figure 9. Lateral tangent treatment field with MLC blocking.
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Figure 10. Isodose distribution of the left breast.
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Figure 11. Isodose distribution of the left breast.

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Figure 12. DVH of left breast treatment plan.