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Adriana Dalea
Clinical Practicum I
February 21, 2014
Metastatic Right Breast Cancer Case Study
History of Present Illness: JE is a 58 year old female diagnosed with metastatic invasive ductal
carcinoma of the right upper outer quadrant of the right breast. In December 2013 JE initially
presented with a right breast mass of 6 weeks duration. Diagnostic mammogram and ultrasound
demonstrated 7.2 x 4.5 x 1.5 cm heterogeneous mass in the right upper outer quadrant. There was
also axillary adenopathy measuring 5.1 x 5.0 x 2.5 cm. The patient had a core needle biopsy of
the mass that demonstrated poorly differentiated invasive ductal carcinoma. Her final diagnosis
was malignant neoplasm of the right breast with lymphovascular invasion. In December 2013 JE
was deemed a poor surgical and poor chemotherapy candidate by two different physicians. In
January 2014 she had a staging PET/CT exam performed, and there were satellite nodules
surrounding the primary mass, conglomeration of axillary and subpectoral adenopathy and right
subcarinal nodes, a paratrachial node - these observations confirming the metastatic disease. At
the time of the last consultation with the radiation oncologist, the patient came in a wheelchair
and complained of severe axillary and right breast pain, radiating down to the right arm. She was
very emotional. She also needed full assistance with all the transfers.
Past Medical History: The patient has a history of metastatic breast cancer, Alzheimer for 10
years and respiratory failures due to aspiration.
Social History: JE has been living in a nursing home for the past 10 years, and more recently at
home with the family and under 24 hours care. She was accompanied for the consultation with
the radiation oncologist by her sister who is a nurse.
Family History: JE family history is negative for malignancy.
Medications: The patient currently takes the following medications: Acetominophen-
Hydrocodone, Albuterol, Dextromethorphan-Guinine, Diazepam for anxiety, Famotidine,
Ibuprofen, Insulin-lispra, Megestrol, Salifenacin and Tizanidine.

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Diagnostic Imaging Studies: Mammogram and ultrasound in December 2013 demonstrated the
main tumor and the lymphovascular invasion. In January 2014 a staging PET/CT was done and
revealed the surrounding nodules.
Radiation Oncologist Recommendations: Based on the presence of the metastatic disease and
the reduced performance status and overall medical condition, the radiation oncologist
recommended a short course of palliative radiation therapy to the right breast and axilla to
decrease the local symptoms.
The Plan (Prescription): The radiation oncologist prescribed 2,500 cGy at 500 cGy per fraction
for 5 fractions with palliative intent. The plan was to use a 6 field 3D conformal plan with mixed
energies, 6 MV and 18 MV. A custom 5 mm bolus (10 cm x 5 cm) was used for each treatment.
Patient Setup/Immobilization: For simulation, the patient was positioned supine on a breast
board with both arms up, right arm taped, and a sponge placed under the knees for comfort
(Figures 1 and 2). A CT was done and sent to the Eclipse treatment planning system (TPS).
Anatomical Contouring: The dosimetrist delineated the anatomical structures to include the
external body, right and left lungs, carina and the heart.
Beam Isocenter/Arrangement: The isocenter and markings were placed during the simulation.
The isocenter was placed on the lateral border of the right breast. The fields used for treatment
were right anterior oblique for 6 MV and 18 MV, right anterior oblique segmental (6 MV) to
treat the internal mammary (IM) lymph nodes, right posterior oblique for 6 MV and 18 MV and
right posterior oblique segmental (6 MV).
Treatment Planning: The planning system used was Varian Eclipse for a 3D plan. The fields
were normalized to the isocenter. For the right posterior oblique 6 MV field a 45
o
enhanced
dynamic wedge (EDW) was used to minimize the hot spot (Figure 6). The 5 mm bolus was used
for each field. The heterogeneity correction was used for this plan and the calculation algorithm
used was Analytical Anisotropic Algorithm (AAA). The heterogeneity correction was used to
compensate for the differences in electron densities of the tissues, these differences counting for
the tissues different beam attenuation properties. This plan was prescribed as palliative for this

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patients condition. The doses delivered to the structured contoured were within the tolerance
limits, and this is demonstrated in the dose volume histogram (DVH) (figure 9).
Quality Assurance/Physics Check: The Monitor Unit (MU) calculation was checked with
RadCalc and for each field the differences were within the 3% limit. The average difference for
the entire plan was 1.5%.
Conclusion: This was the first case study of the clinical internship. This palliative treatment plan
was a good learning experience as it introduced 3 D planning and provided an understanding of
tangential fields in breast treatments, how dose was distributed, and how wedges are used to
create a more uniform dose. There were studies performed and investigators agreed that the use
of partial wide tangential fields help achieving the optimal blend of target coverage and normal
tissues sparing.
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This patient was prescribed a palliative treatment to alleviate the pain, I firmly
believe that this task was accomplished.













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Reference
1. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia,
PA:Lippincott Williams & Wilkins; 2012.


















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Figures

Figure 1. Patient position during simulation.



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Figure 2. Isocenter placement AP set up DRR with graticule.


Figure 3. Isocenter placement sagittal set up DRR with graticule.


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Figure 4. Isocenter placement in the beam eye view, right medial DRR with graticule.

Figure 5. Isocenter placement in the beam eye view, right lateral segments DRR with graticule.


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Figure 6. Isodose lines distribution axial view.

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Figure 7. Isodose lines distribution coronal view.


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Figure 8. Isodose lines distribution sagital view.

Figure 9. Dose volume histogram (DVH).