ABSTRACT: This will be left blank until the end of the semester

I.Introduction:
a. Survivorship is an important concept for individuals diagnosed with early stage,
left sided breast cancer.
b. The increasing survival rate for breast cancer patients has prompted a growing
concern to reduce the risk of developing a secondary lung malignancy or cardiac
complication.
c. Lara et al10 reported that there has not been a thorough comparison of the mean
dose to the heart for all breast techniques, for various breast sizes and/or seroma
locations
d. DIBH causes an increased spatial separation between the heart and target volume,
which results in a decreased volume of the heart within the tangential fields.
e. Patients with inner-quadrant tumors had a more than doubled risk of
cardiovascular mortality compared with patients with outer-quadrant tumors.
f. For individual patients it is difficult to predict the optimal treatment position
without taking both FB and DIBH CT scans into consideration
g. Although prone treatment is generally reserved for women with large, pendulous
breasts, the prone setup reduced the amount of irradiated lung in all patients.
h. The goal of this retrospective study was to develop a tool that predetermines best
position for optimal heart and lung sparing to minimize multiple CT scans.
II.Methods and Materials
a. Patient Selection
i.The patients selected for this study were all diagnosed with cancer of the left
breast without lymph node involvement.
ii.Each patient underwent CT simulations in the supine free-
breathing (FB) and supine deep-inspiration breath hold (DIBH) positions.
iii.Following completion of the FB and DIBH simulations, each patient was
also simulated in the prone position on a CDR prone breast board.
b. Contouring:
i.Contouring was performed on each of the prone, DIBH, and free breathing
using either Raystation or Eclipse software.
ii.The heart and left lung were
contoured referencing the Radiation Therapy Oncology Group (RTOG) 110
6 Thoracic Atlas.
c. Treatment Planning:
i.Tangential fields were created utilizing the borders indicated by
the radiation oncologist at the time of simulation.
ii.All plans were calculated to receive 45 Gy in 25 fractions at 180cGy/day on
a Varian TrueBeam Linac using Eclipse treatment planning software (TPS)
and Analytical Anisotropic Algorithm (AAA).
iii.Measurements were acquired from each scan including the following:
the mean heart and lung dose, the maximum heart and lung dose, the
hotspot, heart separation, chest expansion, and breast size.
 d. Plan Comparisons:
i.P-value tests were performed to evaluate the change in mean heart and lung
doses.
ii.Scatter plots were created to evaluate for correlation between sternal
separation and the change in mean heart and lung doses from FB to DIBH
scans
iii.Additionally, the patients' BMI, smoking history, breast size, and primary
tumor quadrant (pre-surgery) were analyzed to see if there was
any correlation to the above findings.
III.Results:
a. The clinical characterization of the patients involved in the study are summarized
in a table.
b. The statistics show that overall DIBH was better for mean and maximum heart
dose, with an average of 2.93% and 33.84% of prescription respectively for DIBH
compared to 4.04% and 62.17% for the free breathing scans.
c. P-value tests were performed to evaluate the change in mean heart and lung
doses.
d. The dose statistics between the factors that we assessed, such as breast size,
sternal separation, smoking status, and breast quadrant failed to show any
correlation.
IV.Discussion:
b. This study failed to find correlation between any measurements that would be
predictive of the best position for the treatment of left sided breast cancer patients.
c. Patient smoking status was not indicative of the mean heart or lung dose.
c. Sternal separation did not prove to be a good indicator of improvement.
d. The measurement of heart separation at the level of isocenter did not show
correlation to the mean heart or lung dose.
e. Breast size measured on a single slice and BMI showed no correlation to each
other and were not predictive of heart and lung doses.
f. Primary tumor breast quadrant statistics did not correlate to lung or heart dose in
this study.
V.Conclusion:
b. This study failed to find correlation between any measurements that would be
predictive of the best position for the treatment of left sided breast cancer
patients and minimize the number of CT simulations.
c. One possible limitation of this study was the limited sample size used.
c. Another limitation of this study was the evaluation of measurements taken in a
single plane.
d. Centers should continue to perform CT simulations in each of the DIBH, FB, and
prone positions to ensure that each patient has the best opportunity for the creation of
an individualized treatment plan which best minimizes heart and lung dose during the
treatment of left-sided breast cancer.
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