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Megan Whitley May Case Study #2 July 29, 2013 Right Breast Radiotherapy with Electronic Compensators History of Present Illness: CN is a 60 year old female who attended a routine mammogram screening in early March of 2013 and discovered possible calcifications centrally within the right breast. Additional mammogram views taken on March 2013 showed an 11-12 millimeter (mm) nodule in the 8 oclock position of the right breast, along with 2, 5 mm nodules in the lateral aspect of the anterior left breast. On March 2013 an ultrasound guided needle biopsy was performed revealing infiltrating ductal carcinoma (IDC), estrogen receptor positive 90%, progesterone receptor negative 0%, human epidermal growth factor receptor 2 negative (ER +, PR-, HER2-). The percentage associated with the estrogen and the progesterone determine how receptive the patient will be to both hormone therapy and chemotherapy.1 Thus, the outcome for the patient is influenced by these percentages; the higher the percentage the better chance for a positive prognosis. On April 2013 she underwent a computed tomography (CT) of the chest, abdomen, and pelvis for further evaluation of the right upper quadrant abnormality defined on her mammogram. This revealed another abnormality in the right kidney measuring 6 x 4.7 x 4.9 centimeters (cm). The mass was solid anteromedially with scattered nodular calcifications. CN is currently awaiting diagnosis from an urologist for this mass, but has been referred for considerations of adjuvant therapy. On April 2013, she underwent a lumpectomy and sentinel lymph node biopsy. The pathology determined a grade 2 IDC with lymphovascular space invasion. The tumor removed measured 1.1 x 1 x 1 cm and the resection margins were negative. Past medical History: CN has a history of hypertension, hypercholesterolemia, basal cell carcinoma, and trigeminal neuralgia. In 1957 CN had a tonsillectomy. In 1976 and in 1979, she had benign cysts removed from her left breast. In the 1980s she had a laparoscopic procedure to assess infertility, and subsequently had in vitro fertilization. CN was on Estrace for 2 years, which is hormone replacement therapy. More recently she added a right breast core biopsy, lumpectomy, and right partial mastectomy to her list of surgeries. Social History: CN is a social worker, who is married with 2 children, ages 21 and 27. She has no history of tobacco use and consumes 1 alcoholic beverage per week. Her mother had lymphoma at age 86, but otherwise there is no known history of malignancy in her family.

Medications: Currently, CN is on metprolol and paroxetine. She has no known drug allergies. Radiation Oncologist Recommendations: Upon meeting with the radiation oncologist (RO), CN and her husband were apprised of the potential treatment options available. The RO discussed with them the rationale for whole breast radiation. She also entailed various fractionation schemes including conventionally fractionated and hypofractionated treatments. Due to the presence of lymphovascular space invasion, she is an ideal candidate for partial breast irradiation. CN asked multiple questions and they were answered to her satisfaction. Both the acute and delayed side effects were discussed. Based on this conversation, the diagnostic imaging, the pathology, and the ROs previous experience, a hypofractionated treatment regimen was decided upon with an initial 16 fractions, followed by a 4 fraction boost. The radiation oncologist recommended CN for adjuvant radiation therapy following breast conservation surgery. Three different treatment regimens were discussed. The first was whole breast irradiation with a boost either in standard fractionation or hypofractionation. Also discussed was the potential for a trial/protocol study. The trial randomizes patients between sequential and concurrent boosts, and CN would be eligible due to her age of less than 50 years. The last option was brachytherapy. In this case a SAVI (strut adjusted volume implant), that utilizes multiple catheters within the lumpectomy cavity, would be placed for customized volumetric irradiation.2 The SAVI is a partial breast treatment mechanism meant as part of breast conservation therapy. Side effects of radiation for all of these options were discussed. Due to a timeframe issue, the protocol was not the correct option for CN. And after a CT scan was performed to evaluate her tumor site, it was determined that her cavity was not viable for SAVI placement. The Plan (prescription): Thus, a prescription was written for 4256 centigray (cGy) to be delivered at 266cGy/day for16 fractions for her initial treatments. After this original dose, a boost plan will be developed that will take the overall dose to 5256 cGy, rendering the boost prescription at 1000 cGy delivered at 250 cGy/day for 4 fractions. The patient will meet with medical oncology for follow-up adjuvant therapy. Electronic compensators were designated to be used as well as mixed energies if necessary. Patient Setup/Immobilization: The patient was placed in a supine position on a wing board with a Vac-Lok and B headrest on the wingboard. A knee wedge was placed beneath the knees. Both arms were extended above her head, holding handles in the B1 position. The radiation oncologist marked the extent of the right breast tissue with superior, inferior, medial, and lateral

markers, lumpectomy scar, and nipple. The laser origin was demarcated with 3 fiducial markers. The scan included 2.5 millimeter (mm) slices. After the scan was complete, the radiation oncologist set the isocenter, the table was shifted, and the treatment isocenter was marked on the patient. The images were then transferred to the picture archiving and communication system (PACS) software and Eclipse treatment planning software (TPS) version 10.0. Anatomical Contouring: After the patient was imported into Eclipse for planning, contouring was done of both the lungs separately, a total combined lung structure, the heart, the body, the scar and all of the field delineating wires, and the thyroid gland. The radiation oncologist contoured the clinical target volume (CTV), which is the lumpectomy cavity, and the clips remaining post operatively to designate the extent of the tumor cavity. The medical dosimterist placed a 1 cm expansion structure was created and labeled Cavity + 1. Both the CTV and the expansion are represented in Figure 1. A plan was generated focusing the prescribed dose on both the expansion and the CTV. Beam Isocenter/Arrangement: The isocenter was established at the time of simulation by the RO. Based on the location of the isocenter, and the directions from the RO, a tangential beam arrangement was produced. The 2 tangents, one medial field and one lateral field, encompassed the extent of CNs breast tissue. The superior field edge was set just beneath the humeral head, while the inferior border was associated with the radiopaque marker at the inferior aspect of the breast tissue. The anterior field edge was set allowing for 2 cm of skin flash, and the posterior edge was set to encompass the chest wall muscle, excluding any excess lung tissue. The flash is the area allowed around the breast tissue, used to account for any changes in respiratory movement and patient setup (Figure 2). Treatment Planning: The medial beam was placed at the time of simulation, so the first step was to oppose it producing the lateral tangent beam (Figure 3). With both of the beams created, a non-coplanar technique was used to provide non-divergent posterior borders and to decrease the radiation received in the lung and heart. The energy was set to 6 megavoltage (MV) for both beams. The separation of the patient was small enough that this energy provided adequate penetration to achieve proper dose distribution. Both the separation and the dose distribution can be seen in Figure 1. An initial calculation was done at this time and it was decided that electronic compensators (ECs) were required. Due to the use of ECs, an equal weighting technique was used. When using ECs, the dose is changed throughout the treatment area by

editing the fluence or the dose cloud. Once the fluence is edited, the algorithm determines how the multi-leaf collimators (MLCs) move to create the chosen fluence. This can be seen in Figure 2. Designed choreographed movements of the MLCs increase or decrease the transmission and influence the dose to the CTV. Once 20% of the lung volume (V20) receives a does less than 30%, the mean lung dose totals less than 20 gray (Gy), the heart V20 dose is less than 10%, and the mean dose to the liver is less than 28 Gy, the dosimetrists work with the plan was completed. The hot spot was decreased as far a possible without effecting the coverage to the CTV. These doses were registered on a dose volume histogram (DVH) and reported to the physician (Figure 4). Once these goals were achieved, the radiation oncologist approved the plan. Then the approved plan was exported to Mosaiq and the beam data was provided to the therapist (Figure 5). Lastly, a quality assurance (QA) plan was generated, digitally reconstructed radiographs were provided for the first day of treatment, and backup calculations were performed and documented by RadCalc (see Figure 6). Quality Assurance/Physics Check: Once the RO approved the plan, the final step was to perform a trial fraction. This ascertained that the information accurately transferred to the record and verify software, and that the plan would perform in the predetermined manner. A QA plan was created by the physicist and compared to the approved treatment plan fluence. For the plan to pass QA, 95% of all the points tested within the phantom must have a 3% more or less deviation from the predetermined dose. This plan passed QA. Conclusion: This plan was a very educational experience in organization of both thought and decision making. During the course of treatment planning the RO designated for CN changed several times, due to schedule complications and vacation. There were communication issues and difficulties determining the RO assigned to the patient, but the treatment planning had to continue. In the end, the practice gained from repeatedly explaining the patients specifics provided the greatest experience. Defending and discussing the reasoning behind treatment planning choices proved hugely beneficial as well.

Figures

Figure 1. This is an axial slice demonstrating the separation across the breast tissue and the dose distribution throughout the area of concern.

Figure 2. This figure demonstrates the manner in which the algorithm designed the MLCs to move to achieve the set fluence. The MLCs will move throughout the treatment, thus this is just one of the many MLC positions utilized by the algorithm.

Figure 3. This figure is representative of the tangential field arrangement, where the beams are opposed from one another.

Figure 4. This is a DVH used to illustrate doses received by both the targets and the organs at risk.

Figure 5. This is the beam report that provides a summary of the treatment plan.

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Figure 6. This is the documentation provided by RadCalc, verifying that the secondary calculation check passed QA.

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References

1. Anderson TJ, Battersby S: The involvement of estrogen in the development and function of the normal breast: histological evidence. Proc R Soc Edinb. 1989; 95(B):23-32. 2. Cianna Medical. Less Toxicity. More Patients. Now That's SAVI. http://www.ciannamedical.com/ 2012. Accessed January 25, 2012.