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PMRT for Male Invasive Ductal Carcinoma of the Left Breast: A Case Study Authors: Dustin Melancon, B S , R T !T" # $ishele Lenards, M S , CMD, R T !R"!T", %AAMD *Medical Dosimetry Program at the University of Wisconsin - La Crosse, WI and Department of Radiation ncology, !ames "raham #ro$n Cancer Center, Lo%isville, &' A&stract: Introduction: (ltho%gh )reast carcinoma in males is rare, it is treated li*e female cases on a stage-)y-stage comparison+1 ,his st%dy aims to eval%ate male post-mastectomy radiation therapy -PMR,. %sing three-dimensional conformal radiation therapy -/D-CR,. $ith the field-in-field -0I0. techni1%e for invasive d%ctal carcinoma of the left )reast+ ,his treatment techni1%e has )een sho$n in literat%re to red%ce dose to organs at ris* - R., s%ch as the heart, and assists in delivering an even dose distri)%tion to the target+ In addition, st%dies reveal that along $ith systemic therapy, PMR, $ith modern techni1%es can red%ce side effects, increase local control, and improve s%rvival+2-3 Case Descri'tion: ,he case involved a male patient diagnosed $ith invasive d%ctal carcinoma $ho received post-mastectomy chemotherapy follo$ed )y radiation therapy+ ,he /D-CR, case feat%red mi4ed energy tangential )eams $ith the 0I0 techni1%e, a s%praclavic%lar field, and an electron )oost+ Conclusion: ,he plan $as eval%ated for ho$ $ell dose o)5ectives and constraints $ere met %sing /D-CR,+ ,he eval%ation also incl%ded doses to critical str%ct%res )ased on a dose vol%me histogram -D67. and the dose distri)%tion thro%gho%t the target+ Using /D-CR, in PMR, has )een sho$n in literat%re to spare critical str%ct%res and improve dose homogeneity+ (ey )ords8 Post-mastectomy radiation therapy -PMR,., three-dimensional conformal radiation therapy -/D-CR,., field-in-field -0I0. techni1%e+

Introduction 9imilar to female )reast cancer patients, male patients $ith advanced stage disease and nodal involvement are at higher ris* of rec%rrence+1 lder PMR, techni1%es esta)lished )etter local control, )%t they also had an e4cessive ris* of cardiovasc%lar death+ More recent st%dies sho$ that modern radiotherapy techni1%es can improve local control and avoid cardiac mor)idity, regardless of t%mor si:e, n%m)er of positive nodes, or histopathologic grade+2,/ ( #ritish Col%m)ia randomi:ed trial $ith 2; years of follo$-%p fo%nd that post-mastectomy patients receiving chemotherapy and irradiation of all regional lymph nodes and chest $all areas had significantly red%ced rates of )reast cancer rec%rrence, compared $ith post-mastectomy chemotherapy alone+< ,he trial also sho$ed a red%ction in overall mortality+ (s in other solid t%mors s%ch as l%ng, esophageal, and rectal cancers, chemotherapy alone cannot al$ays eliminate all resid%al disease+ ,he microscopic disease may )e resistant or )ecome resistant to chemotherapy+ (d5%vant PMR, can )e delivered to optimi:e the o%tcome+3 ,he /D-CR, techni1%e is commonly %sed for PMR,, $hich %ses tangential radiation fields to treat the chest $all+ ,he physician may prefer the tangential fields to feat%re a com)ination of lo$ and high energy photon )eams for )etter dose homogeneity+ ,he lo$ energy )eams allo$ for ade1%ate dose near the s*in s%rface $hile higher energy )eams can achieve greater depth+ Patients $itho%t a4illary lymphatic involvement are sometimes treated %sing only tangential fields to the chest $all+ ,he a4illa and s%praclavic%lar regions may )e treated )ased on prognostic ris* factors, s%ch as involvement of < or more positive nodes+ (n electron )oost is %s%ally delivered to the e4cision site )eca%se local t%mor rec%rrence is most fre1%ently o)served near the site of the t%mor )ed+< ( standard co%rse of PMR, consists of 3;;; to 3;<; centigray -c"y. delivered in 23 to 2= fractions -f4., follo$ed )y a >;;; to >=;; c"y )oost to the mastectomy scar+< Potential effects of PMR, incl%de s*in reactions, lymphedema, )rachial ple4opathy, radiation pne%monitis, ri) fract%res, cardiac to4icity, radiation-ind%ced secondary neoplasms, and poor cosmetic res%lts+=,? ,he data s%ggested that the incidence of many of these to4icities $ill )e lo$er $hen modern radiotherapy techni1%es are %sed@ therefore, the case presented has )een planned and treated %sing a modern techni1%e+

,he remainder of this case st%dy $ill foc%s on delivering a homogeno%s dose to the target $hile minimi:ing dose to critical str%ct%res+ Danish trials have sho$n that PMR, $ith modern techni1%es did not increase the ris* of ischemic heart disease-related mor)idity or mortality+ < 9everal st%dies have sho$n )enefits of the 0I0 techni1%e for improving target conformity and red%cing dose to R d%ring tangential irradiation+A,B ,he 0I0 techni1%e also demonstrated 0I0 techni1%e had s%perior res%lts to most cases %sing dynamic or physical $edges+B Res%lts s%ch as these provide evidence that modern treatment techni1%es, s%ch as the 0I0 techni1%e, allo$ %s to provide patients the )enefits of PMR, $ith less to4icity to R+ Cven $ith these improvements, it is important that the doses are properly doc%mented in the treatment planning system+ >; ,he case presented $as planned $ith a 0I0 techni1%e %sing a m%lti-fractionated approach to PMR,+ ,he plan $as eval%ated )ased on a c%m%lative dose vol%me histogram -D67., prescription dose coverage, and ma4im%m and mean doses to R+ Case Descri'tion Patient Selection ( =3 year-old male $ith invasive d%ctal carcinoma of the left )reast $as referred to the facility for PMR,+ ,he patient $as selected for this case st%dy to demonstrate that PMR, for men is treated $ith a similar approach as $omen+ ,he patient had standard fractionation as $ell as an electron )oost to the mastectomy scar+ ,his case demonstrated the %se of mi4ed energy tangential fields feat%ring the 0I0 techni1%e for )etter homogeneity and less dose to critical str%ct%res+ 9eparate plans $ere %sed in the ,P9 for the tangential fields, s%praclavic%lar field, and electron )oost+ Patient Set-up ,he patient %nder$ent a C, scan head first in the s%pine position on a tilt )oard immo)ili:ation device+ ,he head $as t%rned to the right and s%pported $ith a tilt )oard headrest+ ,he left %pper arm $as e4tended and positioned a)ove the head $hile the right arm $as positioned a*im)o+ ,he patient had a sponge %nder the *nees for s%pport+ ,he radiation oncologist mar*ed the s%perior, inferior, medial, and lateral regions of the left chest $all $ith radiopa1%e mar*ers+ ,he radiation therapist o%tlined the patientDs mastectomy scar $ith a radiopa1%e $ire to assist the medical

dosimetrist d%ring treatment planning+ Target Delineation ,he 6arian Cclipse ,reatment Planning 9ystem -,P9., version >;+;, $as %sed for all target delineation+ ,he radiation oncologist placed the isocenter )ased on the desired treatment regimen+ ,he radiopa1%e mar*ers $ere demonstrated on the ,P9 and helped the medical dosimetrist determine the target+ (ny PMR, techni1%e re1%ires irradiation of the entire mastectomy flap, incl%ding the entire mastectomy scar, s%rgical clips, and drain sites+/ ,he fields for the patient e4tended from the stern%m to at least the mid-a4illary line+ It $as important to provide ade1%ate coverage in the inferior )order+ ,his )order $as placed a)o%t 2 cm ca%dal to the previo%s location of the inframammary s%lc%s+ ,he s%perior )order of the chest $all fields a)%tted the s%praclavic%lar field+ ,o avoid e4cessive dose at the field 5%nction, the radiation oncologist preferred %sing a monoisocentric techni1%e to create a non-divergent edge+ In order to create a non-divergent field edge, asymmetric-5a$s )eam-split the tangential and s%praclavic%lar field along the central-a4is plane+ Critical normal str%ct%res near the treatment area incl%ded the spinal cord, left l%ng, right l%ng, and heart+ ,he medical dosimetrist %sed the radiopa1%e $ire that o%tlined the mastectomy scar to plan the electron )oost plan+ ( > cm )ol%s $as added in the ,P9 for the electron )oost plan+ ,he medical dosimetrist added a 2 cm margin in all directions of the s%rgical scar+ Treatment Planning ,he dose prescription and *ey planning parameters are presented in ,a)le >+ ,he plan $as generated %sing for$ard planning+ ,he tangential fields for the chest $all feat%red mi4ed energy photon )eams $ith the 0I0 techni1%e+ ,he 0I0 techni1%e can atten%ate radiation in small areas of the field $ith c%stomi:ation of the MLCs+ 7igh dose areas are common $ith = megavoltage -M6. )eams in large separation si:es+ When there is a s%)stantial amo%nt of tiss%e in the field, a mi4t%re of higher-energy )eams can )e %sed to red%ce the areas of higher dose+ ,he lo$er energy remains in the tangential fields to treat the s%perficial areas of the )reast+= ,angential, s%praclavic%lar, and electron )oost plans $ere optimi:ed $ith heterogeneity corrections on+ ,he goals $ere to achieve conformal target coverage and preserve as m%ch normal tiss%e as possi)le+

,he challenge of delivering a prescription dose of 3;;; c"y in 23 f4 to the tangential fields $as complicated )y the close pro4imity of the heart and left l%ng+ ,he o)5ectives incl%ded8 ma4im%m spinal cord dose less than <3;; c"y, mean heart dose less than 2;; c"y, and the left l%ng dose to )e as lo$ as reasona)ly achieva)le+ ,he prescription dose for the conventional tangential fields $as prescri)ed to a calc%lation point placed )y the medical dosimetrist at a depth of >2+> cm $ithin the left chest $all+ ,he medical dosimetrist placed the calc%lation point near the midplane depth of the medial and lateral tangential )eams, in the center of the s%perior and inferior e4tents of the left chest $all vol%me, and appro4imately >+3 cm from the left chest $all+ pen tangential fields of = M6 and >A M6 )eams $ere %tili:ed for )etter dose homogeneity+ M%ltileaf collimators -MLCs. helped to )loc* e4cessive R doses in the open tangential fields+ ,he )loc*ed R incl%ded the heart and a portion of the left l%ng $hile ens%ring the chest $all still received ade1%ate dose+ ,he 0I0 techni1%e %sed portals treated thro%gh the same gantry angle to red%ce high dose regions -0ig%re >-2.+ ,he medical dosimetrist accomplished this )y converting the >>2E isodose level to a str%ct%re in the ,P9+ Fe4t, the medical dosimetrist loo*ed at the )eamDs eye vie$ of the 0I0 portal and ad5%sted the MLC to cover the >>2E str%ct%re+ nce calc%lated, all of the fields $ere appropriately $eighted+ ,he medical dosimetrist then converted the >;BE isodose level to a str%ct%re to increase dose homogeneity and lo$er the ma4im%m dose region+ In the s%praclavic%lar field, there $as a /<3G gantry rotation to red%ce dose to the spinal cord+ ,he MLCs $ere c%stomi:ed to protect the h%meral head and spinal cord+ 0or the mastectomy scar, electrons $o%ld deliver dose to the scar and limit the dose to ad5acent tiss%e+ ,he medical dosimetrist %sed B mega-electron volts -Me6. $ith a > cm )ol%s at >;3 cm so%rceto-s*in distance -99D.+ ( )loc* $as created in the ,P9 that provided a 2 cm margin aro%nd the scar+ ,he medical dosimetrist set the gantry at /3G $ith the collimator at >;G+ ( 23423 cm cone si:e $as large eno%gh to cover the entire mastectomy scar+ ( calc%lation point $as placed at a depth of 2+> cm, the ma4im%m dose -dma4. of B Me6+ ,he calc%lation points for the tangential fields, s%praclavic%lar field, and the electron )oost $ere normali:ed to >;;E of the prescription dose+ ,he medical dosimetrist analy:ed the B3E isodose line to ens%re each field $as ade1%ately covered+ Plan Analysis & Evaluation ,he o)5ective of radiation therapy in the management of PMR, is to minimi:e the ris* of

locoregional rec%rrence $hile minimi:ing the dose to R+ ,he 1%ality of the plan for PMR, can )e assessed )y ho$ $ell the plan covers the chest $all and doses to the left l%ng and heart+ ,he case $as analy:ed as to ho$ $ell dose o)5ectives and normal tiss%e tolerances $ere met+ ,he radiation oncologist $anted the mean dose for the heart )elo$ 2;; c"y and the left l%ng dose as lo$ as reasona)ly achieva)le+ ,he c%m%lative doses -,a)le 2. and constraints $ere eval%ated -0ig%re /-=.+ ,he ma4im%m point dose in the heart $as A;/+/ c"y, >2/+B c"y in the spinal cord, <A>3+/ c"y in the left l%ng, and >2>+2 c"y in the right l%ng+ Mean doses incl%de >2B+B c"y in the heart, 3B+2 c"y in the spinal cord, A3?+= c"y in the left l%ng and >>+A c"y in the right l%ng+ (ll of the dose constraints $ere achieved in the c%m%lative plan+ (gain, properly $eighting the mi4ed energy )eams and %sing the 0I0 techni1%e provided an accepta)le treatment plan+ ,he medical dosimetrist esta)lished a good compromise )et$een ade1%ate chest $all coverage and *ept the R doses as lo$ as reasona)ly achieva)le+ Conclusion ,he patient in this st%dy )enefited from receiving PMR, )eca%se it red%ces the ris* of rec%rrence and improves long-term s%rvival+< ,his treatment is )eneficial for patients $ith the greatest ris* of rec%rrence $hich incl%des positive nodes, positive margins, and lymphovasc%lar invasion+ (ltho%gh PMR, can improve local control and s%rvival, this does not diminish the importance of systemic ad5%vant therapy+ ( speciali:ed management plan for patients sho%ld )e developed to ma4imi:e the therape%tic ratio+ Radiotherapy can res%lt in long-term mor)idity and mortality, so it is vital that PMR, is planned caref%lly+ Principles of radiation )iology, radiation physics, mathematics, and anatomy m%st )e %nderstood for treatment planning+ Radiation fields %sed for male PMR, are )ased on the same principles as females, )%t each field is individ%ali:ed according to patient anatomy and the str%ct%res at ris*+ ,reatment planning demands e4perience and caref%l attention to detail for the )est patient care+ ,he goal of PMR, is to not only ens%re accepta)le dose is delivered to the target, )%t also minimal dose is given to the heart, l%ngs, and spinal cord+ ,his can )e achieved $ith mi4ed energy )eams and the 0I0 techni1%e+

References >+ '% C, 9%:%*i 7, 'o%n%s !, et al+ ,he impact of post-mastectomy radiation therapy on male )reast cancer patients H a case series+ Int J Rad Oncol Bio P ys+ 2;>2@A2-2.8=B=-?;;+ http8IId4+doi+orgI>;+>;>=I5+i5ro)p+2;>>+;>+;>; 2+ De$ar !(+ Postmastectomy radiotherapy+ !lin Oncol+ 2;;=@>A-/.8>A3->B;+ http8IId4+doi+orgI>;+>;>=I5+clon+2;;3+>>+;;= /+ Chao &9, Pere: C(, #rady LW+ Radiation Oncology "anagement Decisions+ /rd ed+ Philadelphia, P(8 Lippincott Williams J Wil*ins@ 2;>>+ <+ Raga: !, livotto I(, 9pinelli !!+ Locoregional radiation therapy in patients $ith high-ris* )reast cancer receiving ad5%vant chemotherapy8 2;-year res%lts of the #ritish Col%m)ia randomi:ed trial+ J #atl !ancer Inst+ 2;;3@B?-2.8>>=->2=+ http8IId4+doi+orgI>;+>;B/I5nciId5h2B? 3+ "e)s*i 6, Lagleva M, &eech (, 9imes !, Langlands ( + 9%rvival effects of postmastectomy ad5%vant radiation therapy %sing )iologically e1%ivalent doses8 ( clinical perspective+ J #atl !ancer Inst+ 2;;=@BA->.82=-/A+ http8IId4+doi+orgI>;+>;B/I5nciId55;;2 =+ Co4 !D, (ng &&+ Radiation Oncology8 Rationale$ Tec ni%ue$ Results+ Bth ed+ Philadelphia, P(8 Mos)y, Inc@ 2;>;+ ?+ 'ang !,, 7o ('+ Radiation therapy in the management of )reast+ Surg !lin # Am+ 2;>/@B/-2.8<33-<?>+ http8IId4+doi+orgI>;+>;>=I5+s%c+2;>/+;>+;;2 A+ Recht (, Cdge 9), 9olin L!, et al+ Postmastectomy radiotherapy8 "%idelines of the (merican 9ociety of Clinical ncology+ J !lin Oncol+ 2;;>@>B-3.8>3/B->3=B+ B+ Lee !, 7ong 9, Choi &, et al+ Performance eval%ation of field-in-field techni1%e for tangential )reast irradiation+ Jpn J !lin Oncol+ 2;;A@/A-2.8>3A->=/+ http8IId4+doi+orgI>;+>;B/I55coIhym>=? >;+ 7arris !R, M%rphy-7alpin P, McFeese M, Mendenhall FP, Morro$ M, Ro)ert F!+ Consens%s statement on postmastectomy radiation therapy+ Int J Rad Oncol Bio P ys+ >BBB@<<-3.8BAB-BB;+ http8IId4+doi+orgI>;+>;>=I9;/=;-/;>=-BB.;;;B=-=

%i*ures

%i*ure + Left medial tangent )eamDs eye vie$ of the 0I0+

%i*ure , Left lateral tangent )eamDs eye vie$ of the 0I0+

%i*ure - ,ransverse vie$ of the chest $all plan+ ,he green isodose line represents the >;;E prescription line+

%i*ure . ,ransverse vie$ of the s%praclavic%lar plan+ ,he green isodose line represents the >;;E prescription line+

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%i*ure / ,ransverse vie$ of the electron )oost plan+ ,he green isodose line represents the >;;E prescription line+ ne cm of )ol%s applied daily+

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%i*ure 0 C%m%lative D67+

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Ta&les Ta&le + Chest Wall, 9%praclavic%lar (rea, and Mastectomy 9car Prescription and ,reatment Planning Parameters Treatment Plannin* Parameters (natomic 9ite #eam Cnergy 0ractionation Prescription Dose #eam (rrangement "antry (ngle-s. Collimator Planning ,echni1%e Left chest $all = M6 and >A M6 9tandard 3;;; c"y in 23 f4 -2. Co-planar )eams >/;G, />;G ;G /D-CR,I 0I0 9%praclavic%lar area = M6 9tandard 3;;; c"y in 23 f4 ->. #eam /<3G ;G /D-CR, Mastectomy scar B Me6 9tandard >;;; c"y in 3 f4 ->. Clectron )eam /3G >;G /D-CR,

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Ta&le , Plan (nalysis and Cval%ation Plan Analysis and Evaluation Organs at Ris& 'OR( 7eart Left l%ng Right l%ng 9pinal cord Dmean 'c)y( >2B+B A3?+= >>+A 3B+2 Dma* 'c)y( A;/+/ <A>3+/ >2>+2 >2/+B