1

Karen Krueger
April Case Study
April 11, 2015
Four-field Conventional Treatment of the Right Chestwall
History of Present Illness: Patient CU is a 55 year-old female who first noticed a mass in her
right breast in October of 2013. She brought this to the attention of her gynecologist on October
23, 2013. Later that day, CU underwent bilateral digital mammogram and right breast ultrasound.
The mammogram and ultrasound exams revealed a 2-3cm malignant appearing lesion in the
upper inner aspect of the right breast with a suspicious appearing right axillary lymph node. The
right axilla demonstrated an enlarged lymph node which exhibited some segmental thickening
and hypervascularity suspicious for regional disease. Biopsies were recommended. The
contralateral breast had no suspicious abnormalities. CU underwent stereotactic core needle
biopsy of the malignant appearing lesion of the right breast on November 5, 2013. The pathology
from the biopsy showed invasive ductal carcinoma, grade 2. In addition, CU underwent an
ultrasound and fine needle aspiration biopsy of the right axillary lymph node on November 5,
2013. The ultrasound revealed a lymph node that measured 1cm. The pathology from the lymph
node showed metastatic breast carcinoma. Estrogen receptors (ER) and progesterone receptors
(PR) were positive. Estrogen and progesterone positive cancer cells receive signals from the
estrogen and progesterone that promote their growth.1 Patients who are ER/PR positive are more
likely to respond well to hormonal therapy and generally have a better outcome than patients
with receptor-negative tumors.2 CU was found to have an overexpression of the human
epidermal growth factor receptor 2 (HER-2/neu) proto-oncogene.3 The HER-2/neu protooncogene encodes a transmembrane protein tyrosine kinase receptor.1 Overexpression of HER2/neu (HER-2/neu positive) is associated with a poor outcome. Patients who are HER-2/neu
positive generally have a more aggressive disease, higher recurrence rate, and shortened survival
compared to HER-2/neu negative patients.3 CU underwent a MRI of the breasts on November 7,
2013. The MRI demonstrated an irregularly shaped mass in the upper inner quadrant of the right
breast which measured approximately 6cm in greatest dimension. The right axillary lymph node
which was confirmed to be metastatic disease was also identified as well as a few additional
more proximal lymph nodes which were also described. No suspicious findings were seen in the
left breast. CU was diagnosed with T3N1M0 invasive ductal carcinoma of the right breast. The

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staging system used for CU is the American Joint Committee on Cancer Staging System.1, 2 It is
the staging system that is most commonly used in the United States. According to the American
Joint Committee on Cancer Staging System: T3-Tumor > 50mm in greatest dimension, N1Metastases in a moveable ispsilateral lymph node(s), and M0- No clinical or radiographic
evidence of distant metastases (no pathologic M0; use clinical M to complete stage group).
Surgical consultation was recommended. CU was seen at a multidisciplinary clinic and elected to
receive neoadjuvant chemotherapy. She received neoadjuvant Taxotere, Carboplatin, and
Herceptin. The patient completed chemotherapy on March 26, 2014. A post chemotherapy MRI
of the breasts was obtained on April 16, 2014. The previously described right upper-inner
quadrant invasive ductal carcinoma was no longer identified as an enhancing mass. No axillary
or internal mammary adenopathy was seen. The previously described abnormal right low axillary
lymph node was smaller and measured to be approximately 9mm. After a consultation with a
breast surgeon, CU elected to have bilateral mastectomy. CU underwent a right simple
mastectomy with sentinel lymph node biopsy, as well as a left simple mastectomy on May 7,
2014. Pathology from her breast surgery revealed no residual invasive carcinoma; however there
was ductal carcinoma in situ (DCIS) present. The DCIS was high grade. A total of 4 sentinel
lymph nodes were obtained, with one containing macro metastasis. The left breast had benign
findings only with no evidence of malignancy. On June 13, 2014 CU met with the radiation
oncologist for a treatment consultation. The radiation oncologist recommended postmastectomy
chestwall and regional node irradiation. After the recommendation, the radiation oncologist
discussed the standard of care for surgical staging of the axilla after a sentinel lymph node biopsy
when a sentinel node is positive. The current standard of care includes lymph node dissection
after a positive lymph node (Wood C, oral communication, April 2015). CU elected not to
undergo lymph node dissection due to her fears of lymphedema. For this reason, the radiation
oncologist recommended chestwall and comprehensive regional nodal irradiation. The radiation
oncologist explained the radiation treatment delivery process as well as the acute and late side
effects of chestwall and regional nodal radiation. Acute and late side effects could include but are
not limited to acute skin reactions, fatigue, tenderness, lymphedema, and pneumonitis (Wood C,
oral communication, April 2015). After speaking with the radiation oncologist, CU decided to
proceed with the radiation therapy treatments.

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Past Medical History: CU has a past medical history of anemia and depression. The patient has
a surgical history that includes two cesarean sections (1996 and 1999), breast biopsy on
November 5, 2013, and bilateral mastectomy on May 7, 2014. CU reported that she has no
known allergies.
Social History: CU is married. The patient and her husband are both self-employed. CU is a
non-smoker and has never smoked. The patient does not consume alcohol. CU reported that her
maternal grandmother is deceased and had a medical history that included colon cancer. The
patient stated that her maternal aunt has a medical history of breast cancer. CU also stated that
her maternal uncle is deceased and had a medical history that included breast cancer.
Medications: CU is currently using the following medications: Toprol XL, and Prevacid.
Diagnostic Imaging: The patient underwent a bilateral digital mammogram and right breast
ultrasound on October 23, 2013. The digital mammogram and right breast ultrasound of the
right breast revealed a suspicious lesion in the upper inner quadrant of the right breast with a
suspicious appearing right axillary lymph node. A stereotactic core needle biopsy of the
suspicious lesion was performed on November 5, 2013. The pathology from this biopsy revealed
an invasive ductal carcinoma that was ER(+), PR(+), and Her2/neu(+). The patient also
underwent a right breast ultrasound on November 5, 2013 that showed an axillary lymph node
measuring at least 1cm, harboring metastatic breast carcinoma. CU underwent MRI of the
breasts on November 7, 2013. The MR images demonstrated an irregularly shaped mass located
in the upper inner quadrant of the right breast which measured approximately 6cm in greatest
dimension. The right axillary lymph node which was confirmed to be metastatic disease was also
identified. The patient received neoadjuvant chemotherapy which was completed on March 26,
2014. CU underwent postchemotherapy MRI of the breasts on April 16, 2014 which revealed
that the invasive ductal carcinoma was no longer an enhancing mass and the abnormal right
axillary lymph node had decreased in size to 9mm. Due to residual disease shown on the MR
images, the patient had a surgical consultation and elected to have bilateral mastectomy. The
patient underwent right simple mastectomy with sentinel lymph node biopsy, as well as left
simple mastectomy on May 7, 2014 with no positive margins. A total of four sentinel lymph
nodes were obtained. CU was found to have 1/4 total lymph nodes positive. The pathology from
the surgery revealed no residual invasive carcinoma, however there was DCIS present.

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Radiation Oncologist Recommendations: After reviewing the patients surgical history and
pathologic reports, the radiation oncologist performed a physical exam of the patient. CU was
found to be alert and oriented, under no acute distress, and the mastectomy scars were healing
well. The patient had no visible masses or palpable concerns in the chestwall. The radiation
oncologist recommended chestwall and comprehensive regional nodal irradiation based on CUs
mastectomy pathology results. The radiation oncologist recommended a 3D tangential plan
matched with a supraclavicular/axilla plan.
The Plan (prescription): The radiation oncologists recommendation was to treat the chestwall
with a tangential plan with an abutting supraclavicular plan to treat the area of the lymph node
involvement. The radiation oncologist prescribed 5000cGy at 200cGy per day for a total of 25
fractions for the tangents, with 0.5cm bolus placed every other day. The abutting
supraclavicular/axilla fields were also prescribed 5000cGy at 200cGy per day for a total of 25
fractions. In addition, an electron boost to the mastectomy scar was prescribed for 1000cGy at
200cGy per day for a total of 5 fractions. The prescribed composite dose to the left chestwall was
6000cGy.
Patient Setup/Immobilization: CU underwent a CT simulation scan for treatment planning on
June 25, 2014. The patient was placed in the supine position on an inclined wingboard/
breastboard with a headrest. Both of the patients arms were extended above her head and she
was holding an indexed handle bar. CUs arms were relaxed against the wingboard. An indexed
hip stop was used to insure that the patient position was reproducible for each treatment. A
knee sponge was placed for support. CUs feet were banded together for further immobilization.
The radiation oncologist outlined the treatment area of the breast by placing CT-spot lines on the
superior, inferior, medial, and lateral borders of the breast. The isocenter was marked at the
tangent and supraclavicular matchline with CT-spot pellets. The breast mastectomy scar was also
outlined with a CT-spot line. The same set-up and immobilization was used for the four-field
chestwall plan and the electron boost.
Anatomical Contouring: After the treatment planning simulation on the CT simulator, the
images were sent to the Eclipse treatment planning system (TPS). The certified medical
dosimetrist (CMD) imported the images into Eclipse, named the CT data set, inserted a new plan,
and inserted a structure set from template before closing out of the patient so that the radiation
oncologist could contour the planning target volume (PTV). The radiation oncologist contoured

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the chestwall PTV, supraclavicular PTV, and axilla PTV. After the radiation oncologist contoured
the PTVs, the CMD contoured the organs at risk (OR). The OR for the treatment of the right
chestwall of this patient included the liver, heart, spinal cord, bowel, and the right and left lungs
as well as the total lung volume. The carina was also contoured as a reference structure for the
radiation therapists.
Beam Isocenter/Arrangement: The CMD received a written directive from the radiation
oncologist with the intended prescription, technique, energy, and treatment machine. The patient
was prescribed 5000cGy at 200cGy per day for a total of 25 fractions to the supraclavicular and
axilla with parallel opposed beams. CU was prescribed 5000cGy at 200cGy per day for a total of
25 fractions to the right chestwall with tangential beams with 0.5cm bolus every other day. CU
was planned for treatment on the Varian Trilogy using mixed energies of 6MV and 23MV. In
addition, an enface electron boost to the mastectomy scar was prescribed for 1000cGy at 200cGy
per day for a total of 5 fractions. At my clinical site, 4-field chestwalls are generally planned and
treated mono-isocentrically. The couch and table rotation are 180 for all fields. The CMD began
by creating a field and placing the isocenter superior to the breast planning target volume (PTV)
and inferior to the supraclavicular PTV and axilla PTV. The amount of lung that would be treated
was also taken into consideration when placing the isocenter. After evaluating the volume of lung
that would be irradiated the CMD moved the isocenter superior. Moving the isocenter superior
generally decreases the lung volume being irradiated when planning a four-field chestwall
(Whittington A, oral communication, April 2015). The matchline was placed in the axilla PTV
(Part of the axilla PTV was included in the supraclavicular field and part of it was included in the
tangential fields). At my clinical facility the CMD generally moves the gantry 10 to 15 off of
180 so that the supraclavicular treatment field is moved away from the spinal cord. Due to the
large amount of lung in the treatment field, the CMD moved the gantry 25 off of 180 to the
gantry angle of 155. By changing the gantry angle, the CMD was able to further reduce dose to
the lung. After selecting the gantry angle, the CMD designed the multi-leaf collimator (MLC)
with a margin of 8mm around the supraclavicular and axilla PTVs with the inferior matchline
border set to 0. The collimator jaw along the inferior border was moved to 0 and the MLC leaves
were closed below the matchline. After customizing the MLC for the left anterior oblique (LAO)
Supraclavicular field, the CMD opposed the beam.

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Lung volume was also taken into consideration when choosing the gantry angles of the tangential
fields. The goal of the CMD was to find gantry angles that allowed coverage of the PTV, with no
more than 3cm of lung in the treatment field. Unfortunately due to the large barrel shaped
chestwall of the patient, the depth of lung treated was approximately 4cm with gantry angles
selected that would provide adequate coverage of the chestwall PTV. A gantry angle was selected
for the medial tangential treatment field which would allow coverage of the chestwall PTV,
reduce dose to the right lung, and minimize dose to the contralateral breast. The MLC leaves
were pulled in close to the PTV along the posteromedial aspect of the PTV. The MLC leaves
were used to block portions of the lung included in the treatment field. The superior matchline
border was set to 0 by moving the collimator jaw. The MLC leaves were closed above the
matchline. The field aperatures of the medial tangential beam were designed to include all of the
right chestwall PTV with an additional margin for flash. After designing the field for the medial
tangential beam, the beam was opposed. The gantry angle of the opposed beam was adjusted
slightly to reduce dose to the right lung. The medial and lateral tangential photon beams utilized
gantry angles of 311 and 127 respectively. The enface electron scar boost was planned with the
Eclipse TPS. The scar that was previously outlined with the CT spot line was contoured within
the TPS. The CMD selected a gantry angle which would allow the beam to be perpendicular to
the scar.
Treatment Planning: Eclipse version 11 TPS was utilized to create a plan for the patient. CU
was planned for treatment on the Varian Trilogy with mixed energies of 6MV and 23MV.
The CMD began by planning the supraclavicular fields. Before the dose was calculated, the
prescription was entered into the Eclipse TPS. The opposed supraclavicular beams were
originally given equal weighting. The plan was calculated and the weighting was adjusted to 0.73
for the left anterior oblique (LAO) field and 0.27 for the right posterior oblique (RPO). The plan
was normalized to achieve desired coverage. The plan normalization value was 94. At this point
the coverage to the axilla PTV was inadequate because part of the axilla PTV was not included in
the supraclavicular plan. A separate plan was created for the chestwall; however the isocenter
was kept in the same position that was used for the supraclavicular plan. Before the dose was
calculated, the prescription was entered into Eclipse TPS. Because the radiation oncologist
prescribed bolus of the chestwall every other day, a chestwall plan needed to be created for bolus
and non-bolus fields. At Self Regional Cancer Center, it is common to have 12 fractions without

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bolus and 13 fractions with bolus therefore 12 fractions were entered into the prescription for the
non-bolus plan. The prescription entered for the non-bolus plan was 200cGy per day in 12
fractions for a total of 2400cGy. The patient had a separation of ~25 cm in the tangential plane.
When a patients separation is greater than 23cm it is often useful to use mixed energies for
breast plans (Whittington A, oral communication, April 2015). Higher energies help PTV
coverage deep within the patient and the lower energy helps achieve superficial coverage of the
chestwall. The CMD began by assigning the energy of 6MV to the medial tangent field that was
created. He then created a new field-in-field and assigned the new field the energy of 23MV. The
MLC leaves were not adjusted at all for this field. The CMD then assigned the energy of 6MV to
the lateral tangent, created a new field-in-field without adjusting the MLC leaves and assigned
the new field the energy of 23MV. At this point, the CMD equalized the weighting of each field.
The plan was calculated and the weighting was adjusted to decrease the maximum dose. The
plan was normalized to achieve desired coverage. The plan normalization value was 86. A 15
wedge was added to the lateral tangent with the heel up to reduce the maximum dose. The wedge
orientation was right. To further reduce the maximum dose or hotspot, the CMD created a
field-in-field of the medial 23MV tangential field. In order to design the MLC leaves for the new
field, the CMD viewed the 3D isodose distribution of 108.3% in the beams eye view (BEV). The
CMD then adjusted the weighting to move the hotspot anterior in the right chestwall. The
MLC leaves were then adjusted to cover the hotspot and the dose was recalculated. After the
plan was calculated, the CMD manipulated the field weighting and normalization until an
optimal plan was achieved. This plan was then copied and pasted, and the prescription was
entered as 200cGy per day in 13 fractions for a total of 2600cGy. Bolus of 0.5cm was then added
to each field. The 23MV field-in-field that was created to reduce the hotspot in the non-bolus
plan was removed. Dose was then calculated. After this, field weighting was adjusted to
minimize the maximum dose. The CMD used field-in-field planning as previously described to
achieve an optimal plan. A field-in-field was created for the 23MV medial plan. The 3D isodose
distribution of 110% was viewed in the BEV. The field weighting was adjusted to move the
hotspot anterior in the right chestwall. The MLC leaves were adjusted to cover the hotspot
and the dose was recalculated. A field-in-field was then created for the 23MV lateral tangent
field. The 3D isodose distribution of 108.5% was viewed in the BEV. The MLC leaves of the
new field-in-field were moved to cover the hotspot and the dose was recalculated. After the

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plan was calculated, the CMD manipulated the field weighting and normalization until an
optimal plan was achieved. Once the right chestwall plan was completed, the CMD created a
plan summation of the chestwall in order to evaluate the dose to the PTV and OR. Once it was
determined that the chestwall plan was acceptable, the CMD created a total summation of the
supraclavicular and chestwall plans. Dose to the PTVs and OR was evaluated. Evaluation of the
summation DVH led to the following determinations: 95% of the suprclavicular PTV received
4911cGy, 95% of the axilla PTV received 4517cGy, and 95% of the right chestwall PTV
received 4626cGy. The axilla and chestwall PTVs received slightly less than 95% of the
prescribed dose in order to reduce the dose to the right lung. The CMD used the following OR
dose constraints: Heart-the volume at 20Gy (V20) = 0, Liver- mean dose less than 28Gy,
Ipsilateral lung- the volume at 25 Gy (V25) < 20%, and Contralateral Lung- the volume at 5 Gy
(V5) < 10%. The DVH showed the heart V20 = 0, the contralateral lung V5 = 0, the mean dose
to the liver was 3.25 Gy, and the ipsilateral lung V25 = 30%. The CMD was unable to achieve
the perfect plan. During the planning process, the radiation oncologist made the decision that
coverage of the PTVs should be reduced to decrease the dose to the right lung. Every effort was
made to decrease the dose to the right lung yet the constraints were not met. Although the dose to
the axilla and chestwall PTVs were slightly less than 95% and the right lung dose didnt make
the constraints, the CMD determined that this was the best compromise of PTV coverage and
right lung dose. The plan was reviewed and approved by the radiation oncologist.
The enface electron scar boost was planned with the Eclipse TPS. After the scar was outlined, the
CMD chose a gantry angle which would allow the electron beam to be perpendicular to the scar.
He then created an electron block within Eclipse with a 2cm margin around the scar. Bolus of
0.5cm was added to cover the entire field. The prescription of 200cy in 5 fractions for a total of
1000cGy was entered into the TPS. The depth of treatment was determined by measuring the
distance from the anterior chestwall to the ribs. The treatment depth for CU was 1.3cm therefore
it was determined that the energy of 6MeV would be used. After entering the energy into Eclipse,
the plan was calculated. The radiation oncologist evaluated the isodose lines to determine the
normalization required for adequate coverage of the boost field. The plan was normalized at
100%. A hand calculation was performed to determine the daily dose.
Quality Assurance/Physics Check: The monitor units (MUs) for the plan were double checked
with the RadCalc program. The accepted tolerance between the TPS MUs and the RadCalc MUs

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is 5% for each field at my clinical facility. Although the medial field-in-field used to reduce the
hotspot was slightly outside of tolerance for the bolus and non-bolus field, this was determined
by the physicist to be insignificant due to the small amount of weighting given to each of those
fields. The physicist approved all plans.
Conclusion: Post-mastectomy radiotherapy (PMRT) treatment planning is challenging because
the target volume covers a large, superficial area that is thin and convex in shape.4 Adding to the
degree of difficulty is the fact that the target volume is immediately adjacent to the lung, heart,
and contralateral breast. Treatment planning for CU proved to be a dosimetric challenge. The
dose to the right lung was taken into consideration throughout the treatment planning procedure.
The isocenter was moved superior into the right axilla PTV in order to minimize irradiation of
the right lung. The gantry angle of the supraclavicular field was rotated 25 off of 180 so that
lung dose might be spared. Gantry angles elected for the tangential fields were steep in order to
minimize the dose to the right lung. Although the dose to the right lung was taken into
consideration throughout each step of treatment planning, the lung constraints were not met. It is
not always possible to create a perfect plan. Each patient is different. The radiation oncologist
may have to compromise coverage of the PTV in order for the CMD to create a plan that spares
the OR. I learned a lot about treatment planning of a large or barrel shaped chestwall through
this case study. I learned that the isocenter can be moved superiorly to minimize dose to the
ipsilateral lung when planning the treatment of the chestwall, supraclavicular nodes, and
posterior axilla nodes. I learned that the angle of the gantry affects how much of the ipsilateral
lung will be in each treatment field. I gained knowledge in field design and field-in-field
treatment technique. I am now able to create an electron block in the Eclipse treatment planning
system. I am aware of how the treatment depth is used to determine the electron energy that
should be used. I have an understanding of how the isodose lines are evaluated to determine the
normalization required for coverage of the electron treatment field. I am new to treatment
planning and I do not have a lot of experience with plans of this type. However, I am now much
more comfortable with planning the treatment of a chestwall with supraclavicular and posterior
axilla.

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References
1. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed.
Philadelphia, PA: Lippincott, Williams, and Wilkins; 2001.
2. Uschold GM, Zhang H. Breast Cancer. In: Washington CM, Leaver D, eds. Principles and
Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010: 866-894.
3. Mitri Z, Constantine T, ORegan R. The HER2 receptor in breast cancer: pathophysiology,
clinical use, and new advances in therapy. Chemother Res Pract. 2012;2012(1):1.
http://dx.doi.org/10.1155/2012/743193
4. Nichols GP, Fontenot JD, Gibbons JP, Sanders ME. Evaluation of volumetric modulated arc
therapy for postmastectomy treatment. Radiat Oncol J. 2014;9(1):66.
http://dx.doi.org/10.1186/1748-717X-9-66

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Figures

Figure 1. Patient hand and arm position on a Med-Tec, Inc. breast board with a wingboard
attached during CT simulation.

Figure 2. Anterior view of CT-simulation set-up, showing the radio-opaque CT-spot pellet used
to mark the isocenter anteriorly and the CT-spot lines used to mark the medial border, superior
border, inferior border, and mastectomy scar.

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Figure 3. Lateral view of CT-simulation set-up, showing the radio-opaque CT-spot pellet used to
mark the isocenter laterally and CT-spot lines used to mark the lateral border, superior border,
inferior border, and mastectomy scar.

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Figure 4. Anteroposterior view of isocenter placement.

Figure 5. Lateral view of isocenter placement.

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Figure 6. LAO supraclavicular field with the supraclavicular PTV shown in blue and the axilla
PTV shown in pink.

\
Figure 7. RPO supraclavicular field with the supraclavicular PTV shown in blue and the axilla
PTV shown in pink.

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Figure 8. Medial tangential field with the axilla PTV shown in pink and the chestwall PTV
shown in red.

Figure 9. Medial tangential field-in-field used to reduce the hotspot with the axilla PTV shown
in pink and the chestwall PTV in red.

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Figure 10. Medial tangential view showing the amount of lung in the tangential treatment fields.
The supraclavicular PTV is shown in blue, the axilla PTV is shown in pink, and the right lung is
shown in green.

Figure 11. Lateral tangential view showing the wedge placement. The axilla PTV is shown in
pink and the chestwall PTV is shown in red.

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Figure 12. Medial tangential bolus field-in-field.

Figure 13. Lateral tangential bolus field-in-field.

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Figure 14. Electron field drawn on patient.

Figure 15. Electron field created in Eclipse with 0.5cm bolus shown in blue.

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Figure 16. Dose distribution of electron field shown in the axial view.

Figure 17. Dose distribution of electron field shown in the sagittal view.

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Figure 18. Dose Volume Histogram showing the dose to the supraclavicular PTV and axilla PTV
from the supraclavicular fields only. The isodose line for the supraclavicular PTV is shown in
blue and the isodose line for the axilla PTV is shown in pink.

Figure 19. Summation Dose Volume Histogram with dose from all fields included. The isodose
lines are shown as follows: supraclavicular PTV-light blue, chestwall PTV-red, axilla PTV-pink,
right lung-green, liver-orange, heart-brown, and left lung-dark blue.

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Figure 20. RadCalc for supraclavicular fields.

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Figure 21. RadCalc for tangential non-bolus fields.

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Figure 22. RadCalc for tangential bolus fields.

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Figure 23. RadCalc for electron boost.