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Jenny Kouri
Clinical Practicum III
10/29/15
Infiltrating Duct Carcinoma of the Upper Outer Quadrant of the Left Breast
Goal of Clinical Lab Assignment: To practice breast tangent planning on with Pinnacle
Treatment Planning Software. I have had no experience planning breasts on Pinnacle (only 3
months on Eclipse). The purpose of this assignment was to become comfortable with Pinnacles
software and evaluation tools. After discussing constraints with our physician, I took a previous
patient plan and created my own. While I understood the concepts of breast planning, I wanted
to become more confident in those concepts with Pinnacle to make myself a more marketable
candidate for a future job position. For this assignment, I decided to create tangent field-in-fields
for the left breast. I noticed on our departments schedule there is a male breast patient scheduled
to undergo a CT simulation this week. I am eager to take what I have learned from this
assignment and apply it to a real-time clinical patient.
History of Present Illness: Patient HW is a 66-year-old female who was initially found to have
developing mass in the anterior 1/3 of the left breast at the 2:00-3:00 position revealed by a
routine mammogram and a follow up diagnostic ultrasound. The biopsy for the lesion was
positive for an ER/PR positive, HER2 non-amplified infiltrating ductal carcinoma. HW
underwent a pre-surgical breast MRI which demonstrated 2 lesions, the first at the 2:00 position
in the left breast 4 cm from the nipple and the second at the 5:30 position of the left breast 5 cm
from the nipple and 3 cm inferior to the biopsy-proven carcinoma. The oclock positions of
breast cancer is shown below.1

The second lesion was not detectable on follow-up ultrasound and underwent a MRI-guided
biopsy, which was positive for an ER/PR positive grade 3 DCIS with a small focus suspicious for
micro-invasive carcinoma. Patient HW proceeded to undergo a lumpectomy and sentinel lymph
node biopsy encompassing both sites of biopsy-proven disease. Surgical pathology was positive
for a 1.5 x 1.5 x 1.2 cm grade 1 infiltrating ductal carcinoma with associated grade 2 DCIS.
During consult, the radiation oncologist discussed with the patient and her family regarding the
role of adjuvant radiotherapy in order to reduce her risk of loco-regional disease relapse
following breast-conserving surgery. It was also discussed the possibility of hypofractionated
course of therapy delivered over approximately 4 weeks although cautioned the final
recommendations of this would depend upon the review of the soft tissue and heart doses during
the radiotherapy planning process. The radiation oncologist reviewed the potential acute and lateterm radiation-induced side effects associated with adjuvant breast radiotherapy, including but
not limited to: fatigue, dermatitis, soft tissue fibrosis, lymphedema, pneumonitis, damage to the
heart and risk of a secondary malignancy.
The Plan (Prescription): The left breast will be treated to a dose of 5,000 cGy in 25 fractions to
be given daily followed by a 1,000 cGy boost to the lumpectomy cavity delivered over the
course of 6 weeks. No chemotherapy was administered due to the oncotype Dx results.
Patient Setup/Immobilization: A CT-simulation was performed after the exam for radiotherapy
planning purposes. HW was positioned supine, head to gantry on the Phillips Brilliance Big

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Bore simulator couch. To stress a reproducible set-up, HW was immobilized on a custom
breast/wing board and a vaclock. A large knee sponge was utilized. A planning CT of thorax
without IV contrast was completed and an isocenter was placed centrally within the
mediastinum. A 3-point set-up was marked with tattoo ink on the patients chest for laser
positioning prior daily treatment.
Anatomic Contouring: After simulation, the CT scans were imported to the Pinnacle3 9.10
radiation treatment planning system (TPS). The physician contoured the lumpectomy and the
breast tissue, which was extracted 3mm away from the external contour. The 3mm extraction is
labeled as the skin contour. No GTV, CTV, or PTV was contoured. The dosimetrist contoured
the total lungs, heart, and spinal cord. This is demonstrated below in Figure 1.

Figure 1. Contours of the lumpectomy, left breast, and organs at risk

Breast Tissue
The delineation of the breast tissue is dependent on the size of breast, position of patient, and
amount of ptosis. The breast tissue serves as the target volume and respected similarly to a PTV.2
Lumpectomy

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Determined by CT scan.
Total lungs
The total lungs were delineated by contouring the contralateral (right) and ipsilateral (left) lungs
volumes separately. The right and left contours were combined to create a total lung volume.
During plan evaluation, I assess the dose uptake by the individual lungs and the total lung
volume. As a hard constraint, the V20 of the total lung volume should not exceed 20%. As a soft
constraint, the V20 should be less than 15% and if tangents only, 10%.
Heart
The superior aspect of the heart was contoured one CT slice below the pulmonary artery trunk
passing midline and extended to the most inferior aspect of the heart, which is found at the end
of the diaphragm.3 The hard constraint and soft constraint of the heart V25 must be less than 10%
and 5%, respectfully. The heart mean must be no greater than 5 Gy.
Spinal Cord
The structure of the spinal cord included the entire spinal canal to decrease contouring
variations.3
Contralateral (Right) Breast
In the case if the tangent field borders exceed midline, the contralateral breast must be contoured
to evaluate the dose. This is especially important in younger patients. The hard constraint of the
contralateral breast has a max dose of 310 cGy.
Carina
The carina is contoured to facilitate with the daily patient set-up. For breast tumor (and all
mediastinal/chest tumors), the carina is contoured and burned onto the DRRs. The radiation
therapists use the carina to match alignment of the daily imaging to the initial CT-simulation
image.
CT Simulation
HW underwent a CT-simulation. The patient was placed supine on the CT simulator couch and
positioned using a wing board to compensate for slope of sternum and to avoid the breast from
falling superiorly into the supraclavicular area. The ipsilateral arm was raised in the cephalad
direction to avoid treatment through the upper arm. Prior to scanning, external markers were
placed anatomically by the radiation oncologist. Four wire markers were placed on the left
breast to estimate the superior (first costal interspace or two fingers below the sternal notch),

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inferior (2 cm inferior of infra-mammary fold), medial (midline), and lateral field borders (2 cm
beyond all breast tissue) in anticipation for tangent beams. Additional wire was placed over the
lumpectomy scar. A planning CT of the chest was preformed, a treatment isocenter was
generated, and a 3-point setup was tattooed on the patient.
Field Borders
The cranial, lateral, and medial borders of the breast tissue are dependent on the following
factors: size of breast, position of patient, and amount of ptosis. The field borders are variable but
must not cross midline (medial border)2. The wires placed during simulation determined the
tangent field borders. The co-planer tangential fields were designed with less than 2 to 3 cm into
the ipsilateral lung volume. A small portion of the lung must be within the field to ensure the
entire breast tissue and chest wall are treated.4 The field was created to block the left humeral
head.
Treatment Planning
The medial tangent field (1a RAO) was created first at 324 with 6 MeV. A 15 wedge was
utilized with the heel oriented away from the patient. MLC blocking of the midline wire and left
humeral head was accomplished with 3D BEV. Superior and inferior borders were extended to
the superior and inferior wires placed during simulation. 2 cm of flash was given. The medial
field was then copy and opposed at 144 with 6 MeV (1b LAO). The MLC blocking was
modified to appropriately cover the midline wire from the lateral view. The plan was calculated
with the medial and lateral tangents and weighted to create a more homogeneous dose
distribution. Field-in-fields, without wedging, were created to reduce hot spots below 110% of
the prescription dose with 18 MeV. This was accomplished by converting a desired isodose line
into a 3D contour that could be visible in BEV. Blocking was altered to cover the isodose line
contours. The left lung and heart were also blocked on the field-in-fields to reduce dose to those
critical structures. The fields were calculated and beam weighting was adjusted appropriately
until the hot spots were reduced. The relative weighting of field-in-fields did not exceed more
than 6% of the primary beams to avoid the creation of cold spots. The fields are shown below.

Figure 2. Right lateral (1a RAO)

Figure 3. Left lateral (1b LAO)

Figure 4. Right lateral field-in-field (1a RAO)

Figure 5. Right lateral field-in-field (1a RAO)

Figure 6. Left lateral field-in-field (1b LAO)

Figure 7. Axial view of tangent fields with 15 wedge pair

Plan Evaluation: The objectives of this plan was to not allow 50% of the dose to cross midline,
95% of the dose to cover 95% of the target, lower the maximum hot spot below 110% of the
prescription dose, and meet OAR constraints. 98.8% of the left breast-skin was covered by 95%
of the dose (4750 cGy). 100.0% of the lumpectomy was covered by 95% of the dose. The
maximum, minimum, and mean dose were 111%, 80.4%, and 103.8% of the prescription dose,
respectively. The heart V25, mean, and maximum dose were 2.31%, 347.9 cGy, and 4742.5 cGy,

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respectively. The left lung V20 and V5 was 12.11% and 18.78%. The isodose line distribution
and DVH is shown below in the axial CT image.

Figure 8. Isodose line distribution is displayed. The 50% isodose line (aqua blue) does not cross
midline.

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Figure 9. Isodose line distribution on the same slice as the simulation/set-up isocenter and
treatment calculation point.

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Figure 10. The DVH of the left breast plan.

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References
1. Breast Coding Guidelines. SEER.
http://seer.cancer.gov/archive/manuals/2010/AppendixC/breast/coding_guidelines.pdf.
Accessed November 29, 2015.
2. White J, Tai A, Arthur D, et al. Breast Cancer Atlas for Radiation Therapy Planning:
Consensus Definitions. Radiation Therapy Oncology Group.
3. Kong FM, Quint L, Machtay M, et al. Atlas for Organs at Risk (OARs) in Thoracic
Radiation Therapy. Radiation Therapy Oncology Group.
4. Vann AM, Dasher BG, Sickle KV, et al. Portal design in radiation therapy. Second
edition. Columbia, South Carolina: DWV Enterprises; 2006.