Capstone Outline – Research Paper

ABSTRACT

Introduction

A. In tangential breast treatment, dose to the heart, lungs, and other surrounding critical
structures can cause serious side effects such as ischemic heart disease and radiation
pneumonitis.1-3

1. There are many techniques to reduce dose to critical structures for breast
treatments, such as intensity-modulated radiation therapy (IMRT), prone breast
radiotherapy, deep-inspiratory breath hold, and proton beam therapy.

i.Current studies recommend a limit of about 5 Gy to the heart for breast

cancer treatments, however, there is still a risk for a major coronary event
below this dose.1

ii.For each Gy the heart receives, the risk for a major coronary event
increases by 7.4%.2

iii. Even with techniques to lower the dose to critical structures the heart still
receives 1-5 Gy in breast cancer treatments which can cause ischemic heart
disease.3

2. In a systemic study on mean heart doses for the treatment of left sided breast
cancer from 2003 to 2013 it was shown that left sided tangential radiation in the
supine position with no breath hold was the most common way breast cancer was
treated.4

B. A collimator angle of 0 degrees is often used for a tangential breast treatment. If

collimator rotations are utilized with tangential breast treatment planning, the collimator
is often rotated parallel to the chest wall to help limit dose to the lung. However, these
commonly used angles could be yielding more interleaf transmission than necessary
when using an Elekta linear accelerator.
 1. Previous studies indicated that interleaf leakage could be increasing dose to
critical structures in various treatment plans.6-10

C. To knowledge, no studies using an optimal collimator angle to reduce MLC leaf

transmission to limit dose to critical structures in breast cancer treatment have been done.

1. The aim of this retrospective study was to determine if reducing leaf transmission
with a collimator rotation of 90 degrees, in a standard right or left whole breast
irradiation plan, will reduce the dose to critical structures while maintaining
adequate coverage of target volume.

Methods and Materials

Patients

A. Sixty-five patients from a single clinical institution were chosen for this study. Patients
included any patient with Stage 0, Stage I, or Stage II breast cancer that has not spread to
lymph nodes and were treated using tangent fields.
1. The patient data was collected retrospectively to include 35 patients with left
sided breast cancer and 30 patients with right sided breast cancer. Of these
patients 15 had Stage 0 ductal carcinoma in situ (DCIS), 43 patients had invasive
ductal carcinoma (IDC) Stages IA-IIB, 6 patients with invasive lobular carcinoma
(ILC) Stages IA-IB, and 1 patient with invasive mucinous Stage IIA.

2. All patients were prescribed a dose of 42.56 Gy in 16 fractions with a curative

intent. Any dose from a boost was not considered in the final plan comparison due
to variations in boost planning methods used at the institution.

B. Each patient was simulated in the desired treatment position. This was with the patient
lying flat, head first supine with both arms above the head. An alpha cradle was created to
reproduce the arm positioning daily.

1. Radio-opaque wires were placed at superior, inferior, medial and lateral borders of
the treatment area decided by the physician.
 2. All patients (65) were CT simulated in a Phillips CT scanner. 30 patients were
simulated using deep inspiration breath hold and 35 patients were simulated free
breathing.

3. Each scan was obtained using a 3 mm slice thickness from the bottom of the
mandible superiorly to 5 cm below the breast tissue inferiorly and exported to
Pinnacle (Version 14.0) for treatment planning.

Contours

A. Target volumes

1. Clinical target volume of the surgical bed (CTVsb) is contoured manually by the
physician.

2. According to department protocols, the planning target volumes were defined

using the tangential beams (further discussed in treatment planning). Coplanar
tangent treatment beams were placed by physician and a breast contour was
created from the 50% isodose line (avoiding exterior of the body contour and
interior of lung contour). The breast contour is contracted 5 mm to create the
planning target volume (PTV_Eval).

B. Normal structures included the heart, left lung, right lung, left anterior descending artery
(LAD) and external body contour.

1. Both lungs were contoured using an auto-contouring tool in Pinnacle (Version

14.0) in a pulmonary window level following the Radiation Therapy Oncology
Group (RTOG) 1106 contouring atlas.11

2. The body contour was completed using an auto contouring tool in Pinnacle
(Version 14.0).

3. The heart was contoured manually by physician or medical dosimetrist following

the RTOG 1106 contouring atlas.11
 i.Heart is contoured adjacent to the pericardial sac. The heart begins at the
inferior aspect of the pulmonary artery superiorly and extends to the base
of the heart inferiorly.

4. The LAD was contoured manually by the physician or medical dosimetrist.

Treatment Planning

A. All 65 patients were planned using an inverse planned 3D conformal technique in the
Pinnacle (Version 14.0) treatment planning system (TPS) as described by Van Asselen.12
This technique uses Pinnacle’s direct machine parameter optimization (DMPO) to
generate segmented fields.

1. A combination of 6MV, 10 MV, and 18 MV for an Elekta Synergy or an Elekta

Agility machine were used depending on patient size and ability to meet planning
objectives.

2. Both medial and lateral tangent beams were placed; gantry angles vary but were
set to encompass entire breast while avoiding any entrance or exit dose to the
contralateral breast and limiting the amount of lung. Beam edges were adjusted to
be nondivergent medially.
i. Open blocks labeled “OpenMed” and “OpenLat” were designed by the
physician utilizing the superior and inferior borders defined during
simulation. Based on the physician's decision, a heart block may be added
for additional cardiac shielding. Open fields include 2 cm of flash on the
anterior border.
1. The collimator angle for each field remained at 0 or was rotated so
that collimator jaw edge was parallel to the ipsilateral lung cavity
to further decrease dose to the organ at risk (OAR).
2. A couch rotation was used to reduce dose to the underarm when
necessary.
 ii. In order to obtain segmented fields, the medial and lateral beam and
corresponding block were copied and labeled “SegMed” and "SegLat”.

iii.Before optimization, the IMRT parameters for OpenMed and OpenLat

were set to “beam weight”.

iv. The IMRT parameters for SegMed and SegLat were set to direct machine
parameter optimization (DMPO). The final plan appropriately weighted
the open fields and created segments to decrease hotspots for a
homogeneous dose distribution.

3. Optimization objectives followed planning objectives and plans were optimized

until planning objectives were met.

i. Planning objectives and dose constraints followed Michigan Radiation

Oncology Quality Consortium (MROQC) breast protocol.

B. Once planning objectives were met, the plan was copied into a new trial.

1. On the copied plan, the collimator on the OpenMed and OpenLat was rotated an
additional 90 degrees so that the MLC leaves run vertically.

2. The collimator angle for the segmented fields remained at the original position.

3. Beams were recomputed and doses to the normal structures and planning volumes
were recorded.

Plan Comparison

A. Planning target volumes were compared between the 2 trials: non-rotated collimator trial
and the 90° rotated collimator trial.
B. The dose to critical structures were analyzed using dose constraints based on the
MROQC protocol.
1. This protocol asked for a 1.2 Gy mean dose to the heart on a left sided breast or
0.7 Gy on the right side. The maximum dose to the heart was also analyzed.
 2. For the LAD (left breast only), the mean and maximum doses were evaluated.
3. For the ipsilateral lung, the volume receiving 20 Gy (V20), V10, and V5 values were
analyzed.

4. The PTV_Eval coverage was analyzed by the percentage of the volume covered
by specific dose values, such as the volume receiving 100%, 95%, and 90% of the
prescription dose.

Results

A. All 65 patients (n=65) plans were evaluated individually to collect data for this study.

1. A two-paired statistical t test between the two plans was performed for each of the
following critical organ doses: mean heart dose, maximum heart dose (Dmax), lung
V20, lung V10, lung V5, mean LAD, and LAD Dmax.

2. A two-paired statistical t-test was also performed for the PTV_Eval coverage at
the following doses: 100% of the prescription dose, 95% of the prescription dose
and 90% of the prescription dose.

3. A value of P= 0.05 was used to reject the null hypothesis (H0 = 0) and determine a
statistical difference between the two plans.

4. As shown in Table 1, statistically significant decreases were shown for all

measured mean heart doses as well as the lung V10, and lung V5 doses.

i. No statistical difference was shown for the lung V20.

ii. No statistical difference was shown for the PTV_Eval coverage at any of
the reported doses.

Table 1: Comparison of dosimetric data of organs at risk between the plans with no collimator
rotation (NCR) and the plans with an additional collimator rotation (CR)
NCR CR Difference P value
Heart Mean (cGy) 86.7 65.2 21.5 P < 0.0001
 Dmax (cGy) 933.5 859.9 73.6 P < 0.0001
LAD Mean (cGy) 353 300.3 52.7 P < 0.0001
Dmax (cgy) 887.6 783.6 104 P = 0.0036
Ipsilateral V20 7.5 7.4 0.1 P = 0.096
Lung
V10 11.6 11.3 0.3 P = 0.0001
V5 18.2 17.5 0.7 P < 0.0001

PTV_Eval 100% 86.7 87.8 -1.1 P = 0.4525

Coverage
95% 98.8 98.7 0.1 P = 0.1684
90% 99.8 99.9 -0.1 P = 0.8045

B. As expected, introducing a collimator rotation of an additional 90 degrees had no effect

on original PTV_Eval coverage and decreased most critical organ doses in this study.

1. When the collimator rotation was applied, the mean heart dose was reduced by
24.57%, and the heart Dmax was reduced by 7.92%.

2. In addition, the lung V10 was reduced by 8.33%, the lung V5 was reduced by
5.56%, and the mean lung dose was reduced by 16.57% with the added collimator
rotation.

3. Although no statistical significance was shown for the lung V20, the percent did
decrease, but only by 0.13%.

4. For left sided breast patients in this study (n=35) the mean LAD dose was reduced
by 15.01% and the LAD Dmax was reduced by 11.71%.

5. For all measured PTV_Eval coverage values the difference between the two plans
remained at less than 1.2%.
Discussion

A. The results of this study were consistent with the findings of Chapek et al,9 which
suggested that using optimal collimator angles, meant to reduce leaf transmission, could
reduce the dose to surrounding critical structures.

1. While the results of this study were applied to breast cancer treatment, the
findings were confirmed using a much larger sample size.

2. Equivalent target volume coverage was also confirmed by this study, showing that
the application of the additional 90 degree collimator rotation did not compromise
PTV coverage.

B. The results were also consistent with the study by Chen et al8 that suggested the lowest
MLC transmission value used showed a decrease in various doses to the lung.

1. While their data showed no statistical significance, this study used a larger sample
size and showed statistical significance in reducing the dose to the heart, lung, and
LAD (in left-sided breast patients).

2. They also suggested that lower MLC transmission could have advantages in lung
sparing, for example, in cases where there was low or intermediate dose exposure.

3. As mentioned previously, for every Gy the heart receives the risks increase.2
Every effort made to reduce these low doses to critical structures can make an
impact when evaluating risk.

C. A similar study utilizing various collimator angles was done by Sharma et al10 regarding
parotid gland irradiation and the dose to the contralateral parotid gland and cochleae.

1. While no difference was shown in dose to these structures regardless of collimator

angle, this study was performed using a Varian linear accelerator.

2. The sample size of this study may have also contributed to the difference in
results.
 D. This technique was proven to reduce dose to critical structures in breast planning. Even if
planning objectives have already been met this simple technique can reduce dose even
further lowering the chance for heart disease or other side effects.

Conclusion

A. The reduction of leaf transmission by using a collimator rotation of 90 degrees can reduce
the dose to critical structures while maintaining adequate coverage of target volume in
standard whole breast irradiation.

1. The greatest effects were seen in the difference of the mean and maximum heart
dose, V10 and V5 for the lung, and mean and maximum dose for the LAD when
the collimator was rotated the additional 90 degrees. Each of these values were
found to be statically significant.

2. While all critical structures demonstrated a reduction in dose, not all the dose
categories were found to be statistically significant.

i. The lung V20 and mean dose were statistically insignificant.

B. Adequate coverage was maintained throughout all plans and any minimal increase in
PTV coverage with the additional collimator rotation was determined to be statistically
insignificant.

C. The limitations of this study include the retrospective nature of the study and the fact that
the technique was only tested at a single institution.

D. Further research may focus on the specific quadrants of the breast that are treated and
determine if that influences the amount of dose reduction to the critical structures.

E. In addition, further research may be completed to evaluate if rotating the collimator on

other anatomical locations can reduce dose to critical structures.

F. Finally, this research could be studied using different treatment machines for the same

anatomical site.
 References

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