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Eyob Mathias January Case Study January 17, 2013 Invasive Ductal Carcinoma of the Right Breast Case Study. History of present illness: Mrs. LW is a 49 years old female recently diagnosed with T1bN0M0, Stage I grade 1 invasive ductal carcinoma of the right breast. On March 14, 2012 she underwent annual bilateral mammography at one of the local imaging clinics in Wilkes-Barre, Pennsylvania. This showed abnormal asymmetry of the breast as well as a 5 X 7 millimeters (mm) nodule in the right upper outer quadrant of the right breast, about 10 centimeters (cm) from the nipple. Right mammogram and right ultrasound were done on September 27, 2012 showing more noticeable asymmetry in the right central posterior breast. The nodule was palpable and measured 4 X 5 X 3 mm in size. Core biopsy was taken on October 4, 2012 which showed invasive ductal carcinoma with a tumor size of 6 mm, E.R. 80% positive, P.R. 50% positive and HER-2 negative. She then underwent bilateral breast Magnetic Resonance Imaging (MRI) on the 11th of October 2012. The result showed the biopsy cavity with residual 4 mm nodule as well as a nonmass like enhancement. Right mammogram was done on the 11th of October, 2012 to correlate the non-mass like enhancement seen on MRI. The result of the mammogram revealed no abnormalities relating to the non-mass like enhancement showed on the MRI. On the 23rd of November 2012, Ms. LW had a CT scan of the abdomen and pelvis. The result showed no metastatic disease. Subsequently, she underwent ultrasound of the right breast because of the MRI findings on Oct. 11th with a suspected intramammary lymph node involvement. Ultrasound showed a 4 x 6 x 6 mm mass with benign intramammary lymph node about a distance of 7 cm from the nipple which appeared to correlate with the MRI finding. On December, 20, 2012, she underwent right partial mastectomy and sentinel lymph node biopsy. Pathology result revealed low grade invasive ductal carcinoma, 6 mm, lymph node negative for metastatic disease. She is currently in a good condition and doesnt have any other symptoms. Family history: She has a family history of breast cancer. She also has a family history of ovarian cancer in her maternal aunt at age 47. Two daughters of different maternal aunts (patients cousins) also have breast cancer as well.

Social history: She lives in Shickshinny, PA and works as a social worker in a college at Nanticoke, PA. She is married and has a 19 y/o daughter who is currently attending college. She is non-smoker and denies using any illegal drugs. Past Medical History: She has no significant past medical history. She had right knee surgery as a teenager, and endometrial ablation for menorrhagia in 2009. Allergies: She has no allergic reaction to any medicine, food or latex. Current medications: Tamoxifen Citrate 20mg and Percocet 5-325mg. Physical examination: On Jan. 3rd, 2012 Ms. LW had her physical examination. She looked very well and had an excellent performance status. General examination was normal with no evidence of jaundice or edema. Vital signs were normal with a blood pressure of 138/70, pulse rate 70, no fever, her weight was 145 pounds, head and neck exam was normal, no palpable lymphadenopathy in the cervical, supraclavicular, or axillary areas, no spinal tenderness, heart sound was normal, abdomen was soft and nontender with no masses, bowel sound was normal, neurological examination was intact, examination of the breasts was normal with no palpable abnormality on the right side. Recommendation: Due to the tumor type and larger size, the doctor didnt recommend chemotherapy. She is young and has an excellent performance status, so the doctor recommended hormonal treatment with Tamoxifen and concurrent radiation treatment. The appropriate diagnostic films were reviewed by the radiation oncologist prior to the simulation process for pre-treatment planning. On Jan. 14th, 2013 she came to the oncology department for radiation treatment simulation process. Patient setup: Breast board was devised for accurate positioning of right breast. The patient was placed in supine treatment position, 50 breast board angle, head turned slightly to the patients left, rounded sponge placed under patients knees and scar mark was obtained by the radiation oncologist. Reference point (BBs) was placed and verified via CT images. CT scan of the target area was then obtained without contrast. The 2 cm margin measurement of the breast tissue was taken and field border lines were marked. The CT images were downloaded to the treatment planning system. The target volumes, which included the tumor and immediate nodal drainage areas, were outlined as well as adjacent critical normal organs at risk.

Plan Prescription: A dose of 4500 cGy in 25 fractions followed by a boost of 2000 cGy in 10 fractions was prescribed to be delivered by using 6MV energy beam per the generated dosimetric plan. Treatment planning process: 1) Isocenter: After importing the CT simulation images into the Philips Pinnacle 9.2 radiation treatment planning system (TPS), I removed the couch view using the setup window and localized the table position by creating isocenter with reference to the BBs placed during simulation. 2) Contouring: The critical structures contoured around the treatment area included the heart, right lung, left lung, nipple and cord. 3) Beam Arrangement: After outlining these structures, the dose calculation point was created and 2 beams (medial tangential beam and lateral tangential beams) were added. The gantry was angled at 590 for the medial tangent beam and 2390 for lateral tangent beam. The collimator was angled at 3430 for the medial tangent and 170 for the lateral beam. The field size auto-surround block method was turned off and half-beam treatment planning technique was used. The beam only included 1.5 cm of the left lung. MLC step and shoot technique was selected. 4) Dose prescription: 180cGy per fraction for a total of 25 fractions was entered and treatment plan was computed. 5) Control points: Three segmental blocks were added to account for hotspots and plan was recomputed with the most accurate beam weighting parameters. 6) Approval: Plan was reviewed and approved by the radiation oncologist. 7) Export Tx plan: Plan was exported to Mosaiq and Radcalc software where the physicist will be able to double check the treatment plan monitor unit and dose calculations. I have been told that there will be no QA done for this treatment plan. 8) Schedule tx start date: Plan was finally approved by the physicist and sent to the treatment machine. Ms. LW was scheduled to start her treatment on January 24, 2013. Conclusion: Overall, this was an interesting breast treatment plan experience for me. I learned basic treatment plan technique. I have also learned about calculation point placement and how the gantry angle affects the divergence of the beam. The patients breast size didnt create any difficulty during simulation. No immobilization devices are utilized during most

breast simulation processes other than breast board positioning device. It will be interesting to read a research study regarding the accuracy of breast plan reproducibility for large breasts. Ms. LW is currently under treatment and is in a very good condition. If everything goes as planned she will complete her radiation treatment on March 13, 2013.

Figure 1 Right breast MRI. October 11, 2012.

Figure 2 Dose distribution

Figure 3 Beam Arrangement/ Field size

Figure 4 Dose volume histogram

Figure 5 Calc sheet

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Figure 6 Point calculation

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Reference 1. (2006) Portal Design in Radiation Therapy, 2nd ed., p. 71-84.