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Megan Whitley Composite Case Study November 23, 2013 Electronic Compensation: An Introduction to an Alternative Treatment Technique for Right Breast Irradiation Abstract: Introduction: This study aims to evaluate the effe tiveness of !le troni Compensation "!C# in treating patients diagnosed $ith %nfiltrating &u tal Car inoma "%&C# of the right breast' %n the literature !C is also ommonly referred as %rregular Surfa e Compensation "%SC# and !le troni Tissue Compensation "!TC#' Case Description: The use of !C as a treatment te hni(ue for right breast an er is demonstrated in the follo$ing ) ases* +atient 1 represents a ,1 year old female $ith %&C, post lumpe tomy, $ith a -.', ubi lumpe tomy, $ith a 13'. entimeter " # lumpe tomy avity lo ated in the inferior outer (uadrant of the right breast/ +atient 2 represents a .1 year old female $ith %&C, post lumpe tomy avity lo ated in the medial outer (uadrant of the right breast/ +atient 3 represents a -) year old female $ith %&C, post lumpe tomy, $ith a 13'0 lumpe tomy avity lo ated in the superior inner (uadrant of the right breast/ +atient - represents a )) year old female $ith %&C, post lumpe tomy, $ith a 1.') a 13'2 lumpe tomy avity lo ated in the later right breast/ +atient ) represents a ). year old female $ith %&C, post lumpe tomy, $ith lumpe tomy avity lo ated in the lateral portion of the right breast''

Conclusion: 1ll plans $ere evaluated and ompared to dose ob2e tives and onstraints for organs at ris3 "45#' 1ll physi ian spe ifi ations $ere a hieved in these ) patients' 1lthough differen es in lumpe tomy avity si6e, lumpe tomy lo ation, body habitus, and lung volume $ere present, this treatment planning te hni(ue proved instrumental in over oming these diversities' The dose volume histogram figures that follo$ this study depi t the a hieved goals' With the fluen e editing apabilities provided by !C, treatment obsta les are more manageable' 1lthough these ) ases share the same effe ted side, diagnosis, patient set7up, target delineation, and pres ription, they differ in tumor lo ation, tumor si6e, age, and body habitus, defining the

need for a dynami treatment solution' The literature re ogni6ed $ithin this omprehensive ase study helps to onvey the details of !C and des ribe the usefulness in radiation on ology' Ke !ords* %nfiltrating du tal ar inoma "%&C#, !le troni al ulator "8MC#, transmission penetration depth "T+&#' Introduction The 1meri an Can er So iety states that breast an er is the most ommon form of an er in 1meri an $omen'1 1ffe ting almost 103,000 $omen annually, it is said to be the se ond leading ause of an er related death, superseded only by lung an er'1 1 staggering 1 in 0 $omen $ill be effe ted $ith breast an er diagnosis' There are many ris3 fa tors asso iated $ith the development of breast an er' The number one ris3 fa tor is being of the female gender, $ith an a ompanying 100*1 ratio for omparison to male diagnosis'1 1n age of ,)7.9 sees the highest in iden e rate, $hile a doubling or tripling potential for an er development o urs $hen family history is onsidered' %nherited germ7line mutations in tumor7suppressor genes also ontribute to a higher potential for breast an er'2 :ormonal fa tors, dietary and environmental fa tors, history of benign disease, and e;posure to radiation, an all ontribute to the formation of breast an er' When breast an er is diagnosed, the tissue is tested to determine $hether or not it is estrogen re eptive "!5# or progesterone re eptive "+5#' The amount of re eptiveness is illustrated in the per entage that follo$s the diagnosis "i'e' !5 < 90=, +57, :!527#' This is notable be ause patients found to be re eptor positive are more li3ely to respond to hormonal therapy, strengthening their prognosis'1 5e eptor7positive tumors are said to respond better to treatment than re eptor7negative ases' The ) ases addressed in this study have differing levels of re eptors, invariably affe ting their prognoses' 4f the primary forms of breast an er, %nfiltrating &u tal Car inoma "%&C# is the most ommon histologi al type of breast an er, totaling .0= to 00= of all breast malignan ies'1 &ue to its high prevalen e %&C is the fo us of this study' The )7year overall survival rate for breast an er, regardless of the disease status, is 09=' %f there is regional eviden e of spreading, the rate ompensation "!C#, %rregular

surfa e ompensation "%SC#, !le troni tissue ompensation "!TC#, fluen e, leaf motion

de reases to 03=, $hile the presen e of distant metastasis further de reases the survival to 20='1 Whether hoosing to treat breast an er $ith hemotherapy, hormone therapy, endo rine therapy, radi al maste tomy, modified radi al maste tomy, lumpe tomy, or radiation therapy, the resear h and development in breast an er treatment ontinues to progress' 1s available treatment options evolve, the in reased effe t on prognosis is reali6ed'2 Traditionally, $ith a diagnosis of %&C, a lumpe tomy is performed, along $ith $hole breast irradiation' Tangential fields in luding $edges are often used to deliver radiation' 5e ent developments in radiation therapy have introdu ed !C' !le troni Compensation provides improved dose homogeneity throughout the breast $hen ompared to standard treatments delivered $ith $edged fields'3 %f dose inhomogeneities are minimi6ed, late adverse effe ts su h as hanges in breast osmesis, induration, and a ute to;i ity an be minimi6ed'3 Women $ith larger amounts of breast tissue an espe ially benefit be ause negative osmeti out omes have been reported $hen using the standard $edged te hni(ue'3 %n the !C te hni(ue, dynami multileaf ollimators "M8Cs# vary the fluen e a ross ea h field to deliver a homogeneous dose'3 !le troni Compensation of surfa e irregularities are used in pla e of me hani al ompensators'The ! lipse treatment planning system "T+S# algorithm reates an optimally modulated field fluen e that is transformed by the leaf motion al ulator "8MC#, into an a tual fluen e'- This designed fluen e determines the M8C pattern of motion' 4n e the al ulation parameters are set, the standard plane ompensator is onverted into an !C, thus reating an optimal fluen e' The al ulation is done for ea h field by s anning all points $ithin the field'- !le troni Compensation is not intensity modulated radiation therapy "%M5T# or inverse planning' >asi ally, !C $or3s li3e me hani al ompensation but is an elegantly horeographed tas3, reated $ithout milling' ?sing this te hni(ue provides de reased lung doses, in reased dose onformity, and de reased inhomogeneities' When stated $ith those hara teristi s and eviden ed $ithin this $or3, !C usefulness is apparent' ! lipse 10'0 T+S $as used to reate the treatment plans for this study' %n 200), the irregular surfa e ompensation algorithm "%SC4M+# $as ommissioned on ! lipse' The %SC4M+ algorithm allo$s for variations in depths, $ithin the tangent field, along the plane of ompensation' The ! lipse user, or Medi al &osimetrist, optimi6es due to the variations a ross this plane'3 @or the purposes of this study, the treatment plans $ere designed using either a

single energy, , megavoltage "MA# or mi;ed energy, , MA and 10 MA' &ue to the potential for neutron ontamination, !C $as only used for the , MA beams' %n a study by :o$ell et al,) an in rease in the overall effe tive dose $as found $hen !C $as added to 10 MA beams versus , MA' This $as said to be attributed to a large amount of neutron ontamination from the 10 MA, $hile no neutron ontamination e;isted $ith the , MA energy') @indings su h as these orroborate the need for pla ing !C on the , MA field'

"ethods and "aterials Patient Selection The patients sele ted re eived a diagnosis of infiltrating du tal ar inoma "%&C# of the right breast and demonstrated the use of !C' +atient 1, a ,0 year7old female, presented $ith a diagnosis of %&C in her right breast $ith a histologi determination of !5 < 90=, +57, :!527' :er mother had lymphoma at age 0,, but other$ise there $as no 3no$n history of malignan y in her family' She has no history of toba o use and onsumes 1 al oholi beverage per $ee3' +atient 2, a .1 year7old female, $as diagnosed $ith %&C of the right breast after an abnormal area $as lo ated during a routine mammogram' The histologi determination for +atient 2 $as !5< )710=, +57, :!527' +atient 2 has no family history of malignan y' She has never been a smo3er and states that she onsumes 172 al oholi beverages per $ee3' +atient 3, a -) year7old @ilipino $oman palpated a lump in her right breast and subse(uently re eived a diagnosis of %&C' The histologi determination for +atient 3 $as !5<, +5<, :!52<' +atient 3 had a maternal aunt $ho had breast an er at age .0 and a maternal ousin $ho had breast an er at age ,0' She had a grandfather $ho had ne 3 lymph node malignan y but the details are un lear' She denies any use of toba o or al ohol' +atient -, a )) year7old female, $ho upon routine breast e;amination, $as found to have a 1'2 entimeter " m# mass in the lateral right breast' &iagnosti mammogram and ultrasound $ere used to onfirm a suspi ious appearing mass and a biopsy revealed grade 2 %&C $hi h $as strongly !5 and +5 positive' +atient - under$ent a lumpe tomy and sentinel lymph node

biopsy $here the final pathology determined a 1'3 m, grade 1, %@&C $ith asso iated du tal ar inoma in situ "&C%S#' The patient onsumes appro;imately 2 al oholi beverages per $ee3 and is a nonsmo3er' The patientBs sister $as diagnosed $ith breast an er at the age of -9 "stage 1, grade 3, !5 +5 negative#, and mother had pre an erous breast "potentially &C%S# at age .9' +atient ), an 0. year7old female, presented upon mammogram to have a ne$ nodule in the lateral portion of her right breast' 1 diagnosti mammogram and ultrasound onfirmed a suspi ious lesion measuring less than 2 m' 1 lumpe tomy determined the histology of a grade 1, 1'1 m %&C $ithin the right breast, $hi h $as strongly !5 and +5 positive' +atient ) has no family history of malignan y and is neither a smo3er nor a drin3er' Patient Set-up &ue to the similarities in diagnosis and effe ted side, the set7up used for ea h patient $as omparable' +atients 1, 2,3, -, and ) $ere s anned in the supine position, using a

$ing

board, #ac$%o&' head rest' and &nee (edge for immobili6ation'

5adiopa(ue mar3ers $ere pla ed on the patient prior to s anning to aid in lo ali6ation of breast tissue' @or planning purposes, 3 fidu ial mar3ers represented laser pla ement and , radiopa(ue mar3ers $ere used to outline breast tissue on the inferior, superior, medial, and lateral aspe ts, nipple and lumpe tomy s ar' 1 C! 8ightSpeed CT s anner $as used for treatment planning simulation and 2') millimeter "mm# sli es $ere obtained' 1fter the s an $as omplete, the radiation on ologist set the iso enter, the table $as shifted, and the treatment iso enter $as mar3ed on the patient' +i tures $ere ta3en of the mar3ers and fidu ials to assist in a urate patient setup during treatment' The pi tures $ere then transferred to the pi ture ar hiving and ommuni ation system "+1CS# soft$are and the omputed tomography "CT# images $ere transferred to the ! lipse treatment planning soft$are "T+S#' Target Delineation %n all ases a CT s an $as obtained $ith the patient in the previously mentioned treatment

position' Dust as the patient set7up $as ommon for all ) patients, so $as the target delineation' &ue to fa ility proto ols, the ontouring regimen and te hni(ues $ere shared by these patients' 1fter the patients $ere imported into ! lipse, ontouring $as done of the lungs, as $ell as a umulative lung stru ture representing the total lung tissue' 4ther ontouring in luded the heart, spinal ord, arina, liver, body, s ar $ire plus the medial, lateral, superior, and inferior field delineating $ires, and the thyroid gland' The radiopa(ue mar3s that are used to indi ate regions of interest have a higher atomi number than that of human tissue' This allo$ed for visuali6ation on the s an, outlining regions of interest' 8astly, the radiation on ologist ontoured the lini al target volume "CTA#' The CTA onsists of the lumpe tomy avity and the lips that remain post operatively $hi h designate the e;tent of the tumor avity' The medi al dosimterist e;panded the CTA by 1 entimeter " m#, labeling it ECTA < 1F' >oth the CTA and the e;pansion for ea h patient are represented in @igures 1, -, 0, 11 and 1-' 1 plan $as generated fo using the pres ribed dose on both the e;pansion and the CTA for ea h patient' Treatment Planning These ) patients shared the same pres ription, and the hallenge of delivering -2), entigray " Cy# in 1, fra tions to the CTA $as ompli ated by the lose pro;imity of both lung tissue and healthy breast tissue to gross disease' %n the ase of +atient 1, the planning $as primarily ompli ated by the large volume of breast tissue' 1 tangential beam arrangement $as pres ribed' The medial beam and iso enter $ere pla ed by the physi ian' 1 lateral opposed tangent beam $as reated' With both of the beams reated, a non7 oplanar te hni(ue $as used to provide non7 divergent posterior borders de reasing the radiation re eived in the lung and heart' The energy $as set to , MA for both beams' The ma;imum separation "Sma;# of the patient $as small enough, 19'3 m, that this energy provided ade(uate penetration to a hieve proper dose distribution' >oth the separation and the dose distribution an be seen in @igure 2' 1n initial al ulation $as done at this time and it $as de ided that !C $as re(uired' &ue to the use of !C, an e(ual $eighting te hni(ue $as used' 4n e the treatment goals and onstraints $ere obtained and optimal overage a hieved, the hot spot $as de reased as far a possible $ithout affe ting the overage to the CTA' These doses $ere registered on the dose volume histogram "&A:# and reported to the physi ian along $ith the organs at ris3 "45# "@igure 3#' 4n e these goals $ere a hieved the radiation on ologist approved the plan'

%n the ase of patient 2, further ompli ations arose due to a deeply seated tumor lo ation and a Sma; of 1.'0 m at the furthest e;tent of her breast tissue' &eep penetration to$ards the hest $all $as re(uired to fully over the CTA and CTA < 1 "@igure -#' This separation demanded the use of mi;ed energies $hi h $ould divide the $eight bet$een both , and 10 MA energies' The initial beams $ere dupli ated for a total of - beams' Changing the $eighting bet$een the fields $as also important be ause it allo$ed the Medi al &osimetrist to obtain needed penetration, in reasing the hest $all dosage' The final $eighting for the plan $as ,0= of the dose from the , MA fields and -0= of the dose from 10 MA fields' Sin e the $eighting on the 10 MA beams totaled greater than 30=, the $eighting $as verified by the radiation on ologist "54#' The last measure ta3en to in rease the depth of the dose $as to pla e the al ulation point posteriorly to the entral a;is, as sho$n in the a;ial vie$ in @igure )' 1fter a lo ation for the al ulation point $as determined, the point $as assigned to the pres ription in order to deliver 100= of the dose to this point, rather than the iso enter' !C $as used to de rease the hot spot in the plan $hile maintaining optimal overage' The overall hot spot for this plan $as 10,')= at ompletion' The 54 $as very pleased $ith this and de ided to pres ribe to the 99= line to in rease the overage' This inherently in reased the hot spot to about 10.')=' This $as still an a eptable range, and the 54 signed off on the plan for a hieving all of the goals set by the dosimetrist' The &A: represents the doses re eived by the 45 and the treatment volumes "@igure ,#' With +atient 3, the same pres ribed dose ob2e tives $ere used' When avoiding dose to the onstrained stru tures, the lo ation of the healthy breast tissue and right lung provided the primary diffi ulties' 4verall +atient 3 held fe$er treatment ompli ations' The presen e of these hara teristi s an reate diffi ulties $ith a hieving proper tumor overage' The presen e often demands the use of mi;ed energies, ompli ating the plan' :o$ever, +atient 3 $as an ideal andidate for single energy, , MA, tangential fields, $ith the Sma; at 10'0 m and her avity pla ement entrally lo ated "@igure .#' The right medial beam $as pla ed by the 54 at the time of simulation' The lateral beam $as pla ed to oppose the medial beam' The gantry angle $as t$ea3ed to a ount for divergen e' @or the field $eighting, e(ual distribution of )0= to the medial and )0= to the lateral $as suitable for overage' The Medi al &osimetrist then onstru ted the !C and the fields $ere assigned $ithin the T+S' >y Epainting outF the fluen e in ertain areas depi ted by isodose lines, a $ell7developed plan an be a hieved' %t is important to

remember not to Epaint overF the al ulation point $hile altering the fluen e "@igure 0#' This $ill ause the algorithm onfusion, sin e the Medi al &osimetrist intends for 100= of the dose to be fo used at this point' The onfusion $ill reate many fla$s in the plan, re(uiring repeated planning' 1fter the hot spot $as de reased to 10,'-= and the ob2e tives $ere obtained "@igure 9#, the 54 $as alerted to revie$ the plan' 1ll of the re(uirements for the plan had been a hieved, thus the 54 approved the plan' %n the ase of patient -, further ompli ations arose due to the large separation of 2-'- m at the furthest e;tent of her breast tissue' &eep penetration to$ards the hest $all $as re(uired to fully over the CTA and CTA < 1 "@igure 11#' This separation demanded the use of mi;ed energies dividing the $eight bet$een both , and 10 MA energies' The initial beams $ere dupli ated for a total of - beams' Changing the $eighting bet$een the fields $as also important be ause it allo$ed the Medi al &osimetrist to obtain needed penetration, in reasing the hest $all dosage' The final $eighting for the plan $as .0= of the dose from the , MA fields and 30= of the dose from 10 MA fields' The last measure ta3en to in rease the depth of the dose $as to pla e the al ulation point posteriorly to the entral a;is, as sho$n in the a;ial vie$ in @igure 10' 1fter a lo ation for the al ulation point $as determined, the point $as assigned to deliver 100= of the dose to this point, rather than the iso enter' !C $as used to de rease the hot spot in the plan $hile maintaining optimal overage' The overall hot spot for this plan $as 10,'0=' The &A: represents the doses re eived by the 45 and the treatment volumes "@igure 12#' With +atient ), the same pres ribed dose ob2e tives $ere used' The primary hurdle en ountered during treatment planning for +atient ) $as the lo$ volume of lung' +atient ) had the lo$est volumes of both ipsilateral lung, 1200') Bs, and total lung volume, 2000 Bs' With smaller volumes omes a higher impa t from radiation' Thus, the highest lung doses seen in this study $ere attributed to +atient ) $ith an ipsilateral A20 at 1,')= and a total lung A20 at 9'0= "Table 2#' 1lthough the lung doses $ere higher than the ompared ases, they $ere $ithin the onstraints set by the 54' +atient ) $as an ideal andidate for single energy, , MA, tangential fields, due to an Sma; at 10'0 m and the avityBs entral lo ation "@igure 1-#' The right medial beam $as pla ed by the 54 at the time of simulation' The lateral beam $as pla ed to oppose the medial beam' The gantry angle $as t$ea3ed to a ount for divergen e' @or the field $eighting, e(ual distribution of )0= to the medial and )0= to the lateral $as suitable for overage' The

Medi al &osimetrist then onstru ted the !C and the fields $ere assigned $ithin the T+S, being areful to avoid removing dose in the area of the al ulation point "@igure 13#' 1fter the hot spot $as de reased to 10)',= and the ob2e tives $ere obtained "@igure 1)#, the 54 $as alerted to revie$ the plan' 1ll of the re(uirements for the plan had been a hieved, thus the 54 approved the plan' %n all ) ases, the medi al dosimetristsB approa h $as to insert !C on any field using the , MA energy' 4n e the %SC, or !C, $as added, the transmission penetration depth "T+&# $as fi;ed' Tissue penetration depth is a user7defined parameter that determines the depth of the surfa e ompensation'3 The optimum T+& an be orrelated $ith the Sma; along the fieldsB posterior border'3 !mmens states that Eredu ing the T+& belo$ )0= pushes the dose to$ards the front of the breast G$hi hH redu es hot spots at the medial and lateral regions ne;t to the posterior border of the tangential fields, parti ularly for patients $ith large separation'F &ifferent institutions have different standards for both T+& and mi;ed energies' The Sma; is an integral omponent for both' %nterestingly, at the urrent fa ility a Sma; of 2- m or more establishes the partial use of 10MA energy' 1t the fa ility $here !mmensB study $as performed, 2- m Sma; $as the ben hmar3 determining the T+& use of belo$ )0='3 !mmensB department proto ol states that, Esub2e t to an a eptable dose distribution, a T+& of -0= is used if Sma; is greater than 2- m/ for smaller separations, a T+& of )0= is usedF' 1fter the T+& is determined, $ith the !C assigned to the fields, a 2'0 m s3in flash is added to the breast tissue' 1dding s3in flash provides an area that allo$s for respiratory movement, patient movement, and breast s$elling, $hile demonstrating to the algorithm that a transition in dose is needed' 1 smoothing of the region $here air meets breast tissue allo$s for the gradual transition in dose' The 2un tion of this area is depi ted in @igure 13, providing a visual of $hat the fluen e $ould loo3 li3e if not smoothed' The last step in adding !C is to alter the generi fluen e generated by the algorithm' >y li 3ing to edit the fluen e, the $or3 of EpaintingF the dose an begin by altering the transmission fa tor $ithin these regions of high dose' >y impa ting the planBs fluen e the isodose lines move and the overage hanges' Constru tion of an ideal breast plan is determined by a de reased lung dose, an in reased tumor dose, and onformal overage $ith a lo$ region of hot spot' >y EpaintingF out the fluen e in ertain areas depi ted by isodose lines, a $ell7 developed plan an be a hieved' Cal ulating bet$een ea h fluen e alteration and evaluating all the available vie$s' This allo$s the dosimetrist to obtain the most onformal dose distribution,

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and meet the goals and ob2e tives established by the physi ian, $hile salvaging the healthy surrounding tissues' Plan Analysis & Evaluation The onstraints used for planning are unanimous for all ) patients involved in this study' The A20 onstraint for the total lung $as set I 10 gray "Cy#' This is interpreted to onstrain 20= of the total lung volume to re eive less than or e(ual to 10 Cy' The heart onstraint for right breast irradiation is stated as a mean dose I -00 Cy, and a A20 I ) Cy' The final demands set are asso iated $ith the hot area $ithin the plan and the overage to the lumpe tomy site and e;pansion' 1 hot area of I 100= of the pres ription is onsidered a eptable' %deally, 100= of the CTA $ould re eive 100= of the dose, and the e;pansion CTA < 1, $ould a hieve 90=79)= of the dose to 100= of the volume' These are ideal guidelines and are not al$ays a hievable' >ased on the plan and the spe ifi demands of ea h patient, the physi ianBs evaluation determines approval' @or +atient 1, the plan nearly a hieved all dosimetri onstraints, deeming it a eptable to the

physi ian on e the umulative dose ob2e tives and onstraints $ere evaluated' The ma;imum dose to the ipsilateral lung and the total lung ma;imum $ere the same at -2-. Cy' The reason for this is that the patient is only re eiving dose to one of her breasts, thus leaving the lung asso iated $ith the unaffe ted side, $ith very little dose' This is a hara teristi of a good breast treatment plan, stating that the radiation administered from the lateral tangent ontributes very little dose, if any' +atient 1Bs total lung A20 $as 3',=, falling $ell $ithin the onstraint' The Medi al &osimetrist a hieved a mean heart dose of 32 Cy and A20 0= for patient 1' +atient 1Bs CTA $as 90= overed by 100= of the dose, and the CTA < 1 re eived 90= of the dose to 99= of the volume' The overall hot spot $as 10)')= "Table 1#' These statisti s an be seen in @igure 3' 4f all ) of the ases, +atient 1 had the largest volume of breast tissue, but her plan a hieved the most ideal out ome' The volume is depi ted in @igure 2, $hile the ubi entimeters " Bs# are represented in Table 3' The plan for +atient 2 also $as very lose to a hieving most of the umulative dose onstraints and ob2e tives' The ma;imum dose to the ipsilateral lung and the total lung ma;imum $ere the same at --1, Cy' +atient 2Bs total lung A20 $as -')=, falling $ell $ithin the onstraint' The

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Medi al &osimetrist a hieved a mean heart dose of 30'1 Cy and A20 0= for patient 2' +atient 2Bs CTA $as 100= overed by 100= of the dose, and the CTA < 1 re eived 90= of the dose to 9,= of the volume' The overall hot spot $as 10,')=' These statisti s an be seen in Table 1 and @igure ,' %n omparison to the other - patients, +atient 2 had the largest overall lung volume "Table 3#' 1ppropriately so, this in reased the total lung A20 to -')= "Table 2#' +atient 2 also had the largest CTA and CTA < 1 volumes "-.', Bs and 1,) Bs in Table 3#' >y a 3no$ledging the in reased lung volume and the larger target stru tures, an e;planation for $hy the Medi al &osimetrist struggled to obtain the overage on the e;pansion volume be omes lear' The e;pansion stru ture traversed into the hest $all, re(uiring dose to abut the hest $all to obtain overage "@igure )#' @or patient 2, the in reased lung tissue and the lo ation of the tumor volume demanded the most attention throughout planning' 1lthough the plan devised for +atient 3 resisted onforming to the onstraints and demands set by the Medi al &osimetrist, an a eptable plan $as inevitably generated and approved by the physi ian' The ma;imum dose to the ipsilateral lung and the total lung ma;imum $ere the same at -10) Cy' +atient 3Bs total lung A20 $as -'2=, falling $ithin the onstraint' The Medi al &osimetrist a hieved a mean heart dose of 20'0 Cy and A20 0= for patient 3' +atient 3Bs CTA $as 9,= overed by 100= of the dose, and the CTA < 1 re eived 9)= of the dose to 9)= of the volume' The overall hot spot $as 10,'-=, as seen in Table 1 and @igure 9' The plan for +atient - also a hieved the umulative dose onstraints and ob2e tives' The ma;imum dose to the ipsilateral lung and the total lung ma;imum $ere the same at -0)2 Cy' +atient -Bs total lung A20 $as 3')=, falling $ithin the onstraint' The Medi al &osimetrist a hieved a mean heart dose of 39'. Cy and heart A20 1', = for patient -' +atient -Bs CTA $as 100= overed by 100= of the dose, and the CTA < 1 re eived 100= of the dose to 9.'-= of the volume' The overall hot spot $as 10,'0= "Table 1#' The volume is depi ted in @igure 11, $hile the ubi Bs are represented in Table 3'

When ompared to the other - patients, the plan for +atient ) most su essfully a hieved the umulative dose onstraints and ob2e tives' The Medi al &osimetrist a hieved a mean heart dose of 33'- Cy and heart A20 1'3= for patient )' +atient )Bs CTA $as 100= overed by 100= of the dose, and the CTA < 1 re eived 100= of the dose to 100= of the volume' The

12

overall hot spot $as 10)',= "Table 1#' The volume is depi ted in @igure 13, $hile the ubi Bs are represented in Table 3' The ma;imum dose to the ipsilateral lung -2)0 Cy and the total lung ma;imum $ere -2-- Cy' +atient )Bs total lung A20 $as 9'0=, barely falling $ithin the onstraint' %n omparison to the other patients, +atient ) had an average amount of breast tissue, CTA volume, and CTA < 1 volume, so it is interesting to mention that $hile +atient 2 had the largest lung volume, +atient ) had the highest A20 lung doses' Sin e the ipsilateral breast tissue si6es $ere omparable bet$een the patients, yet the doses $ere higher in +atient ), only one on lusion an be madeJthat +atient ) has less lung volume, ausing in reased per entages in both her ipsilateral and total lung doses'

Results and Discussion &esigning appropriate dose distribution, fluen e, and onformity by means of !le troni Compensation is an e; ellent option for radiating breast tissue' 1s $ith any treatment te hni(ue, the hurdles of in reasing the dose to target stru tures, de reasing the dose to healthy tissue, and maintaining a onformal plan, is ompli ated' !C an be used to de rease the hot spot in the plan $hile maintaining optimal overage be ause they an provide the effe t of both a blo 3 and a $edge in one me hanism' These multifa eted treatment tools prevailed as the optimal te hni(ue in these ) ases' With the help of !C, plans $ere designed by the Medi al &osimetrist $ith onfiden e that the safest and most pre ise dose deliveries $ere al ulated' !le troni Compensation is a huge step for$ard in an er treatment, and predominantly in breast an er treatment' &ue to the over$helming number of diagnoses made ea h year, having !C as an on ologi al resour e is vital to developing high (uality plans' :opefully, $ith more resear h and reativity, designs li3e !C $ill be embra ed by the medi al ommunity, and the enhan ement of out omes an ontinue' )igures

13

)igure *+ 1 sagital vie$ of the CTA "red#, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient 1'

14

)igure ,+ 1n a;ial vie$ of the CTA "red#, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient 1' The isodose line that represents 100= overage is in green and the 90= line is in blue'

)igure -+ 1 &A: illustrating the high dose re eived by target volumes and the lo$ dose re eived by 45 for +atient 1'

15

)igure .+ 1 sagital vie$ of the CTA "red#, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient 2'

16

)igure /+ 1n a;ial vie$ of the CTA "red#, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient 2' 5epresents the planning diffi ulties $ith a CTA < 1 stret hing from superfi ial to deeply seated e;tents of breast tissue' The isodose line that represents 100= overage is in green and the 90= line is in blue'

17

)igure 0+ 1 &A: illustrating the high dose re eived by target volumes and the lo$ dose re eived by 45 for +atient 2'

18

)igure 1+ 1 sagital vie$ of the CTA "red#, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient 3' The isodose line that represents 100= overage is in green and the 90= line is in blue'

19

)igure 2+ 1n a;ial vie$ of the CTA "red#, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient 3' The isodose line that represents 100= overage is in green and the 90= line is in blue'

)igure 3+ 1 &A: illustrating the high dose re eived by target volumes and the lo$ dose re eived by 45 for +atient 3'

20

)igure *4+ 1 sagital vie$ of the CTA, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient -' The isodose line that represents 100= overage is in green and the 90= line is in bro$n'

21

)igure **+ + 1n a;ial vie$ of the CTA "red#, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient -'

)igure *,+ 1 dose volume histogram "&A:# illustrating the high dose re eived by target volumes and the lo$ dose re eived by organs at ris3 "45s# for +atient -'

22

)igure *-+ 1 sagital vie$ of the CTA "red#, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient )'

23

)igure *.+ 1n a;ial vie$ of the CTA, CTA <1 "blue#, the al ulation point and the isodose distibution for +atient )'

)igure */+ 1 &A: illustrating the high dose re eived by target volumes and the lo$ dose re eived by 45 for +atient )'

24

Tables Table *+ +lan 1nalysis and !valuation for all ) ases' Coverage +t K1 CT# 90= of vol L 100= of dose 100= of vol L 100= of dose CT# 5 * 90= of vol L 90= of dose 6ot 7pot 10)')0=

+t K2

9,= of vol L 90= of dose

10,')0=

+t K3

9,= of vol L 100= of dose 100= of vol L 100= of dose 100= of vol L 100= of dose

9)= of vol L 9)= of dose 9.'-= of vol L 100= of dose 100= of vol L 100= of dose

10,'-0=

+t K-

10,'00=

+t K)

10)',0=

25

Table ,+ 4b2e tives and Constraints 1 hieved for all 3 ases' 8b9ectives and Constraints Achieved %psilateral lung A20 Constraint LA20I1)= :t ;* %psilateral 8ung Ma; dose Cy Total 8ung Ma; dose Cy -2-. Cy A20 total lung onstraint LA20M10= mean heart dose Cy

,')0= -2-. Cy

onstraintLA20I)= mean I -00 Cy 3',0= 0= 32'0 Cy -')0= 30'1 Cy 0=

:t ;,

0'30= --1, Cy

--1, Cy

:t ;-

.= -10) Cy

-10) Cy

-'20= 20'0 Cy

0= 1',=

:t ;.

,= -0)2 Cy

-0)2 Cy

3')0= 39'. Cy 1'3 =

:t ;/

1,')0= -2)0 Cy

-2-- Cy

9'00=

33'- Cy

26

Table -+ Aolumes of interest in

Bs for all 3 ases'

#olumes of Interest in CC<s :t ;* %psilateral >reast tissue volume in Ns 919 Tumor volume in Ns 13'0 Tumor < 1 m volume in Ns ,,'2 %psilateral 8ung volume in Total lung volume in

Ns 1300

Ns 2)-3

:t ;,

-21

-.',

1,)

1010'3

3302'3

:t ;-

,1-

13'.

.2'3

1-0)

2300

:t ;.

10)-

1.')

00'0

129)'-

2232'-

:t ;/

,99

13'2

.9

1200')

2000

27

References 1' Washington CM, 8eaver &' Principles and Practice of Radiation Therapy' 3rd ed' St' 8ouis, M4* Mosby7!lsevier/2010*0,,70.,' 2' >u hhol6 T1' 5adiation therapy for early7stage breast an er after breast onserving surgery' N Engl J ed! 2009/3,0*,37.0' doi* 10'10),ON!DM t0003)2)'

3. !mmens &D, Dames :A' %rregular surfa e ompensation for radiotherapy of the breast*

orrelating depth of the ompensation surfa e $ith breast si6e and resultant dose distribution' "r J Radiol! 2010/03"90,#*1)971,)' doi* 10'12)9Ob2rO,)2,-91,. -' Pinhi3ar 51, Sharma +P, &eshpande &&' !le troni tissue ompensation a hieved $ith both dynami and stati multileaf ollimator in e lipse treatment planning system for Clina , !Q and 2100 C& Aarian linear a elerators* @easibility and dosimetri study' J ed Phys! 200./32"2#*),7)9' )' :o$ell 5M, :ertel N!, Wang R, :ut hinson D, @ullerton C&' Cal ulation of effe tive dose from measurements of se ondary neutron spe tra and s attered photon dose from dynami M8A %M5T for , MA, 1) MA, and 10MA beam energies' 33"2#*3,073,0' ed Phys! 200,/