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Nick Piotrowski Dos 773 Clinical Practicum III October 25, 2013 Right Breast Carcinoma History of Present Illness: MJ is a 68 year old female with a tumor extension 1, no lymph node extension, and no metastatic disease (T1c N0 M0) right breast carcinoma. In July 2013 an abnormality was found in the right upper outer quadrant (RUQ) during a routine mammogram. After the completion of a percutaneous core biopsy, a grade 1 infiltrating ductal carcinoma was determined, spanning 0.7 centimeters (cm) in the greatest dimension. Past Medical History: The patient has not had many serious past medical experiences. She suffers from hypertension, hypercholesterolemia, and gastroesophageal reflux disease (GERD). She has also had a variety of procedures done including a tonsillectomy, appendectomy, and tubal ligation. Social History: MJ is currently married and has one son and a daughter. While she occasionally consumes alcohol on a social basis, and smoked over 40 years ago, she does not use drugs or have any family history of cancer. Unfortunately her father, mother, and two sisters have all passed away from heart disease at a young age. Medications: MJ is currently taking a 10 milligram (mg) pill of atorvastatin 3 times per week, 20 mg of lisinopril and 40mg of omeprazole daily, 400 mg of ibuprofen every 6 hours, and 1 tablet of Loperamide as needed. The only known allergy she has is to sulfonamide antibiotics. Diagnostic Imaging: At her annual mammogram a 0.7 cm lesion was discovered in the RUQ of the right breast. To determine the pathology, an ultrasound guided core biopsy was completed. To verify the size and location of the lesion a magnetic resonance image (MRI) was performed prior to treatment. Finally 1 week before radiation treatments a treatment planning computed tomography (CT) scan was completed to develop a plan off of. Radiation Oncologist Recommendations: As recommended, a right lumpectomy was initially performed before being sent to the radiation oncologist for post-operative radiation. The postoperative radiation dose recommended was 52.56 Gray (Gy) in a total of 20 fractions over 4 weeks. The Plan (prescription): As recommended by the radiation oncologist, MJs plan was taken to 52.56 Gy. The initial plan consisted of 16 fractions at 2.66 Gy/fraction, resulting in 42.56 Gy.

Once finished, MJ would be treated with a 4 fraction boost at 2.5 Gy/fraction. This additional 10 Gy allowed the tumor volume to receive the total 52.56 Gy. Patient Setup/Immobilization: During the treatment planning CT, MJ was placed supine on the table with her arms raised above her head. In order to help with immobilization, she was position on a wingboard with a vaclok created around her arms and upper body. To keep her mandible out of the field, her head was turned to the left as it was her right breast being treated. Radio-opaque markers were placed on the clinical borders of the fields on all sides, as well as on the lumpectomy scar (Figure 1). The isocenter was not set in the simulation by the physician, but BBs were placed on the skin to assist with patient setup. Anatomical Contouring: Breast cancer cases at this facility require a variety of major organs to be contoured. The heart, liver, lungs, carina, and spinal cord were all contoured, as well as the radio-opaque wires. These wires were forced to a density of -1000 Hounsfield Units (HU), to assure they did not affect the treatment planning calculations. The lumpectomy cavity was contoured by the physician, and a 1.0 cm margin was added to create a planning target volume (PTV). In addition, the physician wanted this PTV cropped 0.5cm from the body and 0.8 cm from the right lung to more accurately describe the disease. Beam Isocenter/Arrangement: As the beam isocenter was not set during the simulation, it was the job of the dosimetrist to do so. While occasionally the isocenter will be set in the lung, and half beam blocked, this was not one of those cases. The isocenter was placed in the center of the breast near the edge of the PTV. As the isocenter was placed 12.3 cm right, 0.5 cm superior, and 3.5 cm anterior of the simulation marks, those were the daily shifts. In this case the jaws were symmetric and opened 4.5 cm both anteriorly and deep. This allowed for the chest wall and 3 cm of lung to be included in the field. The medial tangent had a gantry rotation of 57 degrees, and a collimator rotation of 350 degrees. The lateral tangent arrangement was determined by matching the angle of the posterior field edge to match divergence. This resulted in a gantry angle of 232 degrees and a collimator rotation of 10 degrees. To help spare the small portion of liver in the field, the physician added blocks to both the medial and lateral beams. In order to bring dose deeper into the breast, two beams of the same angles were also created, but instead of 6 megavoltage (MV) energies, they were 18MV beams. These beams were weighted 35%:35%:15%:15% with the 6MV beams contributing the majority of the dose.

Treatment Planning: MJs right breast treatment plan was designed using treatment planning system Eclipse 10.0. The goal of this initial treatment plan was to get 42.56 Gy to the breast while minimizing dose to critical structures such as the heart and right lung. For the 6 MV beams, irregular surface compensators were used to modify the dose. A 2 cm margin of dose was added anteriorly to ensure the coverage of the breast each day and avoid marginal miss. After the initial calculation, a global maximum of 113.7% was produced. Using the irregular surface compensation, the dosimetrist was able to minimize this global maximum to 106.1% while maintaining sufficient coverage around the breast (Figure 2). While a wedge technique is also efficient at decreasing a global maximum, irregular surface compensation has shown better results.1 Reviewing the dose volume histogram (DVH), 96% of the PTV received 100% of the dose, and 100% of the cavity also received 100% of the dose (Figure 3). The physician also put constraints on the heart and right lung, at 10% of the volume to receive less than 25 Gy, and 30% of the volume to receive less than 20 Gy respectively. These constraints were met as 10% of the heart received 0.67 Gy, and 30% of the lung received 3.4 Gy. Quality Assurance (QA)/Physics Check: Before printing, the monitor units (MU) that were calculated by Eclipse 10.0 were double checked using RadCalc. Once the numbers were found to be within the 2% tolerance, the plan was sent to the medical physicist for quality assurance (QA) of the irregular surface compensation. Using MapCheck the physicist measured the output of these two beams to verify the MU recorded is within 1% of the MU that was planned. After approval, it was double checked and approved by both the physicist, as well as the attending physician. Conclusion: While there are always standards of treatment at any center, each case needs to be treated individually. This case in particular was as standard as it gets, but it still required the necessary thought process. Depending on the attending physician, it most often falls on the shoulders of the dosimetrist to choose the appropriate angles. This means keeping dose out of the lung and heart while providing enough coverage both medially and laterally. This thought process is also needed to determine the ratio of the beam weighting and whether or not a mixed energy technique is useful. Regardless of the difficulty of the plan, it is these decisions that create the demand for dosimetrists and skills that they possess.

Figures

Figure 1. Radio-opaque marks labeling the field borders and lumpectomy scar.

Figure 2. Dose distribution with 106.1% hot spot.

Cavity PTV

Rt Lung

Heart

Figure 3. DVH summary

References 1. Fujita H, Kuwahata N, Hattori H, et al. Improvement of dose distribution with irregular surface compensator in whole breast radiotherapy. Journal of Medical Physics. 2013;38(3):115-119. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775034/. Accessed October 30, 2013.