1

Comparison of VMAT vs. a 4-Field Technique for Post Mastectomy Irradiation of Barrel
Shaped Right Chest Walls: A Case Study
Authors: Tayisiya Polishchuk, R.T.(T), Karen Krueger, R.T.(T), Michelle Rocque, R.T.(T),
Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD, Ruth Ann M. Good, RT (R)(T), CMD, Alex
Whittington, CMD
Medical Dosimetry Program at the University of Wisconsin La Crosse, WI
Abstract:
Introduction: This study aims to evaluate the dose variations of planning treatment volumes
(PTVs) and organs at risk (OR) between two treatment techniques for barrel shaped right chest
wall post mastectomy patients.
Case Description: In the treatment of the post mastectomy chest walls, some patients present
with chests that are thick anterior to posterior and somewhat resemble the shape of a barrel.
Barrel shaped right chest wall patients require involvement of additional volumes of the
ipsilateral lung in order to achieve adequate coverage of the chest wall and lymph node area.
Increasing the target volume increases the volume of the ipsilateral lung in the treatment fields,
and therefore increases the potential of higher toxicity to the ipsilateral lung volume and other
OR.1 Patients were selected based on the barrel chest wall criteria of 3.5 to 4.5 cm ipsilateral lung
depth involvement, when evaluating tangent fields covering total nodal chest wall volumes. Two
techniques were performed to evaluate the ipsilateral lung dose. A 4-field plan utilizing extended
tangents with the supraclavicular (SCL) field and a posterior axilla boost was used as one of the
chest wall treatment techniques. A 3 mm thick bolus was applied every other day to the chest
wall area. The volumetric modulated arc therapy (VMAT) plan consisting of two coplanar arcs
with opposite rotation (clockwise and counter-clockwise) was utilized as the second treatment
technique. A total of 3 patients were selected to evaluate doses to the ipsilateral lung and other
ORs for both treatment techniques.
Conclusion:
Key Words: Barrel shaped chest wall irradiation, 3DCRT, VMAT, radiation pneumonitis
Introduction
Radiation pneumonitis is the radiation-induced inflammation of the lungs caused when
delivering radiotherapy to the intrathoracic malignancies.2 Despite the fact that most risks of
radiation pneumonitis is caused while delivering lung cancer treatments, the literature suggests
that up to 5% of breast cancer patients will experience radiation induced symptoms when
receiving breast cancer treatments.3 There are guidelines provided by the National

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Comprehensive Cancer Network (NCCN) highlighting the importance of including total nodal
regions in the treatment fields when planning for the chest wall irradiation.4 Due to the higher
possibility of nodal recurrence, it is strongly recommended to consider treating the internal
mammary nodes (IMN) when delivering chest wall radiation therapy, especially if any of the
following criteria was found during the mastectomy surgery: positive margins, negative axillary
nodes and tumor>5 cm, or the presence of positive axillary nodes. Extended tangents technique
is required when performing total nodal irradiation in order to encompass all of the lymph nodes
involved, in addition to including the chest wall treatment volume. Increasing the fields in order
to include all of the disease volumes can increase the lung volume in the extended tangent fields.
Increasing the lung volume in the treatment fields of total nodal post-mastectomy barrel shaped
chest walls can potentially increase the risks of radiation pneumonitis.
Two treatment techniques were utilized when planning for each of the 3 patients with the
total nodal barrel shaped right chest wall volume. A 4-field three-dimensional conformal
radiation therapy (3DCRT) with partially wide tangential fields and parallel opposed
supraclavicular portals treatment plan was used as one of the treatment techniques. A VMAT was
the second treatment planning method. Evaluating doses to the chest wall, supraclavicular,
axillary, and internal mammary lymph nodes, as well as heart, contralateral lung, and
contralateral breast were closely evaluated. In addition, dose to the ipsilateral lung was analyzed
for each patient in both 3DCRT and VMAT plans. The same treatment prescription of 50 Gy in
25 fractions was applied to the selected 3 patient cases. The plans were evaluated and compared
for acceptability against criteria in the National Surgical Adjuvant Breast and Bowel Project
(NSABP) B-51 protocol (also known as the Radiation Therapy Oncology Group RTOG-1304
protocol).5
Case Description
Patient Selection
A total of 3 patients were selected for the study utilizing a variety of factors. Two of the
patients were diagnosed with invasive ductal carcinoma, and the third patient was diagnosed with
infiltrating ductal carcinoma. Each patient underwent right-sided mastectomy and sentinel lymph
node evaluation. A curative dose of 50 Gy in 25 fractions was prescribed by the physician to the
barrel chest wall and the lymph nodes, and definitive radiation treatment following NSABP B-51
protocol was suggested.
Each patient was placed in the supine position, head first into the CT scanner, and
simulated via free breathing. Two of the patients were simulated on the Phillips CT scanner and

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the third patient was simulated on the General Electric CT scanner. Patient #1 and patient #2
were simulated utilizing a breast board with the right arm up, the left arm by patients left side,
and the head slightly turned to the left. Patient #3was simulated utilizing an inclined
wingboard/breastboard with both arms raised above the head, and the head slightly turned to the
left. In order to facilitate contouring segmentation of the CT data-set, radio-opaque markers were
placed on the patients skin in the treatment position as external landmarks at the acquisition of
the CT scan.4 These markers identified the mastectomy scar, as well as the outline of the
physicians clinical assessment of the at risk chest wall which included postoperative changes
and where the ipsilateral breast previously was located. Weekly MV imaging was used to aid in
reproducibility.
Target Delineation
The Philips Pinnacle 9.6 treatment planning system (TPS) or the Varian Eclipse Version
11.0 TPS were utilized to outline targets in each of the selected patients. The chest wall Clinical
Target Volume (CTV) was delineated by the physician utilizing radiopaque markers placed at CT
simulation identifying the clinical extent of the chest wall, surgical changes visualized by CT,
and consensus definitions of anatomical borders of the chest wall from the RTOG Breast Cancer
Atlas.6 The chest wall CTV was limited by the skin anteriorly and did not extend deeper than the
ribs to exclude the lung and heart. In addition, the chest wall CTV did not cross midline (Figure
1). The CTV was expanded 7 mm (excluding the heart and not crossing midline) to form the
chest wall Planning Target Volume (PTV) (Figure 2). The chest wall PTV evaluation (PTV Eval)
structure was created based on the chest wall PTV with some limitations. The chest wall PTV
Eval was limited anteriorly to exclude the part outside the patient and the first 3 mm of tissue
under the skin in order to remove some of the buildup region for the dose volume histogram
(DVH) analysis. In addition, the chest wall PTV Eval was limited posteriorly to no deeper than
the posterior rib surface and to exclude the lung and the heart (Figure 3). The chest wall PTV
Eval was the structure utilized for DVH constraints and analysis and not for beam aperture
generation. In addition, the supraclavicular CTV was outlined by the physician following the
RTOG breast cancer atlas. The CTV was expanded 5 mm in all directions to create the
supraclavicular PTV (Figure 4). The axillary CTV was created to include all three levels of the
axillary nodes. The CTV was then expanded 5 mm to create the axillary PTV (Figure 5). The
IMN CTV included the internal mammary/thoracic vessels in the first three intercostal spaces,
and then expanded 5mm medially, laterally, superiorly, and inferiorly to create the IMN PTV

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(Figure 6). Contoured structures at risk included the ipsilateral lung, contralateral lung, heart,
spinal cord, and contralateral breast.
Treatment Planning
Philips Pinnacle 9.6 TPS was utilized when planning patient 1, and Varian Eclipse
Version 11.0 TPS was utilized when planning patients 2 and 3. Each patient chest wall case was
planned utilizing VMAT and a 3DCRT 4-field technique using plan comparison to evaluate the
ipsilateral lung dose in both plans. In both planning techniques on patient 1 and 3, the
calculations were performed with a 3.0 cubic-millimeter dose grid resolution. For treatment
planning techniques on patient 2, the calculations were performed with a 2.5 cubic-millimeter
dose grid resolution. A 4-field plan utilizing extended tangents with the SCL field and a posterior
axilla boost was used as one of the chest wall treatment techniques. A 3 mm thick bolus was
applied every other day to the chest wall area. A VMAT plan consisting of 2 coplanar arcs with
opposite rotation (clockwise and counter-clockwise) was utilized as the second treatment
technique. According to the NSABP B-51 protocol no bolus was necessary for the VMAT plan.
The path length of each arc for patient 1 was 135 (75 - 210) with the collimator rotated 5 in
the clockwise arc and 355 in the counter-clockwise arc. The path length of each arc for patient 2
was 180 (180 - 360) with the collimator rotated 90 in the clockwise arc and 180 in the
counter-clockwise arc. The path length of each arc for patient 3 was 210 (330 - 120) with the
collimator rotated 30 to 150 in the clockwise arc and 30 to 210 in the counter-clockwise arc.
Both VMAT and the 4-field plans followed the prescription of 2 Gy for 25 fractions to a total
dose of 50 Gy without any boost to the post-mastectomy chest wall. In addition, both plans
encompassed the chest wall PTV, as well as the SCL, axillary and IMN targets. Although these
plans were designed for dosimetric comparison only, field arrangements for 3DCRT and VMAT
were at the discretion of the treating physician in order to produce optimal plans to meet the
dose-volume constraints provided by the NSABP B-51 protocol. The goals of treatment planning
were to encompass the Chestwall PTV and regional node targets, as well as minimize inclusion
of the heart and lung. Dose constraints and maximum point doses to Chestwall PTV, SCL PTV,
Axillary PTV, IMN PTV were provided by the NSABP protocol (Table 1). In addition, there
were dose constrains assigned for the heart, the ipsilateral lung, the contralateral lung, and the
contralateral breast. The NSABP B-51 provided per protocol and acceptable variations for all of
the structures in both the written and tabular formats.
Plan Comparison, Analysis and Evaluation

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When evaluating 3DCRT treatment plan for patient #1, 2 of the dose constraints were
acceptable by the protocol variations, 2 of the dose constraints did not meet the acceptable
criteria, and the rest of 14 dose constraints were met as per protocol (Table 2). The acceptable
variation for the chest wall PTV and the supraclavicular PTV was to deliver 90% of the
prescription dose to cover 90% of the PTV volume per NSABP protocol. The criteria was met by
the 3DCRT plan delivering 90% of the prescription to the 94.3% of the chest wall PTV volume,
and 90% of the prescription to the 91.9% of the SCL PTV volume. The 3DCRT treatment plan
was not able to achieve 2 of the ipsilateral lung dose constraints. When evaluating VMAT
treatment plan for patient #1, 3 of the dose constraints were acceptable by the protocol
variations, and the rest of 13 dose constraints were met as per protocol (Table 3).
When evaluating 3DCRT treatment plan for patient #2, 3 of the dose constraints were
acceptable by the protocol variations, 1 of the dose constraints did not meet the acceptable
criteria, and the rest of 12 dose constraints were met as per protocol (Table 4). The criteria for the
chest wall PTV and the SCL PTV was met by the 3DCRT plan delivering 90% of the
prescription to the 99.4% of the chest wall PTV volume, and 90% of the prescription to the
95.9% of the supraclavicular PTV volume. In addition, all of the axillary PTV volume (100%)
received 95% of the dose. The 3DCRT treatment plan was not able to achieve the constraint for
the ipsilateral lung and instead 48.7% of ipsilateral lung received more than 20 Gy. Evaluating
the VMAT treatment plan for patient #2, 2 dose constraints were acceptable by the protocol
variations, 9 dose constraints did not meet acceptable criteria, and 5 dose constraints were met
per protocol (Table 5). The VMAT plan was unable to meet per protocol or variation acceptable
compliance criteria for the following target volumes: chest wall PTV maximum dose,
supraclavicular maximal point dose, 2 of the 3 heart dose constraints, 3 ipsilateral lung
constraints, contralateral lung, and contralateral breast constraints.
When evaluating the 3DCRT treatment plan for patient #3, 5 of the dose constraints were
acceptable by the protocol variations, none of the dose constraints were unacceptable, and 11
dose constraints were met as per protocol (Table 6). The criteria for the chest wall PTV and the
SCL PTV was met by the 3DCRT plan delivering 90% of the prescription to the 95% of the chest
wall PTV volume, and 90% of the prescription to the 99.2% of the SCL PTV volume. When
evaluating the VMAT treatment plan for patient #3, 8 of the dose constraints were met as per
protocol, 5 of the dose constraints were acceptable by the protocol variations, and 3 of the dose
constraints were unacceptable variations of the dose criteria (Table 7). The VMAT plan was

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unable to meet per protocol or variation acceptable compliance criteria for the following target
volumes: one of the ipsilateral lung constraints, contralateral lung, and contralateral breast
constraints.
In order to compare the deliverability of the 3DCRT treatment plans versus the VMAT
plans, a scoring system developed by the NSABP protocol was created. The scoring system
assigned number 1 through 3 to the compliance criteria in order to evaluate a total of 16 dose
constraints for each plan and each patient. The score of 1 was assigned to the plan meeting
protocol criteria, the score of 2 was assigned to the plan meeting the acceptable per protocol
variation, and the score of 3 was assigned to the unacceptable deviation. In the event the plan
could not meet the dose constraints and scored 3 for any unacceptable deviations, the plan will
not be acceptable for treatment delivery per NSABP protocol. For patient #1, none of the dose
constraints received a score of 3 in VMAT plan, and therefore this plan passed as a deliverable
treatment plan per NSABP protocol. The 3DCRT plan for patient #1 was undeliverable treatment
plan due to 2 dose constraints receiving a score of 3. Both, VMAT and 3DCRT plans for patient
#2 contained unacceptable deviations and neither of the plans were deliverable per NSABP
protocol. For patient #3, 3 dose constraints were assigned a score of 3 in VMAT plan, which
made it undeliverable treatment plan. As to 3DCRT plan for patient #3 all of the constraints were
met and the treatment plan passed as a deliverable treatment plan per NSABP protocol.
Evaluating 6 plans for 3 patients, one VMAT plan and one 3DCRT plan were deliverable per
NSABP protocol. Despite the fact that most of the plans did not meet protocols criteria, it was
important to evaluate ipsilateral lung dose. Analyses of the ipsilateral lung dose were
demonstrated in Table 8. The dose of 20 Gy was evaluated by displaying the amount (in percent
value) of ipsilateral lung volume receiving 20 Gy. Comparison of lung doses in both treatment
plans, 3DCRT and VMAT, were displayed for each patient, and the values were evaluated based
on the NSABP protocol guidelines. According to the protocol, the acceptable variation for the
ipsilateral lung is 35% of the ipsilateral lung to receive no more than 20 Gy. Three out of 6
plans met the acceptable lung dose variation guideline of the NSABP B-51 protocol. Two of the
plans were performed utilizing VMAT technique, and one was performed utilizing 3DCRT
technique.

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Figures

Figure 1. The chest wall CTV (orange) is delineated according to the definitions of anatomical
borders of chest wall from the NSABP breast cancer atlas (patient 1).

Figure 2. The chest wall PTV (blue) was expanded 7mm in all directions from the chest wall
CTV, excluded the heart, and did not cross the midline (patient 1).

Figure 3. The chest wall PTV Eval (red) was limited anteriorly to exclude the part outside the
patient and the first 3 mm of tissue under the skin, and posteriorly was limited to no deeper than
the posterior rib surface excluding the lung and the heart (patient 1).

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Figure 4. Supraclavicular CTV (purple) delineated according to the definitions of anatomical

borders of SCL CTV from the NSABP breast cancer atlas. The SCL CTV was expanded 5mm in
all directions to create the SCL PTV (pink), excluding the ipsilateral thyroid, trachea, esophagus,
vertebral body, and ipsilateral lung (patient 3).

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Figure 5. The axillary lymph node PTV (yellow) expanded 5 mm from the axillary lymph node
CTV (cyan) outlined according to definitions contained in the NSABP breast cancer atlas
(patient 3).

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Figure 6. Internal mammary node CTV (pink) delineated according to the definitions of
anatomical borders of IMN CTV from the NSABP breast cancer atlas. The IMN CTV was
expanded 5 mm medially, laterally, superiorly, and inferiorly to create the IMN PTV (green),
excluding the sternum, lung, and heart (patient 4).

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Tables
Table 1. Objectives and dose constraints for 3DCRT and VMAT plans.

Table 2. Dose constraint structures with the protocol doses and the collected data for the 3DCRT
treatment plan for patient#1.

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Table 3. Dose constraint structures with the protocol doses and the collected data for the VMAT
treatment plan for patient#1.

Table 4. Dose constraint structures with the protocol doses and the collected data for the 3DCRT
treatment plan for patient#2.

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Table 5. Dose constraint structures with the protocol doses and the collected data for the VMAT
treatment plan for patient#2.

Table 6. Dose constraint structures with the protocol doses and the collected data for the 3DCRT
treatment plan for patient#3.

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Table 7. Dose constraint structures with the protocol doses and the collected data for the VMAT
treatment plan for patient#3.

Table 8. Comparison of lung doses in 3DCRT versus VMAT displayed to evaluate the amount of
ipsilateral lung volume (in percent value) receiving 20 Gy.

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Ipsilateral Lung dose comparison

3DCRT

Patient 3

VMAT

28.6
31.3

57.8

Patient 2

Patient 1

48.7

35
51.9