1

Taisa Polishchuk
DOS 773 Clinical Practicum III
11/24/2015
Final Clinical Project Photon-Electron Mix for Multi-Field Breast Technique
OB is a 70 year-old female with pathologic T1N1Mx invasive ductal carcinoma of the
left breast, status post breast conserving surgery and axillary lymph node dissection. The patient
underwent a screening mammogram which revealed an abnormal mass in the lower-inner
quadrant of left breast. OB returned for an ultrasound guided biopsy of the left breast which
revealed a grade II invasive moderately to poorly differentiated carcinoma with possible lymphovascular invasion. The patient underwent a left segmental mastectomy, as well as an axillary
dissection removing 13 lymph nodes. OB was scheduled to receive 50 Gy in 25 fractions, to treat
the breast, as well as the supraclavicular (SCLV), axillary, and internal mammary (IM) lymph
nodes. Dose constraints were taken from the NSABP B-51 (also known as RTOG 1304)
protocol.1 Due to the lymph nodes being at high risk for metastatic disease, the physician decided
to encompass the breast tissue and all of the lymph nodes utilizing the multi-field treatment
technique with tangents, SCLV and IM fields.2
Photons were used on the tangent and SCVL fields, whereas electrons were used on the
IM field. Utilization of electrons for the IM field was used in order to minimize the heart dose
for the patient. In addition, the heart and the lung dose were minimized by using Active
Breathing Coordinator (ABC) breath hold technique that was scheduled for the simulation day.
ABC is a technology that helps the patient hold her breath while she receives radiation therapy.
When ABC is used during radiation therapy, the patient takes a deep breath before the beam of
radiation is delivered. This deep breath increases the distance between the area receiving
radiation (the breast tissue or chest wall on the patients left side) and the heart. Increasing this
distance means there is less risk the heart will receive any unnecessary radiation. The image
below has the patient scanned in free breathing and contours done on the ABC scan, which
clearly shows expansion of the lung volume on the treatment side and pulling the heart further
away from the treatment field, therefore reducing the potential dose received by those two
structures. It was important to evaluate the lung volume in free breathing versus ABC to
understand if it will be beneficial for this patient. The left lung volume in free breathing showed
to be at 1267 cc, whereas in ABC breath hold it was at 1787 cc. The physician decided to utilize
the ABC breath hold technique on this patient due to 500 cc increase in the ipsilateral lung
volume and therefore the potential of sparring healthy lung tissue.

The patient was simulated on the breast board with the left arm up and the head slightly
turned to the right. The instruction for treatment was to set up the patient in free breathing at
Gantry angle 294 and 87SSD, then perform needed shifts for a single isocenter treatment
delivery, and then deliver treatment in the ABC breath hold mode. Once the patient received
doses through the supraclavicular and tangent fields, the therapist drew the medial border for the
IM field matching. The therapists used the electron cutout to clinically match the superior border
to left SCLV field and 2 mm overlap into the medial tangent field. The treatment was performed
at 105SSD in the breath hold. Below is the field light of the medial tangent, SCLV and IM fields
as they appeared daily on this patient.

Contouring of organs at risk was performed utilizing RTOG atlas and the following
structures were outlined by the physician: left and right lungs, cord, heart, supraclavicular nodes,
level 1, 2 and 3 axillary nodes (combined into 1 structure labeled axillary nodes), and internal

mammary nodes.3 Cavity was also outlines by the physician and is displayed in red in the image
below.

In order to treat this patient the physician decided to utilize a 5-field isocentric technique
with electron and photon mix energies.4, 5 Due to patients separation being 27 cm utilization of
both 6 MV and 18 MV energies were essential to get good coverage for tangent fields. Below are
the fields with the parameters and the energies used.
Field

Energy

Gantry angle

Collimator

Couch angle

1.1 LtMedTang
1.1a

6MV
18MV

320
320

angle
0
0

0
0

LtMedTang
1.2 LtLatTang
1.2a LtLatTang
2.1 RAO SCLV
2.2 LPO SCLV
3.1 Lt IM

6MV
18MV
18MV
18MV
12 MeV

139
139
345
165
325

0
0
0
0
0

0
0
0
0
0

Heart was blocked on tangent fields and humeral head was blocked on the SCLV fields
(single isocenter is displayed in green point).

IM electron field cutout was designed to encompass 2 cm around IM nodes (IM nodes are
displayed in yellow on the image below) and followed the match line superiorly and medially
(the match line is displayed in light blue).

Treatment planning was performed on the Philips Pinnacle3 planning system. I started
planning this patient by optimizing the tangent fields first. Once I got good coverage I prescribed
my plan to 93% isodose line (in red), and the hot spot was 107%.

Then I zeroed out my dose to the tangent fields and focused on optimizing the supraclavicular
fields reducing the hot spot to 107.5%, and prescribing to 93% isodose line (in red) as well.

The next step was to combine both of the optimized sites of treatment and look at the composite
of the dose distribution in absolute values. Thick red line represents the 50 Gy prescription, and
the hot spot of 110% is displayed in orange.

The next step was to compute the IM electron field and evaluate the composite of all of the 5
fields together. Once I calculated 12 MeV electron beam prescribed to 90% I got 148% hot spot
and had to work on cooling it off to an acceptable range. I utilized segments on SCLV and medial
tangent fields to cool off the hot spots and the bowing out effect of the electrons into the medial
tangent field. The acceptable variation per protocol guidelines is to keep the hot spot under 120%
for the breast cavity and under 115% for the lymph nodes. I was able to achieve these guidelines
and cool off my hot spot to 117%. I stopped chasing the hot spot once it jumped into the electron
field. I knew I couldnt cool off my plan any more than I have already done. Below is the view of
the coverage with 50 Gy line (displayed in bold red) combined with the SCLV and IM fields. The
plan is hot on the junction of the electron and photon fields, in the IM electron field and on the
junction of the SCLV and medial tangent fields. Despite the plan being hot in those areas I was
satisfied with its location and knew I have done everything possible to use the plan for treatment.

All of the protocol dose constraints were achieved in this plan and below is the list of the
required doses received by cavity, lymph nodes and other organs at risk.1
Dose constraint
structures

Dose (Gy)

Goal (%)

Volume

Compliance

Achieved

criteria per
Protocol
NSABP B-51

Breast cavity
Breast cavity
SCLV nodes
SCLV nodes
Axillary nodes
Axillary nodes
IM nodes
IM nodes
Heart constraint1
Heart constraint2
Heart constraint3
Left Lung

>47.5Gy
<57.5Gy
>47.5Gy
<55.0Gy
>47.5Gy
<57.5Gy
>45.0Gy
<57.5Gy
<25Gy
<15Gy
<4Gy
<20Gy

95%
Max
95%
Max
95%
Max
90%
Max
5%
30%
Mean
30%

100%
55.4Gy
99.6%
54.5Gy
95.5%
57.1Gy
91.2%
57.1Gy
0.9%
2.7%
3.1Gy
25.9%

Per protocol
Per protocol
Per protocol
Per protocol
Per protocol
Acceptable
Acceptable
Acceptable
Per protocol
Per protocol
Per protocol
Per protocol

constraint1
Left Lung

<10Gy

50%

37.3%

Per protocol

constraint2
Left Lung

<5Gy

65%

48.3%

Per protocol

constraint3
Right Lung

<5Gy

10%

4.0%

Per protocol

Below is the DVH with dose received by the breast cavity and the doses to organs at risk.

Multi-field breast treatment planning is one of the most challenging treatment techniques
performed in our clinic. Most of our left breast patients are treated utilizing this technique in
addition to ABC breath hold, and therefore there is a high importance in knowing how to plan it
and feeling comfortable doing it. When working on understanding how to plan such an advanced

treatment I ran into some difficulties, such as creating proper angles for the treatment fields,
creating the electron field, cooling off the hot areas of the plan, meeting the dose constraints of
the cavity, the lymph nodes, and all of the organs at risk. Following the procedure document
created by one of our dosimetrists and practicing on multiple datasets of patients I was able to
get more confident and efficient in doing this multi-field technique.

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References:
1. Wolmark N. Standard or Comprehensive Radiation Therapy in Treating Patients With EarlyStage Breast Cancer Previously Treated With Chemotherapy and Surgery. Bethesda, MD:
U.S. National Library of Medicine; 2012. A Randomized Phase III Clinical Trial Evaluating
Post-Mastectomy Chestwall and Regional Nodal XRT and Post-Lumpectomy Regional Nodal
XRT in Patients with Positive Axillary Nodes Before Neoadjuvant Chemotherapy Who
Convert to Pathologically Negative Axillary Nodes After Neoadjuvant Chemotherapy. NIH
publication NCT01872975. https://clinicaltrials.gov/show/NCT01872975. Updated
November 26, 2012. Accessed October 14, 2015.
2. Strom EA, Woodward WA, Katz A, et al. Clinical investigation: regional nodal failure
patterns in breast cancer patients treated with mastectomy without radiotherapy. Int J Radiat
Oncol. 2005;63(5):1508-1513. http://dx.doi.org/10.1016/j.ijrobp.2005.05.044
3. White J, Tai A, Arthur D, et al. Breast cancer atlas for radiation therapy planning: consensus
definitions. Radiation Therapy Oncology Group (RTOG).
http://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx. Accessed October
14, 2015.
4. Scrimger RA, Connors SG, Halls SB, Starreveld AA. CT-targeted irradiation of the breast
and internal mammary lymph nodes using a 5-field technique. Int J Radiat Oncol.
2000;48(4):983-989. http://dx.doi.org/10.1016/S0360-3016(00)00738-0
5. Hurkmans CW, Saarnak AE, Pieters BR, et al. An improved technique for breast cancer
irradiation including the locoregional lymph nodes. Int J Radiat Oncol. 2000;47(5):14211429. http://dx.doi.org/10.1016/S0360-3016(00)00504-6