Heather Tlougan

Clinical Practicum I
March Case Study
3D Treatment Plan for Left Breast
History of Present Illness: The patient is a 65 year old female with ductal carcinoma of the left
breast. The patient had a screening mammogram in December of 2013, which showed a nine
millimeter mass in the 2 o clock position of the left breast. Ultrasound-guided biopsy showed
ductal carcinoma in situ, cribriform with apocrine features, grade 2/3 with no necrosis. Ductal
Carcinoma In Situ (DCIS) involved a radial scar. The estrogen receptor analysis was negative.
The patient had a lumpectomy and sentinel node biopsy in December of 2013. The pathology
again showed ductal carcinoma in situ, nuclear grade 3, with no invasive malignancy. The
margins were clear. The maximum tumor dimension was 1.7 centimeters. Two lymph nodes
were removed, including one sentinel node, both were negative for metastasis.
Past Medical History: The patient has a past medical history of sleep apnea, supraventricular
tachycardia, and atrial fibrillation. She reported her first menstrual cycle at age ten. Her last
menstrual cycle was at age 45. She reported intermittent hormone replacement therapy.
Social History: The patient is married with no children. She retired in 2013.
Family Hisory: The patients mother had breast cancer which was diagnosed at age 85 and died
two years later due to another illness. Her father had both prostate cancer and pancreas cancer.
Medications: The patient is currently taking the following medications; Allegra, Aspirin,
Calcium plus vitamin D supplement, Diltiazem, Epinephrine, Fluticasone aerosolized nasal
spray, Lisinopril, and Simvastatin.
Radiation Oncologist Recommendation: The radiation oncologist suggested proceeding with
postlumpectomy radiation therapy to the entire left breast to reduce the risk for local recurrence.
The potential risks and benefits were discussed with patient. The patient wanted to proceed with
treatment as recommended. Following the consultation, and after obtaining informed consent, a
Computed Tomography (CT) scan of the left breast was performed.
Treatment Plan Prescription: The radiation oncologist prescribed 5040 cGy at 180 cGy per
fraction over 28 fractions total. The prescription was a curative intent. The treatment plan
involved a mixed beam approach using 6MV and 18MV using a 3D conformal treatment
technique. The plan consisted of two tangential beams treating the entire left breast volume.
The plan also used a field in field approach to decrease the hot spots to the anterior breast. In
addition, a boost was planned treating the gross tumor bed to 1400 cGy in 7 fractions after
completion of the initial fields.
Set Up/Immobilization: In late January of 2014, the patient had a CT simulation scan to image
the area that needed to receive radiation. The patient was placed supine on a Bionix Breast
Board with a sponge under her knees. The radiation oncologist used wire to mark the scar and
the field borders. The patient was simulated in the supine position with feet first into the
scanner. Upon completion of the scan, the images were sent to the Advantage Work Station. At
this station the images from the CT scan were uploaded. The physician decided where to place
the central axis for the radiation beams. Upon completion of setting the central axis, the
coordinates were sent back to the CT simulation for coordinate shifts. The patient was given
tattoos for setup purposes. See Figure 1 for setup position.
Anatomical Contouring: After completion of the CT simulation scan, importing the images to
the Advantage Work Station was completed. The radiation oncologist set the central axis for the
treatment plan. The images were transferred into the Varian Eclipse Treatment Planning System.
The radiation oncologist then contoured the Gross Tumor Volume (GTV) and the Planning
Target Volume (PTV). The medical dosimetrist then contoured the lungs, heart, and spinal cord.
The wires that were used for localization were also contoured, labeled appropriately, and their
Hounsfield units were set to -1000. This step is completed so they do not interfere with the
treatment planning. Lastly, the couch was added with its appropriate Hounsfield units to match
the machine.
Beam Isocenter/Arrangement: A Varian 2100 EX Linear Accelerator was used for this
treatment. The machine has the capability of treating with dual energies of 6MV or 18MV. The
central axis placed by the physician is evaluated by the medical dosimetrist at this time. They
are able to change the position if it warrants a better plan. There were no shifts made for this
patient. Next, the radiation oncologist contours the PTV and GTV. After this is complete, the
dosimetrist is ready to start treatment planning.
Treatment Planning: The dosimetrist imports the patient information into the Varian Eclipse
treatment planning software. The radiation oncologist has prescribed 180 cGy per fraction to the
PTV for a total of 28 fractions totaling 5040 cGy. After reviewing the prescription, the
treatment plan starts by determining the angles for the tangential fields. The field size is
determined by the wires that the radiation oncologist placed at simulation. Multi Leaf
Collimators (MLC) are used to block areas that are not suppose to be treated. Before drawing
the block, the dosimetrist needs to take into account where the heart, medial wire, and PTV are
located. Once both beams are determined and blocks are drawn the calculation is next. After the
initial calculation, there was a 114 % hot spot. Also after reviewing the isodose lines, there was
not adequate coverage posteriorly. The medical dosimetrist then decides what approach to use
next. In addition to the It was determined that using a field in field approach to block the hot
spots and using 18MV would get better coverage posteriorly.