Abstract ID:

1078
A Novel Inverse-planned 5-field Intensity Modulated Radiation Therapy (IMRT) Technique for
Regional Nodal Breast Irradiation
S. Jolly*, I. S. Grills*, L. L. Kestin*, Q. Wu*, L. Burgess*, V. Williams*, A. A. Martinez*, D. Yan*, F. A.
Vicini*. , William Beaumont Hospital, Royal Oak, MI,
Purpose/Objective(s): Intensity modulated radiation therapy (IMRT) for treatment of the breast alone
has been shown to improve dose uniformity. We developed an inverse planned 5-field IMRT technique for
treatment of the breast or chest wall and regional lymphatics, and compared this to a 3-field
monoisocentric technique for regional nodal irradiation currently employed at our institution.
Materials/Methods: Ten patients with stage II-IIIA breast cancer, previously treated with a 3-field
monoisocentric "mixed" technique combining forward planned IMRT with tangents for the breast/chest
wall and a single oblique supraclavicular beam (6 MV photons prescribed to 3 cm depth), were compared
to a monoisocentric 5-field inverse planned IMRT technique designed using direct machine parameter
optimization (DMPO) (Pinnacle version 7.4). Two unopposed tangential beams were used to treat the
breast/chest wall, while 3 additional beams were directed to the lymph node regions at risk. 50.4 Gy was
prescribed to the breast and supraclavicular/level III axillary nodes for all plans. Institutional regional
lymph node delineation guidelines were established prior to planning. Beam angles were chosen to avoid
dose to the contralateral breast and lung. IMRT optimization parameters were not specifically designed to
reduce heart or lung dose, but to match that achieved using the 3-field plan. Dosimetric uniformity and
target volume coverage were evaluated for the 2 plans.
Results: 5-field inverse-planned IMRT significantly improved coverage of the regional nodal region and
resulted in a better matchline dose distribution (see table). The 5-field IMRT plans reproducibly achieved
at least the same degree of breast homogeneity as the 3-field plans while maintaining the same dose to
the ipsilateral lung and heart. There was no increase in the dose to the contralateral breast or ipsilateral
lung. IMRT resulted in slightly increased dose to the contralateral lung (average mean dose=1.2 Gy vs 0.8
Gy), spinal cord, and contralateral thyroid related to improved supraclavicular region coverage. Although
the total number of monitor units (MUs) was higher with 5-field IMRT (mean=580 vs 401, p<0.01), this is
still lower than conventional 3-field with wedges due to the superior efficiency of tangential IMRT.
Conclusions: This study is the first to show the technical feasibility of a 5-field inverse planned IMRT
technique for breast/regional nodal irradiation without resulting in significant increases in contralateral
breast or lung dose. The 5-field monoisocentric technique was dosimetrically superior in terms of nodal
coverage compared to a 3-field mixed plan using IMRT for the tangent beams only.

Planning Comparison (Mean Values)

5-Field
3-Field Mixed - Tangent
Dosimetric
Inverse
pIMRT & Conventional
Parameter
Planned
value
Nodal Field
IMRT
Target
Coverage
Target
Overdosage

Breast V95

95.7%

91.5%

0.02

Nodal D90

46.1 Gy

32.4 Gy

0.005

Breast V105

9.7%

12.8%

0.24

Breast V110

0.7%

1.6%

0.25

0.9 Gy

0.89

10.6 Gy

10.8 Gy

0.77

0.9%

1.0%

0.80

Contralateral
0.9 Gy
Breast Mean Dose

Dose to Critical
Ipsilateral Lung
Structures
Mean Dose
Heart V30

Author Disclosure Block:

S. Jolly, None; I.S. Grills, None; L.L. Kestin, None; Q. Wu, None; L. Burgess, None; V. Williams,
None; A.A. Martinez, None; D. Yan, None; F.A. Vicini, None.