A Dosimetric Comparison of the Field-in-Field Method versus Electronic Compensation in

the Treatment of Left Sided, Low Stage Breast Cancer: A Case Study
Authors: Ryan Salem, BS, RT(T), Christina Ong BS, Sean Fergusson BS, RT(T), Rodger
Williams, BS, CMD, RT(R)(T)
Medical Dosimetry Program at the University of Wisconsin – La Crosse, WI
Abstract
Introduction: The objective of the case study was to perform a dosimetric comparison between
the 3D conformal field-in-field (FIF) and electronic compensation, or irregular surface
compensator (ISC), techniques in whole breast radiation therapy for low stage breast cancer.
The metrics of target coverage, healthy tissue constraints, and maximum dose regions were
analyzed to determine the more effective treatment method.
Case Description: Ten patients, retrospectively, were selected from a single cancer center who
were diagnosed with low stage, left sided breast cancer ranging from ductal carcinoma in situ
(DCIS) to Stage II T2N0M0. All patients received a lumpectomy procedure prior to radiation
treatment planning. The patients’ planning target volume (PTV) and gross tumor volume (GTV),
representative of the breast tissue and lumpectomy site, respectively, were contoured by a single
physician according to Radiation Therapy Oncology Group (RTOG) 1005 guidelines for all the
CT datasets. The PTV Eval from this protocol was also contoured and was the PTV used for
treatment planning. The PTV Eval is limited to exclude the PTV outside the ipsilateral breast and
5mm of tissue under the skin. Per RTOG 1005 the PTV Eval is used for dose constraints and
coverage analysis. Treatment plans were created by a single dosimetrist for each respective
treatment method following RTOG 1005 recommendations and a series of dose delivery metrics.
Conclusion: **
Key Words: Field in field, electronic compensation, irregular surface compensator, low stage
breast cancer **
Introduction
In women, breast cancer has the highest incidence of all cancers in the United States at
125 cases per 100,000 women, per the Center for Disease Control. It is also the second deadliest
cancer in women behind lung and bronchus cancer.1 Whole breast, or intact breast, radiotherapy
is a common way to treat low stage breast cancer. Radiotherapy is the use of high energy x-ray
beams to kill cancer cells while sparing the healthy tissue surrounding the tumor. Both FIF and
ISC techniques are modern methods used in breast radiotherapy, as they use advanced
technology to improve dose conformity while reducing dose to healthy tissues throughout
treatment.2
Irregular surface compensation and the FIF technique are used in whole breast therapy
due to the way dose can be specially constructed and targeted by a dosimetrist .The FIF
technique is a widely preferred method of delivering tangential whole breast radiation therapy by
utilization of multi leaf collimation (MLC) field shaping. Open tangential fields are created by
use of MLCs to deliver a marjority of the dose. To further increase target dose, the FIF technique
incorporates subfields with MLCs to block high dose regions, resulting in increased dose
conformity. Many studies suggest that the FIF technique results in better dose homogeneity,
reducing hot regions, and limiting dose to healthy tissue.3 Irregular surface compensation is an
intensity modulated radiation therapy (IMRT), tangential breast technique that utilizes forward
planning to deliver a homogenous dose to irregular surfaces by use of dynamic MLC. The MLC
movement is determined by the treatment planning system’s (TPS) calculated intensity of the
treatment beam to areas receiving dose.4 The modification of fluence is also performed by the
MLC leaves which improves dose homogeneity when delivering treatment to an irregular
surface, such as a breast. The ISC has been found to reduce hot regions of dose and acute toxicity
in women, particularly those with larger breast and inferior tumors.5
By increasing dose homogeneity and reducing dose to healthy tissue, many post-
treatment complications from breast radiotherapy can be reduced. Common post-treatment
complications include tumor recurrence, chest wall recurrence, contralateral breast tumors, heart
toxicity, and radiation pneumonitis.6 Guidelines in RTOG 1005 were followed for both target
delineation and OAR dose constraints. A single physician drew all target volumes in this study. 7
Many studies that have demonstrated comparisons in common breast radiotherapy
techniques, including FIF and ISC, are ridden with variables that can lead to inaccurate findings
regarding the most effective treatment method. Single, low population studies included breasts
on either side of the body, a wide range in breast sizes with PTVs not drawn consistently, and
tumors of variable stages. Various treatment machines, manufacturers, MLC sizes, and treatment
energies are also mixed into the same studies, posing high variability in treatment planning
results. Some research has found treatment differences when the PTV is determined by a GTV
expansion, but not with a physician contoured PTV representative of the whole breast on the
affected side. Additionally, different dose algorithms and different TPSs have also been used in
studies with a single patient population. The accuracy of correction factors and calculation
methods can also lead to result inaccuracies. A goal of the researchers in this study was to limit
variables within treatment planning to ensure the accuracy of the results.
The objective of this study was to perform a comparison between the FIF and ISC
techniques in 3D conformal, whole breast radiotherapy. By minimizing variables in the patient
selection, target delineation, and planning process, this study provided a true comparison of two
modern planning techniques. While using the same controls within the study for patient
population and dose delivery metrics, both treatment methods were compared. This study aims to
compare the two planning methods regarding dose homogeneity, target coverage, maximum dose
regions, and OAR doses for whole breast tangents. Although dosimetrists tend to be more
talented in one method versus the other, this study aims to distinguish each methods advantages
over the other. If one treatment method proves significantly better than the other, further research
on a larger patient population will be needed to confirm the findings.
Case Description
Patient Selection
Ten patients who were diagnosed with low stage breast cancer ranging from DCIS to
T2N0M0 in the left breast were retrospectively selected for this study. Only patients with a
lumpectomy procedure were selected so that the physician could delineate the lumpectomy
cavity, or GTV. Left sided patients were selected so that breast tissue, heart, lung, and
contralateral breast doses could all be analyzed and compared at the completion of treatment
planning. The “bridge” separation, or distance between the medial and lateral borders was taken
into consideration to avoid cases outside the norm. Although variable breast sizes and
lumpectomy site locations were used, extremes were avoided so that research could be
representative for the majority of breast patients.
The patients selected underwent a free breathing CT simulation from a Phillips Brilliance
large bore CT scanner with 3 mm slices. All patients in this study were simulated in the same, or
similar treatment position to further avoid variability in the research. Patients were simulated in
the head first-supine position, flat with both arms up holding a T-grip in the central region. The
patients were on a flat breast board indexed to the table. The treatment position included a
vacuum bean bag used under the arms and head while tilting the patient’s head away from the
affected side. The vacuum bag was limited under the thorax. An unindexed knee cushion was
used for leg and back support. A ring was used around the feet for all patients to limit leg
movement during treatment and simulation (Figures 1-4). Free breathing was used to further
emphasize the importance of target coverage and OAR avoidance, as well as to limit variability
between the locations of target volumes and lungs in this study.
Target Delineation
To allow for a quantitative analysis of treatment plan quality, breast tissue of the affected
breast (PTV), the lumpectomy site (GTV), and the PTV Eval were contoured according to
RTOG 1005 by a single physician following the 3D CT simulation using the Varian Eclipse TPS
version 13.6. This version makes use of the Analytical Anisotropic Algorithm (AAA) for photon
energies in this study. The targets used in this study align with target definitions in RTOG
1005.7The lumpectomy GTV was defined as the excision cavity volume, lumpectomy scar,
seroma, and/or extension of surgical clips. All patients in the study had a clearly identifiable
lumpectomy bed (Figure 5). The breast PTV Eval was drawn to include the palpable breast
tissue, apparent glandular breast tissue, and the lumpectomy site. This contour was limited to
5mm from the skin and extended no deeper than the anterior surface of the ribs.7 (Figure 5).
Contoured OAR included the contralateral breast, ipsilateral lung, contralateral lung, and
heart in accordance with RTOG 1005. The contralateral breast included visible glandular tissue
delineated from the CT while following the RTOG Breast Atlas. All lung volumes were
contoured with auto-segmentation and manual editing and verification. The heart was contoured
from the pulmonary trunk bifurcation into the left and right pulmonary arteries and extended to
its most inferior region in the diaphragm or lower.7
Treatment Planning
The prescription and fractionation schedule in this study were consistent with Arm 1 of
RTOG 1005, Standard Whole Breast Irradiation with Sequential Boost, delivering 50 Gy in 25
fractions of 2Gy, 5 days a week for the primary tangential plan to the whole breast. Because
boost treatment modalities and available options at different sites were variable, only the primary
plans of 50Gy were analyzed in this study to strictly compare FIF and ISC methods of treatment.
Both FIF and ISC techniques were planned for treatment on a Varian TrueBeam linear
accelerator with the same MLC configuration. Both treatment machines had an equal number of
0.5cm and 1.0cm MLC leaves used in collimation. Field in field had access to 6 megavoltage
(MV), 10MV, and 15MV beam energies available for planning. Irregular surface compensation
had 6MV and 15MV beam energies available. In this study, 6MV beams were required in both
planning modalities, and higher energies were used to achieve planning outcomes. All planning
was completed using Varian Eclipse version 13.6 TPS, utilizing AAA.
Beam angles were determined by medical dosimetrists to best suit coverage needs based
on external patient contours, RTOG constraint recommendations, and the visual analysis of a
reviewing physician. The PTV size, GTV location, and energy availability all helped determine
gantry angles of the treatment beams. Collimator angles for the primary treatment beams were
consistent with 0 or 90 degrees but could be modified in the FIFs or ISC. Primary collimator
angles were kept this way to ensure that the radiation field was consistent between both
treatment modalities.
To accurately compare both treatment methods, all plans were normalized to achieve 3
coverage goals to the PTV and GTV. Firstly, the maximum permissible hot spot for any plan was
115%. Secondly, 95% of the PTV was required to be covered by 95% of the prescription dose,
and lastly, 100% of the GTV was to be covered by 99% of the prescription dose. The medical
dosimetrist chose a normalization value that achieves all three of these requirements, even if
OAR dose constraints fail. There was no modification of target coverage doses in this study to
accommodate OAR limitations to help distinguish the capabilities of each treatment modality
regarding target coverage and OAR avoidance.
Delivered doses to OAR were to not exceed the regulations per the RTOG 1005 protocol,
or be kept as low as possible without sacrificing target coverage. The contralateral breast was to
not exceed 310 cGy, and no more than 5% of the tissue it was to exceed 18 6cGy. Per RTOG,
the volume of the ipsilateral lung receiving 20 Gy was to be no more than 15% (V20 < 15%).
Additionally, for the ipsilateral lung, the V10 was to be less than 35% (V10 < 35%) and the V5
was to be less than 50% (V5 < 50%). For the contralateral lung, 5Gy could not exceed 10% of the
contoured organ (V5 < 10%). No more than 5% of the whole heart was to exceed 20Gy (V20 <
5%). Also, no more than 30% of the whole heart was to exceed 10Gy (V10 < 30%). The heart
also had a mean dose limit of 400cGy.7 The medical dosimetrists in this study ensured that OAR
doses were as low as they could be given the target dose requirements.
Plan Analysis and Evaluation
Conclusion
 With so many variables in previous studies comparing different methods of whole breast
radiation therapy, this study emphasized a comparison without variability. By using the same
treatment machines, planning systems, and patient datasets, treatment plans were extremely
limited in variability. With the use of a single protocol and physician to outline PTVs, GTVs,
and OARs, the analysis of dose delivery was much more accurate than previous research. The
only notable variables in this study include having different dosimetrists perform each method of
planning and FIF having access to 10MV beams. The research also represents a majority of the
patient population due to the utilization of patients with different breast volumes, body sizes, and
lumpectomy cavity locations.
-Here is the rest of our outline that will be expanded upon as planning is completed-
V. Plan Analysis and Evaluation
a. Every patient had a sentence or short paragraph simply describing the planning
done for both FIF and E-comp
b. Plans were evaluated for overall dose conformality, hot spots, and OAR dose
constraints.
c. The average doses to the targets in both FIF and E-comp were described. Charts
showing dose statistics for targets were shown with averages and different metrics for
each method here.
d. Average hot spot and hot spot location in each plan following the same visuals as
above.
e. Each OAR dose constraint, value, and whether the specs passed or failed for each
treatment technique for each plan was shown the same way as above.
f. Both planning methods were compared in terms of target doses, dose
conformality, hot spots, and OAR doses. (This paragraph and discussion will
be long)
g. Describe if one method of planning was better than the other and to what degree.
If the information shows one method better than the other, statistics were used to
determine if the findings are significant.
h. Explain and determine whether visual analysis identified trends or variables in
treatment planning. Ex: Did FIF work better on smaller PTV volumes... Did E-comp
work better on smaller GTV volumes... Did e-comp provide better GTV coverage
when the GTV was further away from the center of the breast?
VI. Conclusion
a. Of all identified variables in the introduction and from previous studies, the study
only included a few small variables like the FIF dosimetrist being able to use 10MV
and the fact that different dosimetrists did the planning.
b. One planning method was or was not better than the other regarding hotspots or
dose constraints when normalization methods were consistent.
c. Described that the patient population was limited, but the population was selected
to represent a vast number of different tissue volumes and lumpectomy sites (GTV) in
different regions of the breast.
d. The research was consistent (or not) with prior research. We found that when
variables are limited, and normalization methods are consistent between planning
techniques, our research shows that FIF or E-comp could be a more effective
treatment planning technique for free breathing, left-sided breast patients across a
variety of patients.
e. Was heart dose a factor? If not, we predicted that this study would also be
reflected on the right side... Was lung dose a factor, if so, did we think the study
should be done with deep inspiration breath hold (DIBH) to further research.
f. Since our findings showed one method to be more proficient in the other to some
regard (whether significant or not), we call upon further research to be done on a
larger population.
 References
1. Breast Cancer Statistics. Centers for Disease Control and Prevention Web site.
https://www.cdc.gov/cancer/breast/statistics/index.htm. Updated June 12, 2018. Accessed
July 23rd, 2018
2. Koivumaki T, Fogliata A, Zeverino M, et al. Dosimetric evaluation of modern radiation
therapy techniques for left breast in deep-inspiration breath-
hold. Physica Medica. 2018;45:82-87. https://dx.doi.org/10.1016/j.ejmp.2017.12.009
3. Tanaka H, Hayashi S, Hoshi H. Determination of the optimal method for the field-in-field
technique in breast tangential radiotherapy. J Radiat Res. 2014;55(4):769-773.
https://dx.doi.org/10.1093/jrr/rrt233
4. Friend M. An overview of electronic tissue compensation (ECOMP) for breast
Radiotherapy. CSM. 2014;R-0170. http://dx.doi.org/10.1594/ranzcr2014/R-0170.
5. Emmens DJ, James HV. Irregular surface compensation for radiotherapy of the breast:
Correlating depth of the compensation surface with breast size and resultant dose
distribution. Br J Radiol. 2010;83(986):159–165. http://dx.doi.org/10.1259/bjr/65264916
6. Fragkandrea I, Kouloulias V, Mavridis P, et al. Radiation induced pneumonitis following
whole breast radiotherapy treatment in early breast cancer patients treated with breast
conserving surgery: A single institution study. Hippokratia. 2013;17(3):233-238.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872459/.
7. Vicini FA, Freedman GM, White JR, et al. A phase III trial of accelerated whole breast
irradiation with hypofractionation plus concurrent boost versus standard whole breast
irradiation plus sequential boost for early-stage breast cancer. Radiation Therapy
Oncology Group (RTOG).
http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?action=openFile&Fi
leID=9366. Updated 2014. Accessed July 23rd, 2018.
 Figures

Figure 1. An image showing how the arms and torso were positioned in CT simulation

Figure 2. An image showing how hands were positioned for all patients. The T-grip could be
moved for comfort.
Figure 3. An image showing the torso from a lateral view in the treatment position, with the
breast board visible.

Figure 4. An example of how the legs and feet were positioned for all patients in this study.
Figure 5. A visual representation of GTV, PTV Eval, and contralateral breast contoured by the
physician.