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

the Treatment of Left Sided, Early Stage Breast Cancer: A Case Study
Authors: Ryan Salem, BS, RT(T), Christina Ong BS, Sean Ferguson 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 early 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: For this retrospective study, 10 patients from a single cancer center were
selected who were diagnosed with early 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 planning target volume (PTV) and gross tumor volume
(GTV) were contoured by 1 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 used for treatment planning. The PTV_EVAL is limited to exclude the PTV outside the
ipsilateral breast, the 5mm of tissue under the skin, and most of the chest wall. Per RTOG 1005
the PTV_EVAL is used for dose constraints and coverage analysis. Treatment plans were created
by 2 medical dosimetrists, one for each respective treatment method following RTOG 1005
recommendations and a series of dose delivery metrics. Following treatment planning,
comparisons dosimetric comparisons were made regarding the two breast treatment methods.
Conclusion: Field in Field and ISC treatment methods for left-sided, early stage breast cancer
can result in dosimetric differences in radiation therapy. The FIF method may be advantageous
when compared to ISC in increasing dose conformity while lowering dose to critical structures
and healthy tissue.
Key Words: Field-in-field, electronic compensation, irregular surface compensator, early 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 early 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 majority 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 a
tangential, forward planning technique utilizing fluence.4 The modification of fluence is
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, have shown mixed results in terms of the best treatment
planning method for early, tangential breast treatment.8,9 Sometimes, increased amounts of
variability in the research could have swayed the accuracy of results10 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.2 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.10 Treatment differences have also been
found in studies comparing treatment methods where the treatment targets were site specific,
rather than protocol consistent.2 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. This case study to limit variables within
treatment planning to ensure the accuracy of the results. Common normalization methods were
also used to provide a true comparison of the two techniques.
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, a comparison of two modern planning
techniques was used to distinguish whether one technique was advantageous over the other.
While using the same controls within the study for patient population and dose delivery metrics,
both treatment methods were compared regarding dose homogeneity, target coverage, maximum
dose regions, and OAR doses for whole breast tangents. 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 & Setup
Ten patients who were diagnosed with early 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 the physician could delineate the lumpectomy cavity, or
GTV. Left sided breast 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 of larger breasted women Although variable breast sizes and
lumpectomy site locations were used, the largest cases were avoided because there are other
methods of immobilization and treatment setup for these patients.11
The selected patients underwent a free breathing CT simulation from a Phillips Brilliance
large bore CT scanner with 3 mm slices at a single cancer center. All patients in this study were
simulated in the same, or similar treatment position to further avoid variability in the research.
The patient position during simulation was head first, supine with both arms up holding a T-grip.
A breast board was table-indexed with a vacuum bag under the arms and head area; head tilted
away from the affected side. A knee cushion was used with a ring placed around the feet to limit
leg movement during treatment (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, the GTV, PTV, and
PTV_EVAL were contoured according to RTOG 1005 by 1 physician following the 3D CT
simulation using the Varian Eclipse TPS version 13.6. This version makes use of the Anisotropic
Analytical Algorithm (AAA) for photon energies in this study. The targets used in this study
align with target definitions in RTOG 1005.7 The 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 PTV. 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 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. Only the primary plans of
50Gy were analyzed for this study to compare FIF and ISC treatment techniques due to the
variability in boost treatment modalities at different treatment centers.
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. Treatment planning was completed by 2
dosimetrists total, one assigned to each treatment method. Field in field had access to 6
megavoltage (MV), 10MV, and 15MV beam energies available for planning. The 10MV beam
energy was left available for the field in field method because the dosimetrist was proficient in
using 10MV at her treatment facility. 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 for target volume coverage were determined by the medical dosimetrists
based on external patient contours, RTOG constraint recommendations, and the visual analysis
of a reviewing physician. The breast tissue size, GTV location, and beam energy availability also
contributed to establishing gantry angles. 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
goals for the coverage to the PTV_EVAL and GTV: (1) the maximum permissible hot spot for
any plan was 115%; (2) 95% of the PTV_EVAL was required to be covered by 95% of the
prescription dose; (3) 100% of the GTV was to be covered by 99% of the prescription dose. The
medical dosimetrist chose a normalization value that achieved all 3 of these requirements, even if
OAR dose constraints failed. 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. To allow for a comparison of treatment methods,
all plans were normalized to achieve minimum coverage of all three requirements.
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 not
to exceed 310 cGy, and no more than 5% of the tissue was to exceed 186cGy. 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
Given the range of differences between FIF and ISC dosimetry, the same patient was
planned in different ways depending on several factors. The dosimetrists were expected to make
the best possible treatment plan using their respected method despite having differences in their
own planning processes. The separation, or distance between the medial and lateral borders of
the treatment field, location of the GTV, and overall size of the breast were key components in
how each medical dosimetrist completed their treatment plans. Table 1 shows the bridge
distances and volumetric differences of the PTV_Eval and GTV in all patients in the study.
Tables 2-5 describe the results of the treatment planning for both techniques. Target coverages,
dose conformity, and OAR dose statistics are shown.
All plans were normalized to meet the coverage conditions mentioned earlier. Every plan
was normalized so that 100% of the GTV was covered by 99% of the prescribed dose in order to
meet all conditions. Following normalization, the ISC technique had an average maximum point
dose of 105.73%, with FIF having 106.35%. This result indicated that the ISC technique was less
than 1% less hot than the FIF technique. Additionally, the FIF method averaged 97.4% coverage
to 95% of the PTV_Eval, with ISC averaging 97.2% isodose. With a 0.2% difference, both
maximum point doses and target coverages were only marginally different, indicating that
neither technique posed an advantage to the other in terms of hot spots, PTV_Eval, and GTV
coverage for a primary breast radiation plan (Table 2).
Overall dose conformality was evaluated using a conformity index (CI). The CI was
implemented into the study to evaluate PTV_Eval coverage based on the 95% isodose line. The
conformity index was defined as a ratio between the volume covered by the reference isodose
line and the target volume. This definition was taken from RTOG and ICRU guidelines and was
presented by the equation
CI = VRI / TV
where VRI = reference isodose volume and TV = target volume. A CI equal to 1 corresponds to
the ideal dose coverage. The further the CI is from 1, poorer dose conformity is apparent as the
irradiated volume further exceeds the target volume and is being deposited in healthy tissue.12 In
this study, all CI values were greater than 1 because of mandatory and similar plan
normalization. The FIF technique produced plans with an average CI of 1.522, whereas ISC
produced plans with a CI of 1.721 on average. The study indicated that the FIF technique was
able to achieve similar coverage of target volumes with better dose conformality (Table 2).
Contralateral breast and contralateral lung maximum doses were evaluated for the
maximum dose delivered to these structures in cGy based on dose volume histograms (DVH) in
each plan. Because these doses were relatively low as the structures are on the opposite side of
the body, maximum doses were evaluated rather than mean dose. With the FIF technique, the
average maximum point dose to the contralateral breast was 165cGy, with the highest dose in
Patient H at 299cGy. The average maximum dose to the contralateral breast with the ISC
technique was 327.4cGy, with a highest dose also in Patient H as 664cGy. This resulted in the
FIF technique having a 49.5% lower dose to the contralateral breast. Following plan
normalization, the ISC technique did not meet the constraint of 310cGy in 6 pateints, where the
FIF technique had zero patients fail that constraint (Table 3). The average maximum dose to the
contralateral lung for the FIF and ISC techniques was 98.4cGy and 196.6cGy, respectively. The
FIF average max dose to the contralateral lung was 50.1%, or 98.2cGy less. In both treatment
methods, all patients passed the V5 < 10% constraint (Table 3). The research suggests that the
FIF technique may be advantageous when compared to the ISC technique regarding contralateral
OAR constraints and overall doses.
All treatment plans passed the 3 ipsilateral lung constraints. The V20, V10, and V5 for the
FIF technique on average was 5.6%, 9.4%, and 15.7%, respectively. The ISC technique yielded
11.3%, 16.6%, and 26% for the same ipsilateral lung constraints. The FIF technique was 5.7%
lower, 7.2% lower, and 10.3% lower when evaluating the V20, V10, and V5 of the ipsilateral lung
when compared with the ISC technique (Table 4). The research suggests that the FIF method
may be better at keeping the ipsilateral lung dose lower than treatments utilizing the ISC
technique.
All treatment plans passed the 3 heart constraints as well. The average V20 of the heart for
the FIF technique was .7% and for the ISC technique was .9%. The averagV10 of the heart for the
FIF technique was 1.38% and for the ISC technique was 1.73%. There was less than a .5%
difference between the two treatment methods for both constraints. The average mean dose of
the heart was 148.9cGy for FIF and 192cGy for ISC, resulting in a difference 43cGy on average
in favor of the FIF technique. The research suggests that heart dose may be kept marginally
lower with the FIF technique without making a tangible clinical difference as all plans passed the
constraint by a large margin in both techniques (Table 5).
Overall, both treatment methods were effective in meeting all the coverage requirement
and most of the dose constraints as only the contralateral breast maximum point dose was not
met by the ISC method in all cases. Considering that all plans were forcibly normalized to
deliver 99% coverage to the entire GTV, it was expected that some dose constraints would fall
out of spec. The largest takeaways from the results include the differences in dose conformity,
contralateral OAR doses, and ipsilateral lung doses. The FIF method consistently provided plans
with a better CI without sacrificing maximum hot spots and target volume coverage. A CI in
between 1 and 2 is considered in accordance with RTOG standards, so in only one case dose
conformity deviated from protocol standards.12 It also produced plans that gave about 50% dose
to both the contralateral breast and contralateral lung. Neither planning method was unable to
produce acceptable plans based on RTOG guidelines, so the research may only suggest that
already acceptable treatment plans can be improved by using the FIF method with 6MV, 10MV,
and 15MV treatment beams (Tables 1-4).
Conclusion
With so many variables in previous studies comparing different methods of whole breast
radiation therapy, this study emphasized a comparison with limited variability. By using the
same treatment machines, planning systems, and patient datasets, the treatment plans in this
study were extremely limited in variability. With the use of a single protocol and physician to
outline PTVs, GTVs, and OAR, the analysis of dose delivery was expected to be more accurate
than previous research. The only notable variables in this study include having different
dosimetrists perform each method of planning and the option to use 10MV beams in the FIF
treatment technique. The research was intended to represent a wide range of the left-sided, early
stage breast cancer patient population, as the study utilized retrospective treatment planning CT
scans of patients with different breast volumes, body sizes, and lumpectomy cavity locations.
When variables are limited, and normalization methods are consistent between planning
techniques, the research suggests that the FIF method may be advantageous to the ISC method in
primary, free-breathing radiotherapy for early stage breast cancer for a variety of patients. Both
methods were extremely comparable to each other in terms of maximum point dose and target
volume coverage. The maximum hot spot was well below the limit of 115% in both treatment
techniques even with the entire GTV covered by the 99% isodose line in all cases. In terms of
dose conformity of the 95% isodose line, the FIF technique was able to provide plans with a CI
much closer to 1 than ISC. It was likely that because the 95% line was tighter around the PTV
when using the FIF technique that the corresponding OAR doses were also lower.
Based on the study findings, a similar study with a larger number of patients may further
suggest that the FIF technique can be advantageous to ISC. Further research should include not
only a larger study population, but also patients with larger bridge separations and amounts of
breast tissue. The differences in both contralateral and ipsilateral lung and heart doses may be a
result of patient respiration, so the use of deep inspiration breath hold (DIBH) may yield
different results regarding dose to these OARs. Because DIBH is practiced at many cancer
treatment facilities for left-sided breast cancer radiotherapy, a similar study involving this
technique would extend this research.
 References
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July 23, 2018
2. Koivumaki T, Fogliata A, Zeverino M, et al. Dosimetric evaluation of modern radiation
therapy techniques for left breast in deep-inspiration breath-
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technique in breast tangential radiotherapy. J Radiat Res. 2014;55(4):769-773.
https://dx.doi.org/10.1093/jrr/rrt233
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July 23, 2018.
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323. https://dx.doi.org/10.1016/j.ejmp.2016.07.213
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12. Petrova D, Smickovska S, Lazarevska E. Conformity index and homogeneity index of the
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https://dx.doi.org/10.3889/oamjms.2017.161
 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.
 Tables
Table 1. Information regarding the patients’ separation and GTV and PTV_EVAL sizes.

Patient Maximum Bridge Separation GTV Volume PTV_Eval Volume

(cm) (cc) (cc)
B 24.5 37.2 1085.7
C 19.7 16.0 490.5
D 26.9 24.4 1058.0
E 22.5 22.7 608.8
F 19.3 21.3 736.0
H 24.2 27.7 849.3
K 26.9 51.6 1460.8
R 22.1 31.5 781.1
S 20.6 11.6 211.7
T 23.3 4.2 607.4

Table 2. A comparative table of target coverages and dose conformity for both treatment
methods.

Maximum Point Dose PTV_Eval Coverage GTV Coverage Conformity

(% of PTV covered by (% of GTV covered by Index (CI)*
% of Rx) % of Rx)
Treatment
Planning FIF ISC FIF ISC FIF ISC FIF ISC
Technique
Patient B 106.7% 106.1% 95% of 97% 95% of 96% 1.33 1.47

Patient C 104.7% 107.1% 95% of 99% 95% of 99% 1.41 1.70

Patient D 107.0% 107.1% 95% of 96% 95% of 98% 1.36 1.81
Patient E 107.0% 104.8% 95% of 98% 95% of 96% All treatment plans 1.34 1.55
104.8% 104.5% 95% of 97% 95% of 98% were normalized to 1.22 1.47
Patient F
100% of GTV covered
Patient H 106.7% 105.4% 95% of 97% 95% of 97% by 99% of Rx 1.35 1.49
Patient K 108.9% 104.6% 95% of 99% 95% of 95% 1.38 1.34

Patient R 107.5% 106.6% 95% of 99% 95% of 99% 1.45 1.77

Patient S 104.4% 105.8% 95% of 95% 95% of 99% 2.90 2.85
Patient T 105.8% 105.3% 95% of 97% 95% of 95% 1.48 1.76
Average 106.35% 105.73% 97.4% 97.2% 1.522 1.721
Difference The maximum point The PTV_Eval coverage at The CI is 0.2
dose is 0.62% less for 95% is 0.02% higher for lower for FIF
ISC than FIF FIF than ISC than ISC

Table 3. A comparison of Contralateral Breast and Contralateral Lung dose for both treatment
methods.

Contralateral Breast Max Dose Contralateral Lung Max Dose (cGy)

(cGy) (Max < 310cGy) (V5 < 10%)
Technique FIF ISC FIF ISC
Patient B 248 332 176 223
Patient C 133 348 103 253
Patient D 159 375 55 56
Patient E 101 247 108 212
Patient F 80 82 24 35
Patient H 299 664 100 137
Patient K 165 420 32 51
Patient R 263 396 29 87
Patient S 88 231 243 570
Patient T 114 179 114 262
Average 165 327.4 98.4 196.6
Comment FIF average max dose to FIF average max dose to contralateral
contralateral breast tissue is 162.4 lung is 98.2 cGy or 50.1% less
cGy or 49.5% less

Table 4. A comparison Ipsilateral Lung dose for both treatment methods.

Ipsilateral Lung Ipsilateral Lung Ipsilateral Lung

V20 < 15 Volume (%) V10 < 35 Volume (%) V5 < 50 Volume (%)

Technique FIF ISC FIF ISC FIF ISC

Patient B 9 11 13 17 22 27
Patient C 4 12 8 19 16 30
Patient D 3 10 5 15 9 24
Patient E 9 14 12 20 19 32
Patient F 2 6 3 9 6 14
Patient H 7 13 11 19 19 28
Patient K 3 8 7 13 16 23
Patient R 6 13 9 17 16 25
Patient S 7 13 10 17 16 24
Patient T 6 13 16 20 18 33
Average 5.6 11.3 9.4 16.6 15.7 26
Notes FIF -5.7 % FIF -7.2 % FIF -10.3 %

Table 5. A comparison of Heart dose for both treatment methods.

Heart Heart Heart

V20 < 5 Volume (%) V10 < 30 Volume (%) Mean Dose (cGy) <
400cGy
Technique FIF ISC FIF ISC FIF ISC
Patient B .5 .02 1 .3 137 135
Patient C 0 0 0 .1 88 127
Patient D 1 .7 2 2.0 163 177
Patient E .4 .6 .8 1.4 129 197
Patient F .9 1.4 2 2.5 171 223
Patient H .3 .6 .8 1.4 153 203
Patient K .04 .6 .2 1.5 122 162
Patient R 2 2.5 3 3.6 210 288
Patient S 1 2.4 2 3.6 175 253
Patient T 1 .5 2 .9 141 155
Average .7 .9 1.38 1.73 148.9 192
FIF -.2 % FIF -.35 % FIF -43 cGy