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Research Proposal

Title: Minimizing dose to the heart, left anterior descending artery, and lungs in whole breast
radiation by reducing interleaf transmission in Elekta linear accelerators.

Problem Statement: The most commonly used collimator angles for tangent breast treatments
could be yielding more interleaf transmission than necessary when using an Elekta linear
accelerator. In order to meet dose constraints based on the MROQC protocol of 1.2 Gy mean
dose to the heart on a left sided breast or 0.7 Gy on the right side, an additional collimator
rotation could be used.

Literature Review: The goal of any radiation therapy treatment plan is to provide adequate
coverage to the tumor volume while sparing surrounding tissue and critical structures. In breast
treatments dose to the heart can cause ischemic heart disease and radiation pneumonitis.
According to Darby et al,1 for every gray the mean heart dose receives, the chance for heart
disease or major coronary events increases by 7.4%. In another study, Taylor et al2 states that
there is no threshold dose to the heart below which no risk for ischemic heart disease occurs.
With respect to coronary artery disease, left‐sided breast patients have a 51% higher rate of
cardiac stress test abnormalities compared to patients with right‐sided breast cancer, and 70% of
those abnormalities occurred in the left anterior descending coronary artery, with stenosis rates at
the mid and distal LAD significantly increased.3 Due to these risks of complications, techniques
to reduce dose to these organs are advantageous to the patient. There are many techniques to
reduce dose to critical structures for breast treatments, such as intensity-modulated radiation
therapy (IMRT), prone breast radiotherapy, deep-inspiratory breath hold and proton beam
therapy.2 Studies have been done to determine if interleaf leakage effects dose to critical
structures in various treatment plans. A study of interleaf leakage in an Elekta Synergy machine
shows that there is an average interleaf leakage of 1.9%.4 The collimation design of an Elekta
linear accelerator is that of a single set of diaphragms that move perpendicular to the MLC.5
Chen et al6compared doses to critical structures in IMRT lung cases with various MLC
transmission values. The lowest transmission value showed a decrease in V5, V20, and mean dose
to the lung which could reduce the chances for radiation pneumonitis. In a study by Chapek et
al,7 dose to the rectal wall in prostate treatment plans was shown to decrease with an optimal
collimator angle meant to minimize transmission through MLC leaves. A similar study was done
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regarding parotid gland irradiation and dose to the contralateral parotid gland and cochleae.
Although, no difference was shown in dose to these structures regardless of collimator angle.8 As
of now, no studies using an optimal collimator angle to reduce MLC leaf transmission to limit
dose to critical structures in a treatment for breast cancer has been done. This study aims to
determine if reducing leaf transmission with a collimator rotation, in a standard 3D whole breast
irradiation plan, will reduce the dose to critical structures while maintaining adequate coverage
of target volume.

Hypothesis: Rotating the collimator angle an additional 90 degrees for a tangent breast plan will
limit MLC leaf transmission which in effect will reduce dose to the heart, LAD, and lung.

Methods and Materials:

Patient Selection

50 patients from one radiation oncology system will be selected for this prospective study. Only
patients treated to the whole breast (right or left breast) with no nodal involvement will be
chosen for this study. Every patient will be treated head-first supine with an alpha cradle used for
immobilization. Patients treated with and without deep inspiration breath hold will be included in
this study.

Planning Procedures

Every patient will be planned using the Pinnacle treatment planning system (TPS) (Version 14.0)
with an inverse planned 3D conformal plan as described by Van Asselen et al9 and treated on
Elekta accelerators (Agility or Synergy) with either 5 mm and 10 mm MLC leaves respectively.
A total dose of 4256 cGy in 16 fractions will be prescribed to cover >90% of the PTV volume.
PTV is defined as the area of irradiated volume contracted 5 mm from the skin and lung
contours. Skin and lung contours will be defined utilizing the auto contouring tool. The heart
contour will be contoured manually following the RTOG 1106 guidelines. Dose from the boost
will not be considered in this study. A collimator rotation of an additional 90 degrees will be
applied to the medial and lateral open fields to limit interleaf transmission in each plan.

Evaluated Variables
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For each patient a plan will be created without an additional collimator rotation. Once
established planning objectives are met, the plan will be copied and a collimator rotation of an
additional 90 degrees will be added to the open medial and lateral fields. Values for mean heart
dose, maximum heart dose, mean dose to LAD, max dose to LAD, mean lung dose, V20 lung
dose, V10 lung dose, and V5 lung dose will be recorded for each plan. A paired t test will be
performed for each value to determine statistical significance (p=0.05).
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References

1. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after
radiotherapy for breast cancer. N Engl J Med. 2013;368(11):987-998
2. Taylor CW, Kirby AM. Cardiac side-effects from breast cancer radiotherapy. Clinical
Oncology. 2015;27:621-629. http://dx.doi.org/10.1016/j.clon.2015.06.007
3. Welsh B, Chao M, Foroudi F. Reducing cardiac doses: a novel multi-leaf collimator
modification technique to reduce left anterior descending coronary artery dose in patients
with left-sided breast cancer. J Med. Radiat. Sci. 2016;64(2):114-119.
https://doi.org/10.1002/jmrs.191
4. Vikraman S, Janardhan N, Kataria T, et al. Study of interleaf leakage and leaf
transmission in elekta synergy S beam modulator. Int J Radiat Oncol Biol Phys.
2010;78(3):S756-S757.
5. Cosgrove V, Thomas M, Weston S, et al. Physical characterization of a new concept
design of an elekta radiation head with integrated 160-leaf multi-lead collimator. Int J
Radiat Oncol Biol Phys. 2009;75(3):S722-S723.
https://doi.org/10.1016/j/ijrobp.2009.07.1646
6. Chen J, Fu G, Li M, et al. Evaluation of MLC leaf transmission on IMRT treatment plan
quality of patients with advanced lung cancer. Med Dosim. 2018;43:313-318.
http://doi.org/10.1016/j.meddose.2017.10.008
7. Chapek J, Tobler M, Toy BJ, et al. Optimization of collimator parameters to reduce rectal
dose in intensity-modulated prostate treatment planning. Med Dosim. 2005;30(4):205-
212. https://doi.org/10.1016/j.meddos.2005.06.002
8. Sharma S, Manigandan D, Goyal S, et al. Influence of collimator rotation on dose
distribution and delivery in intensity modulated radiation therapy for parotid cancer. Int J
Cancer Ther Oncol. 2015;3:3212. http://dx.doi.org/10.14319/ijcto.32.12
9. Van Asselen B, Schwawrz M, Vliet-Vroegindeweeij C, et al. Intensity-modulated
radiotherapy of breast cancer using direct aperture optimization. Radiother Oncol
2006;79:162-169