Minimizing dose to the heart in left sided post mastectomy patients by using the field-in-

field flattening filter free technique with deep inhalation breath hold
I. Abstract
II. Introduction
A. PI: Go over breast patients
B. PII: Heart dose introduction (Reference: Hu J,1 Hong JC,2 Darby SC,3 Piroth
MD,4)
C. PIII: Deep Inhalation Breath Hold (Reference: Sripathi L,5 Bergom C,6 Smyth L,7)
D. PIV: Flattening Filter Free (Reference: Xiao Y,8 Morris R,9 Barsky,10)
E. PV: Summarize introduction points
1. Problem: The problem is increased heart toxicity for left-sided chest wall
patients.
2. Purpose: The purpose of the study is to compare the heart dose for FFF
and FF DIBH field-in-field treatments for left-sided chest wall patients.
3. Hypothesis: The research hypothesis (H1) is that using FFF beams for a
tangential chest wall plan will reduce mean heart dose while maintaining
the same coverage to the chest wall.
III. Materials and Methods
A. Patient selection
1. PI: Patient population
a. 12 patients
b. Inclusion criteria: Left sided post mastectomy patients with SDX.
SDX is a breathing control system that enables the reproducible
positioning of the tumor from medical imaging through to the final
session of treatment, limiting excessive irradiation of healthy tissues
and contiguous organs. Patients that received a total dose of 50 Gy and
a daily dose of 2 Gy per fraction will be included. Patients will not be
excluded based on lymph node involvement.
A. Contours
1. PI: The contours drawn by the medical dosimetrist are chest wall, heart,
left lung, right lung, total lung, humeral head.
 2. PII: The contours drawn by the radiation oncologist are internal
mammary lymph nodes (IMN), level 1 axillary nodes, level 2 axillary
nodes, level 3 axillary nodes, supraclavicular nodes, planning tumor
volume (PTV)
B. Treatment Planning
1. PI: Planning Details
a. Field in field with 6FFF
b. Same supraclavicular fields
c. Same gantry angles and field sizes
d. Same heart and lung MLC block
2. PII: Different field in field due to beam profile of FFF
C. Plan Comparison
1. PI: A comparison of a previous physician approved and clinically treated
plan to the re-plan using FFF
2. PII: Evaluated metrics
a. Mean heart dose, heart Dmax, mean target coverage, mean OAR
coverage
D. Statistical Analysis
1. PI: Wilcoxon signed rank tests will be used
2. Wilcoxon signed rank tests were used rather than paired t-tests
due to small sample sizes and outliers observed in some of the samples.
3. P <0.05 is considered statistically significant
IV. Results
A. PI: Heart mean dose
1. The distribution for heart mean dose is significantly lower for the
population of patients where planning was done using FFF than for FF (P
< 0.0005) (Figure 1)
2. Heart mean dose=fail to reject null hypothesis
V. Discussion
A. PI: Summarize role of FFF with decreasing dose to heart
B. PII: Summarize heart mean dose
C. PIII: Discuss benefits of reducing mean heart dose
VI. Conclusion
A. PI: Summarize study
1. Problem: increased heart toxicity for left-sided chest wall
patients.
2. Purpose: The purpose of the study is to compare the heart dose
for FFF and FF DIBH field-in-field treatments for left-sided chest wall
patients.
B. PII: Limitations/future research
1. Limitation: All patients collected at one institution and one TPS
2. Future research: Different TPS, additional patients

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