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Clinical Oncology Assignment

Introduction and Diagnosis

A 45-year-old pre-menopausal female with pathologic prognostic stage 1B (anatomical stage II

cT2NOMO) mpT2 pN2a cMO left breast invasive ductal carcinoma. In September of 2020, she

presented with pain in the lateral left breast. Left breast masses and the left axilla were biopsied which

showed stromal hyperplasia and unremarkable breast tissue and associated calcifications. The left axilla

presented with benign fibroadipose tissue. In February of 2022, she completed a mammogram that

presented a 2.5 cm calcification and distortion in the upper right quadrant. She is HER2-negative post

bilateral mastectomies with immediate placement of pre-pectoral tissue expanders. The tumor board

recommended systemic chemotherapy, followed by radiation and endocrine therapy. Chemotherapy

began in June of 2022, starting with Adriamycin and Cytoxan followed by Paclitaxel. She has a large

family history of breast cancer that includes her maternal aunt, sister, maternal grandmother and paternal

grandmother.

Simulation

The patient was simulated on our breast board in the head-first supine orientation. Her arms were

raised above her head into cup holders on each side of her and resting above her head in a holder. The

arm cup holders will be in the same orientation for treatment to ensure her humeral head is in the same

positioning for treatment to the supraclavicular field. The breast board was at a tilt of 10 degrees to

ensure that any breast tissue or excess skin is to slope downwards in a consistent matter for treatment.

The physician had requested a 2mm aquaplast bolus to be customized and laid over the patient's skin,

making sure to cover all areas that are within the borders drawn. The goal of using bolus during

treatment is to ensure that the target volume is receiving the prescribed dose as well as the skin. The
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bolus will be placed on the patient’s skin every day for treatment in the same exact location. At any

point during treatment, the physician can request that the bolus be removed. On occasion the physician

will request this if the patient is having a severe skin reaction from the treatment due to the bolus.1 Any

patient that is being treated to the left breast and occasionally right, it is our standard to always attempt

to train the patient on our SDX breathing machine. During the training, the patient will take in a deep

breath, without arching their back and hold in a band on the screen for as long as they can. The volumes

of the inhalation will be used every day for treatment to ensure consistency. The purpose of an SDX

machine is to reduce the irradiated dose to the heart by separating the target volume from the heart.2 She

was successful during SDX training with a 50 second beath hold. Figure 1 displays the patient and how

she was set up during her simulation. The images show the borders that the physician drew, her arm

position, and the aquaplast bolus.

Figure 1
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Fractionation Regimen

The fraction regimen that was prescribed for his patient is 2.00 Gy delivered in 25 fractions to a total of

50 Gy. The treatment frequency is five days a week, Monday through Friday. According to the

prescription, the plan is to be normalized to 100%. In some cases, there will be a prescription written to

boost the scar on the chestwall. For this patient, the physician deemed this not necessary. Figure 2 below

displays the prescription that I was given at the time of planning utilizing our Blueprint software. It is

recommended that total dose to the entire breast of chest wall and regional nodes should receive 50 Gy

in 1.8-2 Gy per fraction. Internal mammary nodes, supraclavicular nodes, and axillary nodes should

receive 45-50 Gy if there is no macroscopic tumor present.3 This dose and fractionation regimen is

standard at my clinic as well as a hypofractionation regimen that is also frequently prescribed.

Figure 2
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Organs at Risk

Many organs are at risk that are near the treatment side of the left chest wall. The heart, left lung, spinal

cord, stomach, and the left anterior descending artery are the structures that are paid close attention to in

this plan. It is important not to exceed the dose limitations of these organs because it could lead to future

complications for the patient. Figure 3 below displays the organs at risk that I contoured for this case.

Figure 4 displays the tolerance doses for each organ at risk based on the physician's prescription. Figure

5 displays the recommended QUANTEC values and values from the physician’s prescription of

tolerance doses per organ at risk and the objective outcome.

Figure 3
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Figure 4

Figure 5
Organ at Risk (OAR) Planning Objective3 Objective Outcome Objective Met (Y/N)?

Heart Mean [Gy] ≤ 2 1.75 Gy Y

Heart V25Gy[%]≤10% 7.2% Y

Left Lung V20Gy [%] ≤ 33% 30.40 % Y

Spinal Cord Max [Gy] ≤ 45.00 4.69 Gy Y

Stomach Mean [Gy] ≤ 5.00 1.34 Gy Y

Anterior Descending D0.1cc[Gy]≤22.00 8.27Gy Y

Artery

Lymph Node Regions

For this patient’s plan there are 3 lymphatic nodal chains that are included within the prescription. The

level III axillary nodes, internal mammary nodes, and the supraclavicular nodes are the chains that are

included. Figure 6 shows the nodal chains that are included in each treatment field. In the medial and
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lateral fields, the internal mammary nodes are being treated. In the supraclavicular field, the level III

axillary lymph nodes and the supraclavicular lymph nodes are encompassed and being treated.

Figure 6

Treatment Boundaries

During the simulation, the physician will be on set prior to the CT scan and will draw the treatment

borders. The physician starts by palpating the suprasternal notch and then from there the superior border

across will be defined meeting at the lateral border. Starting at the suprasternal notch inferior following

the patient's midline and sternum will be the medial border. The inferior border is defined by 1.5

centimeter below the inframammary crease. The lateral border is drawn from the midaxillary region,

ensuring that the breast tissue is included with a 1.5 cm margin from the breast tissue. Once the

physician is finished drawing the borders, the therapists will then place radiopaque markers along the

border in order visualize them on the scan as shown in figure 7. Figure 8 displays the borders of the

treatment fields that were created based off the treatment borders.
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Figure 7

Figure 8
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Radiation Therapy Treatment Technique

The plan was created using a 3D conformal treatment technique. Three different gantry angles were used

which defined the supraclavicular field, medial field, and lateral field. Each field utilizes field-in-field to

control the hot spots and move dose around where needed. All the fields used 6X as their energy besides

the field-in-field on the supraclavicular field (Sclav.1) which uses 16X. The 16X was used to ensure that

the axillary lymph nodes were receiving the prescription coverage needed because these nodes are

deeper within the patient. Figures 9-17 display the treatment borders, collimator and angle

arrangements, and MLC shape for each field that was created for this plan.

Figure 9
Field 1: Sclav- 6X energy, gantry angle 348 degrees, collimator angle 0 degrees.
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Figure 10
Field 2 (field-in-field): Sclav.1- same angle arrangements as the primary field but instead using 16X as
the energy.

Figure 11
Field 3: Med- 6X energy, gantry angle 305 degrees, collimator angle 0 degrees.
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Figure 12
Field 4 (field-in-field): Med.1- same angle arrangements and energy as the primary field.

Figure 13
Field 5 (field-in-field): Med.2- same angle arrangements and energy as the primary field.
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Figure 14
Field 6 (field-in-field): Med.3- same angle arrangements and energy as the primary field.

Figure 15
Field 7: Lat- 6X energy, gantry angle 129 degrees, collimator angle 0 degrees.
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Figure 16
Field 8 (field-in-field): Lat.1- same angle arrangements and energy as the primary field.

Figure 17
Field 9 (field-in-field): Lat.2- same angle arrangements and energy as the primary field.
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Plan Dose Volume Histogram and Organs at Risk Tolerance Guidelines

After the plan was completed, it was pulled into our Blueprint software where it was evaluated based on

the tolerances that the physician requested. The physician will also put priority levels for all of the

structures. All the OAR tolerances where met which were all priority 1’s besides the A_LAD which was

still met being at a priority 3. The supraclavicular lymph node D95%[%!] ≥ 95 was met as well as the

chestwall D0.1ccc[%!]≤ 107. The other structures that were not met were all priority 2 or 2.5 and then it

is the physician's decision on if it was acceptable. In this situation, the physician was okay with what

was being met and what was close to being met. Figure 18 displays the goals and metrics for this plan in

Blueprint and figure 19 is the final DVH of the plan that includes the targets and organs at risk.

Figure 18
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Figure 19

Conclusion

After the plan was completed, it was sent off to the physician for review. The feedback from the

physician was that it was overall a great plan. This assignment allowed me the opportunity to learn and

understand the details that are put into creating a sufficient plan for the patient. Many obstacles can

occur when creating a plan due to every patient’s anatomy being unique. It is important to understand

how to troubleshoot these obstacles as they occur in order to manifest a plan that is safe and effective for

the patient.
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References
1.Shu-Hui Hsu, Roberson P, Chen Yu, Marsh R, Pierce L, Moran J. Assessment of skin dose for breast

chest wall radiotherapy as a function of bolus material. Phys. Med. Biol. 2008;53(10): 2593.

https://doi.org/10.1088/0031-9155/53/10/010

2. Hirata, K., Narabayashi, M., Hanai, Y. et al. Comparison of thoracic and abdominal deep inspiration

breath holds in whole-breast irradiation for patients with left-sided breast cancer. Breast

Cancer.2021;28:1154–1162. https://doi.org/10.1007/s12282-021-01259-4

3. Chao K.S.C., Perez C.A., Wang T.J.C. Radiation Oncology: Management Decisions. 4th

Ed.Philadelphia, PA: Wolters Kluwer Health; 2019.