Introduction

A 61-year-old female presents with clinical stage IIIB (T2 N3b M0) invasive ductal

carcinoma (IDC) of the left breast. IDC accounts for about 75% of all breast cancers, making it

the most common form of breast cancer. This type of breast cancer arises from the lactiferous

(milk) ducts in the nipple, which is where the term “ductal” comes from in the name. It is

considered invasive because it has spread out to other breast tissue.1 Her initial imaging showed a

2.6 cm mass. She underwent a subsequent lumpectomy showing an additional 1.2 cm of invasive

disease with positive surgical margins, meaning the surgeons were not able to get all of the

disease while they were in there for the surgery. She also underwent a sentinel lymph node

biopsy in which they tested a total of 9 lymph nodes for the presence of cancer cells, where one

lymph node came back positive. Re-excision was performed later and showed no additional

malignancy. In addition, a sample of the cancerous cells were analyzed for hormone receptors.

This patient’s cancer was found to be estrogen receptor (ER) positive, progesterone receptor

(PR) positive, and human epidermal growth factor receptor (HER) positive. This means the

cancer cells have a lot of hormone receptors and hormone therapy will be included in her

treatment regimen. Hormone therapy utilizes medications to inhibit the body's hormones,

particularly estrogen, from stimulating the growth of any residual cancer cells following

surgery.2 Due to concern for internal mammary adenopathy, adjuvant chemotherapy was

recommended, as well. An adjuvant radiation therapy dose of 267 cGy for 15 fractions to a total

of 4005 cGy to the left breast, axilla, supraclavicular nodes, and internal mammary nodes was

prescribed by the radiation oncologist. This breast treatment is considered hypofractionated

radiotherapy, as the older conventional treatment regimen was 50-50.4 Gy over 25-28 fractions.

In a 2021 study done by Najas et al. designed to evaluate the long-term survival rates, local
tumor control, and the occurrence of short-term and long-term side effects in patients who

underwent hypofractionated breast treatment, it was found that this shorter regimen demonstrated

its safety and efficacy. The new protocol boasted high rates of disease control and overall

survival, while also exhibiting low rates of both short-term and long-term side effects. 3

Simulation

Patient was positioned supine with her arms up on an All-In-One Orfit device. She would

be receiving treatment to her supraclavicular nodes, so she was placed on a 5-degree wedge to

separate the breast tissue from the lymph nodes slightly without causing a skin fold to form

inferiorly. Her head was placed on head holder #2 with her chin turned slightly to the right to

help with sparing dose to her esophagus. There was a knee sponge under her knees for comfort

which decreases the chance of patient movement during treatment. Adhesive wires were placed

by the radiation oncologist on the patient’s lumpectomy and lymph node biopsy scars along with

a wire encompassing all left sided breast tissue. A metal BB was placed on the patient’s nipple as

well. At the time of simulation, two scans were completed. One with the patient breathing freely

and one scan with a deep inspiration breath hold (DIBH). This is because the cancer is located in

the left breast, on the same side as the heart. In order to spare dose to the heart, left sided breast

cancers are treated with the patients taking a deep breath in, creating space between the breast

tissue and heart tissue.

Treatment Outlining

In the treatment planning system, organs at risk (OAR) are contoured by the dosimetrist

and target volumes are contoured by the physician. The most common OARs with left sided
breast treatment are the ipsilateral lung, the contralateral breast, heart, esophagus, and spinal

cord. In Figure 1, you can see the contoured OARs in all 3 planes. In this particular case, all of

the OARs mentioned were contoured, along with the lumpectomy clinical target volume (CTV),

whole breast CTV, axillary node CTV, internal mammary node (IMN) CTV, supraclavicular

CTV, and the lumpectomy planning target volume (PTV). All target volumes were contoured by

the physician. These target contours are visible in Figures 2 and 3. In table 1, you can see the

tolerance doses for the OARs listed above. If these tolerance doses are exceeded, depending on

the organ, there could be serious complications. For example, if more than 25 percent of the

heart volume exceeds 10 percent of the dose, the heart muscles could become inflamed. If lung

dose is surpassed, radiation induced pneumonia could occur. Unacceptable doses to the

esophagus would cause serious esophagitis, and side effects of excessive radiation to the spinal

cord could cause sensation issues or worse, paralysis.4

When setting up the field orientation for a breast and nodes treatment plan, it’s important

to think about the anatomical borders for each individual field. This is important when it comes

to avoiding OARs in the vicinity while trying to maintain adequate coverage. The inferior border

of the Supraclavicular/Axillary fields should be just under the head of the clavicle. Medially, it

should extend far enough to include the full nodes, but MLCs should be used to block out spinal

cord and esophagus medially, if possible. In this particular case, the supraclavicular nodes extend

very medially so there is more spinal cord and esophagus in the left anterior oblique fields than

we would normally want. Refer to Figure 4 to view all three nodal targets labeled on a beams eye

view of one of the supraclavicular fields.

 For the chest wall fields, the ultimate goal is to spare as much of the lung as possible and

avoid all of the heart. The lung dose was difficult with this plan because of the location of the

IMNs. Because of this, very steep angles were needed on the tangents. With steep tangent fields,

you need to be aware of any dose penetrating the contralateral breast. In order to avoid this, very

tight blocking of the fields posteriorly was required. Refer to figure 5 to view MLC blocking. It’s

also important to make sure the posterior borders of your parallel opposed tangent fields are

completely parallel to avoid any divergence of the beams into the lungs.

This breast and lymph node plan was planned with a conformal monoisocentric treatment

technique. In breast planning, when using a monoisocentric technique, the lymph node plan and

the breast plan both have the same isocenter, but the jaws are pulled closed on either side of the

isocenter to avoid hot or cold spots or overlapping beams. This is called “half- beam blocking”.

The isocenter is typically placed at the level of the clavicular heads and then the inferior jaw is

pulled up to block out the breast fields for the supraclavicular plan and on the breast plan the

superior jaw is pulled down to block out the lymph node plan. A monoisocentric technique can

only be used when the breast fields are less then 20cm because of jaw limitations. Figure 6

shows isocenter placement for this treatment plan.

On the supraclavicular plan there were a total of 4 fields. One left anterior oblique

(LAO), one right anterior oblique (RAO) and two field in fields from the right anterior oblique

angle. For most supraclavicular treatment plans with field in field arrangements, a field in field

would be placed on both the LAO and the RAO, but with this case, the supraclavicular nodes

extended so far medially, it was hard to block the spinal cord and esophagus out of the LAO

field, as opposed to the RAO field, where there is much less spinal cord and esophagus included
due to the angulation. In Figures 7 and 8 you can compare the spinal cord and esophageal

exposure within the LAO and RAO fields. It’s clear that there is less dose to those particular

OARs in the RAO so a second field in field was added to the RAO. The left anterior oblique was

angled at 15 degrees and the right anterior obliques were all angled at 345 degrees. All fields had

the collimator positioned at 90 degrees in order for the wedges to push dose where needed. A 45-

degree wedge was placed on both primary oblique fields with their heels together in order to

create a wedged pair isodose distribution and cover the full field. All fields were created with

15X energy, besides one of the right anterior oblique field in fields in order to achieve a little

more superficial coverage. 15X was used for the primary fields due to the depth of the axillary

nodes. In order to get adequate coverage that deep, a higher energy was required. Refer to

Figures 9-12 for beams eye views (BEV) of all 4 fields.

On the chest wall plan, 4 fields were used to achieve adequate coverage. One medial

tangent, one lateral tangent and one field-in-field for each primary field. Initially, a medial and

lateral tangent were added to the plan and wedges and weighting were adjusted to make the plan

as cool as possible while also keeping coverage of the whole breast CTV up. When this is

completed, a field in field was added to each tangent in order to diminish the hot spot areas in the

breast. The energy used on the medial tangent and medial field-in-field was 10X and this was

because of the IMNs being so medial. To achieve adequate coverage of the nodes, a moderate

energy was needed in order to not loose coverage superficially, but also contribute enough to the

coverage of the chest wall target volume. The lateral tangent and lateral field-in-field used 15X

because the patient’s separation was thicker and to cover the rest of the chest wall target. The

gantry angle for the medial tangent and medial field in field was 316 degrees and the lateral
tangent and lateral field in field were positioned at 139.5 degrees. All collimators we positioned

at 90 degrees for correct wedge positioning to push dose posteriorly, which is needed because of

the difference in tissue thickness between the breast and thorax. A 15-degree wedge was placed

on the medial tangent with the heel positioned away from the patient and a 20-degree wedge

placed on the lateral tangent, again, with the heel positioned away from the patient. Refer to

figures 13-16 for beams eye views of all 4 fields.

Because this breast plan was planned using a monoisocentric technique, there was no

need for table rotation on the tangent fields because fields were half beam blocked by the jaws to

avoid hot and cold spots at isocenter from beam divergence.

Treatment Plan Assessment

In order for dosimetrists to view and keep track of all target doses and OAR constraints, a

plan sum is created that includes both the lymph node plan and the breast plan. This is

particularly important for this case because of where isocenter was placed. There is CTV whole

breast in both plans, along with CTV axillary nodes. This is viewable in Figure 17. If you were to

look at the dose to those two targets in just one individual plan, the DVH would not be accurate

considering the axillary nodes and whole breast CTV have contributing dose from both plans. In

Figures 18 and 19, you can see all beams in the plan sum. As you can see by the included

ClearCheck constraints and labeled DVH (Figures 20 and 21), this was a tough case to plan. Not

all targets are receiving the standard passable dose. At this facility, physicians usually strive for

100 percent of the whole breast CTV to receive at least 90 percent of the prescribed dose. In this
plan the whole breast CTV is receiving 93.4 percent. With nodal target volumes, the goal is for

100 percent of the volume to receive at least 95 percent of the dose is possible, but 95 percent of

the volume receiving 95 percent of the dose is passable. The supraclavicular CTV received an

adequate 90.7 percent of the dose, but the axillary and IMN coverage was not met. The axillary

node CTV was very close with 100 percent receiving 87.5% and the achievable IMN coverage

reached was 95 percent of the volume receiving almost 92% dose. This is very common in

dosimetry due to that fact that all patients have different anatomy and sometimes the prescribed

dose is not reachable due to healthy organs in the region or difficult body habitus and

compromises must be made at the physicians approval. Although, standard protocols were not

met completely on some targets, the plan was still adequate and approved by the physician. On

the other hand, all OAR doses in the area were kept below the constraints allowed, including the

heart, which is very important with left sided breast treatment. It is recommended that the mean

heart dose be kept below 200-500 cGy and in this plan the heart is only receiving 147.4 cGy. The

left lung dose was kept down to 24.4 percent, with the constraint stating to keep the volume of

lung receiving 2000cGy below 30-35 percent. Another important OAR in this case was the

contralateral breast. The goal for the mean dose to the contralateral breast is to keep it below

500-800 cGy and this plan measured the right breast dose as 21.8 cGy.

Conclusion

Breast cancer, being one of the most prevalent forms of cancer, is often treated with

radiation therapy. Given its tendency to spread to lymph nodes, it is crucial to devise a treatment
strategy that effectively targets both the primary tumor in the breast or chest wall and the

involved lymph nodes. A monoisocentric technique, combined with a half beam block, is a

dependable method for treating all designated targets. By employing a plan sum along with a

corresponding dose-volume histogram (DVH), dosimetrists can evaluate the plan to ensure that

organs at risk (OARs) receive acceptable doses to minimize adverse effects. In this patient's case,

a treatment plan using a monoisocentric technique with tangential fields and a wedged pair

achieved complete coverage of all targets while sparing OARs, meeting the physician's criteria.

Tables

Table 1. QUANTEC Organs at risk with dose constraints. 3

Heart Mean dose < 200-500 cGy

Ipsilateral Lung V25 < 10%; V20 <30-35%

Contralateral Breast Mean dose < 500-800 cGy

Spinal Cord Max dose = 50 Gy

Esophagus V15 < 54 Gy

Figures

Figure 1: Contoured OARs in all 3 views – Lt Lung, Rt Lung, Esophaugs, Heart, Spinal Cord

Figure 2: Nodal Targets Contoured

Figure 3: Whole Breast Targets contoured

Figure 4: Nodal chains labeled

Figure 5: Tight blocking required to block out heart and contralateral breast

Figure 6: Isocenter placement for a monoisocentric breast plan

Figure 7: Esophagus (blue) and spinal cord (yellow) in the LAO supraclavicular field

Figure 8: Esophagus (blue) and spinal cord (yellow) in the RAO supraclavicular field
Figure 9: BEV of LAO field on supraclavicular plan

Figure 10: BEV of RAO field on supraclavicular plan

Figure 11: BEV of RAO field in field 1 on supraclavicular plan

Figure 12: BEV of RAO field in field 2 on supraclavicular plan

Figure 13: BEV of medial tangent field
Figure 14: BEV of medial tangent field in field
Figure 15: BEV of lateral tangent field
Figure 16: BEV of lateral tangent field in field

Figure 17: Whole breast CTV extends sbove isocenter and axillary nodes extend inferior to
isocenter
Figure 18: Whole breast beams and dose distribution in the final plan sum

Figure 19: Nodal beams and dose distribution in the final plan sum
Figure 20: Clearcheck constraints of Targets and OARs

Figure 21: Final DVH for Lt Breast and Nodes treatment plan

References:

1. Types of Breast Cancer. Invasive ductal carcinoma (IDC): Grade, symptoms & diagnosis.
Accessed April 23, 2024. https://www.breastcancer.org/types/invasive-ductal-carcinoma.
2. Clifford CKS, Perez CA, C. WTJ. Radiation Oncology: Management Decisions. Wolters
Kluwer; 2019.
3. Najas GF, Radwanski Stuart S, Marta GN, et al. Hypofractionated radiotherapy in breast
cancer: A 10-year single institution experience. Reports of Practical Oncology and
Radiotherapy. 2021;26(6):920-927. doi:10.5603/rpor.a2021.0109
4. Thomsen MS, Berg M, Zimmermann S, et al. Dose constraints for whole breast radiation
therapy based on the quality assessment of treatment plans in the randomised Danish
Breast Cancer Group (DBCG) hypo trial. Clinical and Translational Radiation Oncology.
2021;28:118-123. doi:10.1016/j.ctro.2021.03.009