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For this paper I have chosen a 4 field left breast plan that I worked on. The patient is a 52
year old female with ER+/PR-/HER2- invasive ductal carcinoma with lobular features. Her stage
is III cT3 cN2 M0. She had bilateral mastectomies with tissue expanders placed at time of
surgery. She has received chemotherapy prior to starting radiation therapy.
For simulation the patient was placed supine on the breast board with both arms above
head with a knee cushion under her knees. The simulation employed respiratory gating since her
breast cancer is left sided. Respiratory gating is used to treat the breast tissue while the patient is
in the inhale phase in order to pull the chest wall away from the heart. This technique reduces the
dose to the heart. The physician placed CT wires on the borders of the desired treatment field and
her scar from the mastectomy. The placement of these radiopaque wires during the CT sim
allows the physician and dosimetrist to visualize on the TPCT the desired treatment area. This is
very helpful to the dosimetrist when designing the fields to include everything the physician
wants to treat.
The physician is targeting the left chest wall, supraclavicular nodes, inframammary
nodes, and left axillary nodes for treatment. The prescription for this plan is 50Gy in 25 fractions
(2Gy/Fx). She also has included 2mm of bolus for treatment. This was placed for the TPCT. This
prescription is based on the FABREC and CHARM trials the physician said. I looked up those
trials and it is comparing the traditional fractionation with hypofractionation. The conclusion that
the trials come to is that it most likely is safe for advanced stage post mastectomy implanted
patients to receive hypofractionated (HFRT) dose schedules but it is still under investigation. 1
This group of patients does have a higher risk of side effects based on many factors.1 The
physician for that reason said she tends to stick with conventional fractionation for more
advanced breast cancer patients like this one.
The OAR that were contoured in this plan include the left anterior descending artery,
heart, lungs, spinal cord, trachea and the carina for visualization. On the next page I have a
screenshot of the contoured structures and the key on the left hand side.
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Below is a screenshot of the table of OAR tolerances that the physician wants the plan to meet. As you can see the heart dose was not met and this
metric has been set by Michigan Radiation Oncology Quality Consortium (MROQC). The physician noted off to the right in the heart comments that
the dose that was planned was acceptable.

The QUANTEC values for the OAR that have been outlined above are:
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Heart- V25< 10% with the endpoint being long term cardiac mortality
Left Lung- V20≤ 30% with the endpoint being symptomatic pneumonitis2
Right Lung- V20≤ 30% with the endpoint being symptomatic pneumonitis2
Spinal Cord- Max = 50Gy with the endpoint being myelopathy2
Left anterior descending artery (ALAD)- not listed in QUANTEC
The lymph node regions that were targeted in this plan are shown in the screenshot below.

Below is another view of the lymph nodes chains and the supraclavicular treatment port.
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Orange- supraclavicular nodes
Blue- Level II axillary nodes
Green- Level I axillary nodes
Magenta- Inframammary nodes

I will answer questions 6 and 7 together. A monoisocentric arrangement is used with field in field segments for this plan.
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The boundaries of the supraclavicular field are shown below which include blocking the left humeral head as well as the trachea in the center
(colored light seafoam green). The field is also shaped to include the targeted lymph node chains. The isocenter was placed where the physician had
wired the top border of the tangent field in the simulation. The inferior border of the field is half beam blocked to create a nice match line between
the supraclavicular field and the tangent fields. Below I have included my field parameters. The supraclavicular field has three segments that were
used to block hot spots. The gantry angle is 350 degrees, collimator 0 and couch 0. Beam energy is 16Mv for this field in an attempt to reach the
deeper nodal volumes. MUs ↓
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For the posterior axillary boost the field design is shown below. This field is shaped to cover more of the level I and II lymph node chains and
block out part of the clavicle and left humeral head. The isocenter remains the same for all fields in this plan. I used 6Mv for this beam because it’s
mainly going through the apex of the lung and it's just helping the supraclavicular field cover the lymph nodes. Gantry is 180 degrees and the
collimator is at 0. MUs ↓
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The medial tangent is half beam blocked superiorly and the gantry is at 311 degrees, collimator 0 degrees and the couch is 0 degrees. This
gantry angle was selected carefully to avoid the opposite chestwall, avoid the heart/lung as much as possible and include the inframammary nodes we
want to treat. In the screenshot below you can see how the half beam block comes down superiorly to create a nice match line with the
supraclavicular field and PAB. There is also a block designed to include the IM nodes and block out the heart. At my clinic the heart dose takes
precedence over the target dose. I also am trying to block out as much lung as possible while still including the PTV chestwall. MUs ↓
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The lateral field is also half beam blocked superiorly with a gantry angle of 136 (which is non coplanar) to make the beam edge matching and
less dose getting to the lung and opposite chestwall. The collimator and couch are both at 0. I created the field and blocking similarly to the medial
tangent. I allowed 2-3cm of flash over the anterior breast for setup and breathing (even though this is a DIBH plan). There is also a superior and
inferior margin of around 1-2cm per the physician on both the medial and lateral tangents. In the image below you can see that the block is blocking
heart and lung while trying to include the IMN and the PTV chestwall. MUs ↓
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The plan design included the use of 6Mv and 16Mv on the medial and lateral tangents. I tried using all 6Mv but it was putting more dose into
the left lung than we wanted and the 16Mv was able to give more dose to the posterior chestwall where it was lacking some coverage. For this
technique I weight the medial and lateral 6Mv so that the dose looks as even as possible. Then I add 17.5% to both the medial and lateral 16Mv
beams. Then with the remaining 65% on the 6Mv I start FIF each tangent. I usually start segmenting the tangent that is opposite of the tumor bed but
in this case I selected the side that had the most hotspot to tackle. I like to work “backwards” from most dosimetrists in that I set the IDL to the max
dose limit on the constraint which is 107% here. Then I FIF using the 107% IDL cloud to create my segments. Alternating tangents when
segmenting. So my first FIF segment will be the most blocked and then move toward least blocked as I add segments. In the end I had 3 segments on
each of the 6Mv open fields and then the open 16Mv fields on each side. On the next two pages are screenshots of the axial plane of the final
approved plan for the tangents and the SCLV region. The first image is of the tangent fields isodose distribution. The second image is of the SCLV
and PAB isodose distribution.
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The above image shows the DVH of the plan including the target lymph nodes, PTV chestwall as well as the OAR structures.
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I thought it would be easier and more visually appealing to show how the clinical goals are being met using BluePrint (University of
Michigan’s in house directive/clinical goal program). Below is an image of the BluePrint highlighting the target structures, their priority, the dose
metric being used for each and how the patient's plan met those goals. As you can see most of the goals were not achieved. When working on the
plan I was told that it is very difficult to get complete coverage on a 3-4 field chestwall. Some of the structures are closer to meeting the goals than
others such as, the level 3 axillary nodes and the IM nodes (the doctor wanted that nodal group to achieve at least 80% of the dose to 90% of the
structure in her notes). It was difficult to allow more dose to the IM nodes due to the heart overlapping with the inferior portion of the IM nodes.
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Below I have the same program to show the dose to the OAR we were monitoring. As you can see the heart dose was higher than the physician
wanted but after reviewing the plan she determined that it was acceptable. The contralateral lung, spinal cord, and the anterior lateral descending
artery were all well below their constraints. The left lung did take some effort with blocking and gantry angles to achieve 33% structure volume
receiving 20Gy.

In conclusion, I enjoyed planning this patient as she was only the second 4 field chestwall I have attempted and the first with tissue expanders.
The plan was challenging to achieve the goals set by the physician but it was a great learning experience that not all plans can be perfectly met. I
worked diligently on the MLC leaves and jaws in many of the fields moving just millimeters to help get the dose to the OAR down and dose to the
targets up. In the end we came up with a plan that was satisfactory to the physician and to the dosimetrist overseeing me.

References:
1. Sayan M, Yehia ZA, Ohri N, Haffty BG. Hypofractionated Postmastectomy Radiation Therapy. Adv Radiat Oncol. 2020;6(1):100618.
Published 2020 Nov 21. doi:10.1016/j.adro.2020.11.003
2. QUANTEC summary: approximate dose/volume/outcome data for several organs. http://individual.utoronto.ca/dtsang/misc/quantec.pdf.
Accessed: Apr. 12, 2024.
*I allowed a narrow margin on my paper to allow for larger viewing of all the images contrary to AMA 1” margins. I hope that is acceptable in this
instance.
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