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Nick Piotrowski Dos 773 Clinical Practicum III September 25, 2013 Right Breast Carcinoma History of Present Illness: MY is an 80 year old female with a tumor extension 1, no lymph node extension, and no metastatic disease (T1c N0 M0) right breast carcinoma. A slight abnormality in a mammogram in December 2012 was noted, but it was her 6 month follow up that revealed a lesion. The ultrasound guided core biopsy and mammogram revealed a grade 3 infiltrating ductal carcinoma spanning 1.5 centimeters (cm) in its greatest dimension. Past Medical History: The patient has not had a very extensive medical history prior to her cancer diagnosis. She does have borderline diabetes, hypertension, and hypothyroidism, with a cholecystectomy completed back in 1996. Social History: MY has been pregnant 5 times, but lost 1 child prior to birth. She has been married for 58 years and never consumes alcohol or uses any tobacco products. While she used to be a stay at home mom, with her kids out of the house she has taken up volunteering at Delnor Hospital. Her mom was previously treated for cervical cancer, but there is no history of ovarian or breast cancer in her family. A family history of either of these cancers dramatically increases the probability of offspring also presenting with the disease.1 Medications: MY is currently taking Ativan, Januvia, Micardis, 2 milligram (mg) tablets of glimepiride, and 112 micrograms (mcg) of levothyroxine. She also has noted that she has a slight allergic reaction to Benzo Cream. Diagnostic Imaging: At a 6 month follow up appointment, a mammogram revealed a 1.5 cm lesion. An ultrasound guided core biopsy and sentinel lymph node procedure T1c N0 M0 diagnosis. While a magnetic resonance image (MRI) was requested, patient anxiety did not allow for this procedure to be completed. However, a computed tomography (CT) scan of the head showed no disease in the brain. To plan the radiation therapy treatment, a planning CT of the thorax and breast was also completed 2 weeks before treatment. Radiation Oncologist Recommendations: A right breast lumpectomy was performed as recommended, and JS was sent to the radiation oncologist for post-operative radiation. The postoperative radiation dose recommended was 52.56 Gray (Gy) in a total of 20 fractions over 4

weeks. While there was talk of a chemotherapy regiment as well, the patient decided to do surgery and radiation alone. The Plan (prescription): As recommended by the radiation oncologist, MYs plan was taken to 52.56 Gy. The initial plan consisted of 16 fractions at 2.66 Gy/fraction, resulting in 42.56 Gy. Once finished, JS would be treated with a 4 fraction boost at 2.5 Gy/fraction. This additional 10 Gy allowed the tumor volume to receive the total 52.56 Gy. Patient Setup/Immobilization: During the treatment planning CT, MY was placed supine on the table with her arms raised above her head. In order to help with immobilization, she was position on a wingboard with a vacklock created around her arms and upper body. To keep her mandible out of the field, her head was turned to the left as it was her right breast being treated. Radio-opaque markers were placed on the clinical borders of the fields on all sides, as well as on the lumpectomy scar (Figure 1). The isocenter was not set in the simulation by the physician, but BBs were placed on the skin to assist with patient setup. Anatomical Contouring: Breast cancer cases at this facility require a variety of major organs to be contoured. The heart, liver, lungs, carina, and spinal cord were all contoured, as well as the radio-opaque wires. These wires were forced to a density of -1000 Hounsfield Units (HU), to assure they did not affect the treatment planning calculations. The lumpectomy cavity was contoured by the physician, and a 1.0 cm margin was added to create a planning target volume (PTV). In addition, this PTV was cropped 0.5 cm away from the skin, and 0.8cm away from the right lung. Beam Isocenter/Arrangement: As the beam isocenter was not set during the simulation, it was the job of the dosimetrist to do so. While occasionally the isocenter will be set in the lung, and half beam blocked, this was not one of those cases. The isocenter was placed in the center of the breast near the edge of the PTV. As the isocenter was placed 11.8 cm right, 2.0 cm superior, and 5.7 cm anterior of the simulation marks, those were the daily shifts. From there the jaws were opened 8.0 cm anteriorly, and 3.8 cm deep. This allowed for the chest wall to be treated and 3 cm of lung. The medial tangent had a gantry rotation of 55 degrees, with no collimator rotation. The lateral tangent arrangement was determined by matching the angle of the posterior field edge to match divergence. This resulted in a gantry angle of 232 degrees and no collimator rotation. To help spare the lung the physician added blocks to both the medial and lateral beams. In order to bring dose deeper into the breast, two beams of the same angles were also created, but instead

of 6 megavoltage (MV) energies, they were 18MV beams. These beams were weighted 3:3:2:2 with the 6MV beams contributing the majority of the dose. Treatment Planning: MYs right breast treatment plan was designed using treatment planning system Eclipse 10.0. The goal of this initial treatment plan was to get 42.56 Gy to the breast while minimizing dose to critical structures such as the heart and right lung. For the 6MV beams, irregular surface compensators were used to modify the dose. A 2 cm margin of dose was added anteriorly to ensure the coverage of the breast each day and avoid marginal miss. After the initial calculation, a global maximum of 114.6% was produced. Using the irregular surface compensation, the dosimetrist was able to minimize this global maximum to 106.6% while maintaining sufficient coverage around the breast (Figure 2). While a wedge technique is also efficient at decreasing a global maximum, irregular surface compensation has shown better results.2 Reviewing the dose volume histogram (DVH), 92% of the PTV received 100% of the dose, and 98% of the cavity also received 100% of the dose (Figure 3). The physician also put constraints on the heart and right lung, at 10% of the volume to receive less than 25 Gy, and 30% of the volume to receive less than 20 Gy respectively. These constraints were met as 10% of the heart received 1.0 Gy, and 30% of the lung received 3.6 Gy. Quality Assurance (QA)/Physics Check: Before printing, the monitor units that were calculated by Eclipse 10.0 were double checked using RadCalc. Once the numbers were found to be within the 2% tolerance, the plan was sent to the medical physicist for quality assurance (QA) of the irregular surface compensation. After approval, it was double checked and approved by both the physicist, as well as the attending physician. Conclusion: One of the more difficult issues when planning a breast case is the differing patient widths. The smaller the patient, the more lung included in the field. In this case the patient was neither large nor skinny creating an easier contour to plan on. While it was a standard plan and not the first one to be completed, there was an unseen challenge with this patient. After planning numerous breast patients before, the dosimetrist starts to know what it is that the physician is looking for. This case on the other hand was the first breast patient planned with the recently graduated physician. As opposed to the typical way of treating with a collimator rotation and no block, he preferred to block the lung and eliminate the collimator rotation. Fortunately this was a small change and did not cause any major difficulties. The longer he is at Delnor Hospital the more the dosimetrist will get to know his style and the more efficient the planning will become.

Figures

Figure 1: Radio-opaque marks labeling the field borders and lumpectomy scar.

Figure 2: Dose distribution with 106.6% dose maximum.

Figure 3: DVH summary

References 1. Genetics of breast and ovarian cancer. National Cancer Institute. 2013. Available at: http://www.cancer.gov/cancertopics/pdq/genetics/breast-and-ovarian/HealthProfessional/page1. Accessed September 25, 2013. 2. Emmens DJ, James HV. Irregular surface compensation for radiotherapy of the breast: correlating depth of the compensation surface with breast size and resultant dose distribution. The British Journal of Radiology. 2010;83:159-165. Available at: http://bjr.birjournals.org/content/83/986/159.full.pdf. Accessed September 25, 2013.