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A Dosimetric Comparison of 3DCRT, TomoDirect and Helical Tomotherapy for Large


Separation of Left Sided Intact Breast Cancer: A Case Study
Authors: Stephanie Olson, B.S., R.T.(T), Tera Christianson, B.S., R.T.(T), Amy Heath, M.S.,
R.T.(T), Zacariah Labby, Ph.D., Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD, Ashley
Hunzeker, B.A., M.S., CMD
Abstract:
Introduction: The purpose of this study is to compare and contrast planning target volume
(PTV) coverage and organs at risk (OR) limits for left-sided, intact breast cancer patients with
large tangential separation using dosimetric comparisons of three-dimensional conformal
radiation therapy (3DCRT), TomoDirect (TD) and Helical Tomotherapy (HT) treatment planning
techniques.
Case description: In the treatment of left-sided, intact breast cancer in patients with large
tangential separation, achieving acceptable target coverage and normal tissue constraints can be
challenging. The large anatomical separation can cause the need for higher beam energies or
intensity-modulated radiation therapy (IMRT) treatment techniques to be used and is
demonstrated in the following 4 patient cases: Patient 1 represents stage IIA invasive ductal
carcinoma of the left breast with a tangential separation of 27.2 cm; Patient 2 represents stage IA
infiltrating lobular carcinoma of the left breast with a tangential separation of 25.9 cm; Patient 3
represents stage IIA infiltrating ductal carcinoma of the left breast with a tangential separation of
24.5 cm; and Patient 4 represents stage IA invasive ductal carcinoma of the left breast with a
tangential separation of 28.8 cm. Three plans were created for each patient using 3DCRT fieldin-field tangents, TD and HT treatment planning techniques.
Conclusion: The 3DCRT, TD, and HT treatment planning techniques are all adequate modalities
for left-sided, intact breast cancer treatments that provide adequate PTV coverage and OR
sparing. A higher integral dose and an increased amount of time for planning and treatment were
seen in HT. TomoDirect results showed equivalent or superior target coverage and OR sparing
when compared to 3DCRT treatment plans. The radiation oncologists treatment delivery
decision should, therefore, remain a patient-by-patient basis.
Key Words: TomoTherapy, TomoDirect, breast cancer treatment, epidemiology

Introduction
Incidence of breast cancer cases has steadily increased over the past 3 decades with an
estimated 1.4 million new diagnoses each year.1 This rise in incidence can be correlated to an
increased use of mammographic screening which began in the 1980s.1,2 Until the use of
mammography, breast tumors were found in the advanced stages through palpable masses and
were often associated with poor prognosis.2 In this day and age, mammographic screening has
led to earlier diagnoses, which combined with surgery, chemotherapy and radiotherapy, has
provided better prognostic outcomes.
Treatment options for women diagnosed with breast cancer have seen dramatic changes
through the years. From the Halstead mastectomy used in the 1880s to breast conserving surgery
combined with external beam radiotherapy (EBRT) in the late 1900s, advances in therapy have
contributed to the declining mortality rate for breast cancer.3 Standard EBRT treatment regimens
consist of adjuvant whole breast radiation therapy of 50 Gy given in 25 fractions with an
additional lumpectomy boost of 10 Gy in 5 fractions.3 More recently, trials evaluating hypo
fractionated treatment regimens of 40 Gy in 15 fractions have been published and found to have
similar results to standard treatment regimens.3,4 Fewer fractions make the course of treatment
more convenient and tolerable for the patient while producing equivalent side effects when
compared to standard fractionation.4
Adverse side effects associated with adjuvant whole breast radiation therapy include
those to the contralateral breast, lung and heart. Dose to the contralateral breast is associated with
increased long-term risk of developing a secondary breast cancer in the opposing breast.5
Radiation induced lung complications are correlated with both the volume of lung irradiated and
the mean ipsilateral lung dose.5 Coronary artery disease can be a late side effect, in particular
with left sided breast cancers, usually occurring 10 or more years after completion of adjuvant
whole breast radiation therapy.4 Through advancements made in radiotherapy treatment
techniques and understanding of the relationship between accurate dose calculations and normal
tissue complication probability, these adverse side effects have been minimized.
Improved imaging and computer technology have made the treatment delivery modalities
such as 3DCRT, IMRT and tomotherapy ideal techniques to treat target volumes precisely and to
higher doses while minimizing dose to nearby critical structures.3 Daily to weekly image

guidance is performed to ensure treatment position is replicated from the treatment planning
session thus confirming the target volume and critical structure alignment.3 Image guidance is
particularly important when using IMRT because escalated treatment doses are often prescribed
and margins added to PTV are minimized. In addition, IMRT has the ability to place high dose
gradients next to the treated volume, necessitating accurate alignment.
In some cases, such as patients with large, pendulous breast anatomy, 3DCRT dose
objectives may be difficult to achieve.5 Static and rotational IMRT can be used in difficult cases
to help improve the dosimetric distribution and homogeneity within a treatment plan.5 Typically,
IMRT techniques are able to increase PTV coverage while reducing the dose to normal critical
structures.5 In women with large breasts, IMRT has shown many benefits including a decreased
risk of moist desquamation, less severe skin reactions and reduced acute toxicities of
telangiectasia and fibrosis.6
Large tangential separation of the breast is the factor most correlated with increased areas
of dose and dose inhomogeneity and can lead to poor cosmetic outcomes.6,7 Tangential separation
is the distance between the midline of the anterior chest and the point 2 cm below the breast
tissue measured along the central axis of the beam (Figure 1).7 Depending on the patients size
and shape, areas exceeding prescription dose could be as high as 20% of the prescription dose
and typically appear in the most superior and inferior portions of the breast tissue.6 Das et al7
concluded that tangential separations of 22 cm or greater resulted in the need for higher beam
energies to improve dose homogeneity. However, with higher beam energy, breast PTV coverage
is reduced because of the increased distance required for dose buildup. To overcome the reduced
breast PTV surface coverage, bolus or Lucite beam spoilers are used as well as more advanced
treatment techniques such as IMRT and field-in-field treatment planning.7 Determination of
which treatment technique is best suited for an individual should be made on a case-by-case
basis. This decision is dependent on the treatment techniques available, the physicians
experience with the technique, specific patient characteristics and risk factors associated with the
chosen treatment technique.5
To investigate which treatment planning technique is able to achieve the most favorable
PTV coverage and OR objectives, 4 patients were selected for this study all of which were
previously treated with adjuvant whole breast radiation therapy to the left breast. All patients had
a tangential separation greater than 22 cm. For each of these 4 patients, a 3DCRT, TD and HT

plan were created. Dosimetric comparisons included PTV coverage and OR sparing. The
analyses of OR objectives included the heart, ipsilateral lung, contralateral lung and contralateral
breast. The purpose of this study is to compare and contrast PTV coverage and OR limits for leftsided, intact breast cancer patients with large tangential separation using dosimetric comparison
of 3DCRT, TD and HT treatment planning techniques.
Case Description
Patient Selection
Four patients were selected for this study based on numerous factors. Each patient was
diagnosed with left-sided breast cancer and had previously undergone breast conserving surgery.
Inclusion criteria used for this study was comprised of a tangential separation of 22 cm or
greater, absence of lymph node involvement and an intact breast post-surgery. Patients selected
were treated with curative intent.
Patients were simulated using a General Electric (GE) CT scanner. Patients were placed
in the supine position using a CIVCO wing board with a standard clear head support and both
arms up holding handles of the wing board. Head position was rotated away from the affected
side of treatment. A sponge was placed under their knees for support. Planning CT images were
acquired using 2.5 mm slices. The scanning parameters included the level of the chin and
extended through the entire thoracic cavity. The patients were marked using one set of 3-point
reference markings on their chest. Radiopaque wires were placed on the patients scars at both
the lumpectomy and nodal biopsy sites for CT visualization. After completion of the CT scan,
permanent tattoos were placed on each patients skin in the chest region at the points of fiducial
placement.
Target Delineation
Computed tomography data sets were transferred into the Philips Pinnacle3 treatment
planning system (TPS) for contouring. The radiation oncologist contoured the tumor bed volume
which was expanded by 1.5 cm to create a lumpectomy PTV. The location and size of the
involved disease was verified from the mammography reports or by the location of the clips
placed during the breast conserving surgery. The left breast tissue and lumpectomy volume were
contoured by the radiation oncologist. The left breast contour was retracted 5 mm off of the skin
surface to create the PTVeval which was used for the dose volume histogram (DVH) constraints

and analysis (Figure 2). Posteriorly, the breast PTVeval was limited to no deeper than the anterior
surface of the ribs to exclude the bony thorax and lung.
The medical dosimetrist contoured the OR which included the heart, spinal cord,
ipsilateral lung, contralateral lung, and contralateral breast. The contralateral breast and heart
structures were contoured as defined in the Radiation Therapy Oncology Group (RTOG) 1005
protocol. The ipsilateral lung, contralateral lung, and spinal cord were contoured using the autosegmentation tools in the Pinnacle3 TPS.
In addition to the OR listed, other planning structures were created to assist in the
treatment planning process. Planning structures included a spinal cord planning at risk volume
(PRV), which consisted of a 5 mm expansion of the spinal cord contour; an external contour,
which was used as a normal structure to keep areas of exceeding prescription dose out of
unspecified tissue; a contralateral breast expansion of 5 to 7 mm to help minimize the
contralateral breast maximum dose beyond what would typically be achieved using a complete
block; and a posterior block which was placed behind the lungs to limit dose through the lungs
and mediastinum (Figure 3). The radiation oncologist completed a treatment planning order
identifying the prescription, dose constraints and other pertinent treatment planning information.
The dose prescription and planning objectives identified by the radiation oncologist are listed in
Table 1.
Treatment Planning
To compare and contrast PTV coverage and OR limits for the patients included in this
study, three plans were generated for each of the four cases selected. Adjuvant whole breast
radiation therapy plans were created using 3DCRT field-in-field tangents, TD and HT treatment
planning techniques. All plans were created from the same CT dataset and contained the same
contouring structures.
Conventional 3DCRT treatment plans were created using the Philips Pinnacle3 TPS. Two
opposed tangential beams were utilized to treat the left breast PTVeval using beams of 6 or 10
MV photons or a combination of the 2. Optimal beam energy was chosen based on dose
homogeneity, areas exceeding prescription dose, and lumpectomy location. Field borders were
set to include the entire left breast PTVeval with a margin extending 1.0 cm in the superior and
inferior directions. Posteriorly, a margin was given to the left breast PTVeval while minimizing
the lung volume to less than 2 cm. Anteriorly, adequate flash was given to the left breast to

account for respiratory motion during treatment. Multi-leaf collimators (MLC) were used to add
blocking along the chest wall to further shield the lung and heart (Figure 4). Beams were
weighted accordingly and a field-in-field treatment plan was created to allow for a more uniform
dose distribution while reducing the hot spots in the most superior and inferior regions of the
breast tissue. To generate the field-in-field treatment plan, beams were calculated using open
field tangents (Figure 4). Beam energies and weightings were manipulated until an optimal dose
distribution was established. Dose clouds were then visualized on the BEV for each beam and a
sub-field was created (Figure 5). Sub-fields were weighted 3% to 8% per field to achieve a
desirable dose distribution. A maximum of 5 sub-fields were used per tangential beam.
For the TD treatment planning, the patients data set and contoured structures were
transferred from the Pinnacle3 treatment planning system to the TomoTherapy Hi-Art version 5.0
planning system. Four tangential beams with jaw field widths of 2.5 cm were used. When TD
beams were used, the pitch value was automatically set to 1/10 of the field width. The pitch value
determined the amount of couch travel in cm per gantry rotation. Medial tangential beam angles
were 315 and 325 and lateral tangential beam angles were 135 and 145 for Patient 1 (Figures
6-7). The coordinate system used by TomoTherapy is in accordance with International Electrotechnical Commission (IEC) 61217. Beam angles were selected on an individual patient basis
depending on patient anatomy. Optimal angles were chosen to avoid dose to OR and lessen dose
to the contralateral breast. Beam angles chosen for each patient are included in Table 2. To help
ensure proper target coverage from intra-fractional motion, 3 leaves of the MLC were opened on
the anterior aspects of the tangential beams. Each leaf is 0.625 cm thus adding 1.875 cm of flash.
By opening the MLC leaves anteriorly, the risk of missing the target due to breathing motion is
reduced. TomoTherapy is a mono-energetic treatment modality; therefore the plan was computed
using 6 MV treatment beams. TomoDirect uses static gantry angles, similar to those of
conventional 3DCRT, along with couch translations and MLC modulation to deliver lower doses
to the OR.5,8
Treatment planning for HT is done similarly to TD planning. Dose objectives were set
according to desired constraints instructed by the radiation oncologist. For HT treatment
planning, there were no set gantry angles as the treatment delivery for HT consisted of a
continuous rotating fan beam along with couch translation and MLC modulation.8 Prior to beam
computation, parameters including pitch, modulation factor, and field width were determined. An

initial pitch value of 0.300, modulation factor of 2.4 and field width of 5 cm were set for all
patient plans. Table 2 lists the final pitch, modulation factor and field width used for each patient.
For all patients, dose limitations to the ipsilateral lung and heart were of high importance
when optimizing individual plans. Left breast PTVeval coverage of 95% of the volume receiving
95% of the dose was the desired goal for all patients. Minimizing dose to the contralateral lung
and breast were additional constraints used when optimizing treatment plans, therefore, a
complete block was placed on the contralateral breast, contralateral lung and posterior block
structures for the HT planning. A complete block is used in TomoTherapy treatment planning to
instruct the machine to not allow for any beam entrance or exit through those structures.
Simultaneous optimization of the left breast PTVeval, ipsilateral lung, contralateral lung, heart
and contralateral breast structures were essential to ensure all dose limiting constraints were met.
Plan Analysis & Evaluation
Dosimetric comparisons of prescription doses and desired planning objectives for the 3
different planning techniques are shown in Table 3. The treatment plans were evaluated using
MIM software version 6.4.7. Figures 8 through 11 portray the DVHs for the 3DCRT, TD, and HT
treatment plans for Patients 1 through 4, respectively. Figures 12 through 14 demonstrate the
isodose distributions for Patient 1 for each different treatment modality.
As seen in the isodose distributions and DVHs in Figure 8 and Figure 12, along with the
analysis in Table 4, adequate left breast PTVeval coverage was accomplished in all treatment
plans for Patient 1. The TD plan demonstrated the best target coverage at 99.8% while also
producing the lowest hot spot of 105.4% of the prescription dose. Planning objectives for the
heart were met in all treatment plans with the HT plan showing the lowest values for all
objectives. The mean heart doses were 2.1 Gy for the 3DCRT and 1.7 Gy for both the TD and
HT treatment plans. Ipsilateral lung objectives were also met for all constraints for Patient 1.
The V16 objective was lowest in the HT plan while the TD treatment plan represented the lowest
for the V8 and V4 constraints. Contralateral lung objectives were obtained with the V4 at 0% in all
plans. Contralateral breast doses were less than the desired 2.4 Gy constraint measuring at 0.8 Gy
for 3DCRT, 0.67 Gy for TD, and 1.2 Gy for HT.
As was seen for Patient 1, the contralateral breast dose for Patient 2 measured highest for
the HT plan and lowest for TD. Similarity between Patient 1 and Patient 2 was also observed in
the contralateral lung, ipsilateral lung and heart constraints. The HT treatment plan resulted in

the lowest doses for all constraints. Mean heart doses measured the same for both TomoTherapy
treatment planning techniques. The ipsilateral lung V16 objective was lowest in the HT plan while
the V8 and V4 constraints were lowest in TD treatment plan. The plan with the greatest PTV
coverage was demonstrated in the HT plan at 98% while the TD plan had the lowest maximum
dose of 105.8%.
All plans for Patient 3 were shown to have adequate left breast PTVeval coverage (Table
3) as seen in the DVHs in Figure 10. The contralateral breast maximum dose was met in all
treatment plans with values of 2.8 Gy, 1.3 Gy, and 2.9 Gy for the 3DCRT, TD, and HT plans,
respectively. As with Patient 1, the contralateral lung V5 was 0% in all plans. Ipsilateral lung
constraints for all plans were met, with the TD plan showing moderately lower doses compared
to 3DCRT and HT. The heart V20 was lowest in the HT while the 3DCRT plan had the lowest
heart V10 and mean doses of 2.4% and 2.1 Gy correspondingly.
The heart V25 was lowest in the HT plan followed by TD and 3DCRT in the DVH
analysis for Patient 4 (Table 3). The mean heart dose was lowest in the TD plan. Dose volume
histograms in Figure 11 show acceptable PTV coverage for the left breast target objectives. The
maximum dose was below the desired 115% of the prescription dose for all treatment plans with
the highest hot spot being 113% in the HT plan. The ipsilateral lung V20 was 12.7%, 9%, and
6.7% for the 3DCRT, TD, and HT treatment plans, respectively. As with all patients, the
contralateral lung V5 constraint was 0% in all plans.
The plan comparison results indicate similarities among all 3 treatment planning
techniques. Target coverage was greater than the desired 95% in all patients and all treatment
modalities. The maximum PTV dose objective was met for all patients and was found to be
highest in the 3DCRT for Patient 1 while for Patients 2, 3, and 4 were greatest in the HT plans.
According to Fields et al,9 the monoenergetic 6 MV beam used by TomoTherapy may be the
contributing factor as to why these hot spots occur especially in patients with larger breasts given
the higher attenuation of the lower energy beam. The heart, ipsilateral lung, contralateral lung
and contralateral breast values were all within desired constraints.
Conclusion
Results from this case study demonstrate adequate target coverage and OR sparing for all
treatment planning techniques. Das et al,7 concluded that patients with a tangential separation
greater than 22 cm can result in treatment plans with increased high dose regions, poorer dose

homogeneity, and reduced coverage resulting in the need for higher energy beams. These
conclusions were observed in the patients presented in this case study. Coverage of the left breast
PTV was the worst for 3DCRT plans when compared to TD and HT plans due to the need for 10
MV beams to be used in the field-in-field 3DCRT treatment plans.
Along with better PTV coverage, TD and HT treatment plans demonstrated greater
reduction in heart dose in the high dose regions when compared to 3DCRT. Minimizing heart
dose is beneficial in reducing the risk of developing CAD after irradiation.4 Nevertheless, heart
dose constraints were met for all treatment plans and not likely to be of clinical significance in
this study. TomoDirect and HT also demonstrated better sparing of the ipsilateral lung dose in the
V16 doses for Patients 1 and 2 and V20 for Patients 4. However due to the rotational delivery of
HT, higher integral doses were observed in these plans.
Rotational delivery using HT also demonstrated an increase in the maximum dose to the
contralateral breast. The maximum dose to the contralateral breast should be kept to a minimum
to reduce the risk of secondary malignancy in the contralateral breast. Depending on the patients
age and other health conditions, the radiation oncologist will need to decide if administering a
higher dose to the contralateral breast with rotational delivery is worth the risk to spare the dose
delivered to the ipsilateral lung and heart.
This case study demonstrated that 3DCRT, TD, and HT treatment planning techniques are
all adequate in the PTV coverage and OR sparing thus making them all possible choices for the
treatment of left-sided, intact breast cancer. Disadvantages to using HT include higher integral
doses and increased time required for both treatment planning and delivery. TomoDirect results
showed equivalent or superior target coverage and OR sparing when compared to 3DCRT
treatment plans. All treatment planning techniques demonstrated to be acceptable; therefore, the
radiation oncologists treatment delivery decision should remain a patient-by-patient basis.

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References
1. Eisemann N, Waldmann A, Katalinic A. Epidemiology of breast cancer-current figures and
trends. Geburtsh Frauenheilk. 2013;73(2):130-135. http://dx.doi.org/10.1055/s-00321328075
2.

Buyske J, Mackarem G, Ulmer B, et al. Breast cancer in the nineties. AORN J.


1996;64(1):64-72. http://dx.doi.org/10.1016/s0001-2092(06)63371-1

3.

Zurrida S, Veronesi U. Milestones in breast cancer treatment. Breast J. 2014;21(1):3-12.


http://dx.doi.org/10.1111/tbj.12361

4. Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation
therapy for breast cancer. N Engl J Med. 2010;362(6):513-520.
http://dx.doi.org/10.1056/NEJMoa0906260
5. Qi XS, Liu TX, Liu AK, et al. Left-sided breast cancer irradiation using rotational and fixedfield radiotherapy. Med Dosim. 2014;39:227-234.
http://dx.doi.org/10.1016/j.meddos.2014.02.005
6. McCormick B, Hunt M. Intensity-modulated radiation therapy for breast: Is it for everyone?
Semin Radiat Oncol. 2011;21(1):51-54. http://dx.doi.org/10.1016/j.semradonc.2010.08.009
7. Das IJ, Shikama N, Cheng CW, Solin LJ. Choice of beam energy and dosimetric
implications for radiation treatment in a subpopulation of women with large breasts in the
United States and Japan. Med Dosim. 2006;31(3):216-223.
http://dx.doi.org/10.1016/j.meddos.2006.02.002
8. Franco P, Catuzzo P, Cante D, et al. TomoDirect: an efficient means to deliver radiation at
static angles with tomotherapy. Tumori. 2011;97:498-502.
http://dx.doi.org/10.1700/950.10404
9. Fields E, Rabinovitch R, Ryan N, Miften M, Westerly D. A detailed evaluations of
TomoDirect planning for whole-breast radiation. Med Dosim. 2013;38(4):401-406.
http://dx.doi.org/10.1016/j.meddos.2013.04.008

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Figures

Figure 1. The red line denotes the tangential separation for Patient 1.

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Figure 2. The breast planning contours used for treatment planning demonstrated in this figure
include the breast PTVeval (red), lumpectomy PTVeval (orange), and lumpectomy volume
(yellow).

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Figure 3. Posterior block structure (teal) placed posteriorly to the lungs to limit dose through the
lungs and mediastinum for TD and HT treatment planning. Other structures include the
contralateral breast (orange), contralateral lung (green), heart (purple), ipsilateral lung (blue),
spinal cord (forest green), cord PRV (lavender), left breast PTVeval (pink) and lumpectomy PTV
(red).

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Figure 4. Beams eye view (BEV) of the 3DCRT medial tangent field for Patient 1. The left
breast PTVeval is shown in pink, ipsilateral lung in blue, and heart in purple.

15

Figure 5. The medial tangential sub-field of the first control point in a field-in-field treatment
plan. The medial sub-field dose cloud is the 122% dose cloud.

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Figure 6. Medial tangent beam angles for the TD treatment plan for Patient 1.

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Figure 7. Lateral tangent beam angles for the TD treatment plan for Patient 1.

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Figure 8. A composite DVH of the 3DCRT, TD, and HT treatment plans for Patient 1. The
3DCRT plan is displayed as the thick dotted line, TD plan as the thin solid, and the HT as the
thick solid line. Dose volume histogram lines include: left breast PTVeval (pink), contralateral
breast (orange), contralateral lung (green), heart (purple), and ipsilateral lung (blue).

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Figure 9. A composite DVH of the 3DCRT, TD, and HT treatment plans for Patient 2. The
3DCRT plan is displayed as the thick dotted line, TD plan as the thin solid, and the HT as the
thick solid line. Dose volume histogram lines include: left breast PTVeval (pink), contralateral
breast (orange), contralateral lung (green), heart (purple), and ipsilateral lung (blue).

20

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Figure 10. A composite DVH of the 3DCRT, TD, and HT treatment plans for Patient 3. The
3DCRT plan is displayed as the thick dotted line, TD plan as the thin solid, and the HT as the
thick solid line. Dose volume histogram lines include: left breast PTVeval (pink), contralateral
breast (orange), contralateral lung (green), heart (purple), and ipsilateral lung (blue).

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Figure 11. A composite DVH of the 3DCRT, TD, and HT treatment plans for Patient 4. The
3DCRT plan is displayed as the thick dotted line, TD plan as the thin solid, and the HT as the
thick solid line. Dose volume histogram lines include: left breast PTVeval (pink), contralateral
breast (orange), contralateral lung (green), heart (purple), and ipsilateral lung (blue).

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Figure 12. Dose distributions for the 3DCRT treatment in the axial views for Patient 1. The
isodose lines (IDL) shown include: 105% (orange), 100% (green), 95% (yellow), 90% (blue),
80% (light blue), 50% (purple) and 20% (white).

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Figure 13. Dose distributions for the TD treatment in the axial views for Patient 1. The IDL
shown include: 105% (orange), 100% (green), 95% (yellow), 90% (blue), 80% (light blue), 50%
(purple) and 20% (white).

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Figure 14. Dose distributions for the HT treatment in the axial views for Patient 1. The IDL
shown include: 105% (orange), 100% (green), 95% (yellow), 90% (blue), 80% (light blue), 50%
(purple) and 20% (white).

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Tables
Table 1. Prescription doses and planning objectives for Patients 1 through 4.

Left breast
Breast PTVeval
Heart
Ipsilateral Lung
Contralateral Lung
Contralateral Breast

Prescription Dose:
Patient 1
Patient 2
42.56 Gy/16 fx 40.05 Gy/15 fx

Patient 3
50 Gy/25 fx

Desired Planning Objectives:


D95% 95%
D95% 95%
D95% 95%
Max dose
Max dose
Max dose
110%
110%
110%
V16 5%
V16 5%
V20 5%
V8 10%
V8 10%
V10 30%
Mean 3.2 Gy Mean 3.2 Gy Mean 4 Gy
V16 15%
V16 15%
V20 15%
V8 35%
V8 35%
V10 35%
V4 50%
V4 50%
V5 50%
V4 10%
V4 10%
V5 50%
Max Dose
Max Dose
Max Dose 8
2.4 Gy
2.4 Gy
Gy

Patient 4
50 Gy/25 fx
D95% 95%
Max dose
115%
V25 5%
Mean 4 Gy
V20 30%
V5 10%

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Table 2. TomoDirect medial and lateral tangential beam angles (in degrees) chosen to best
minimize dose to OR and avoid dose to the contralateral breast are shown in the upper portion of
the table. The final pitch, modulation, and field widths (in cm) used for the HT plans are shown
in the lower portion of the table.
Gantry angles (degrees) chosen for the TD plans
Patient 1
Patient 2
Patient 3
Patient 4
Medial tangent 1
315
315
315
315
Medial tangent 2
325
325
325
325
Lateral tangent 1
135
130
130
135
Lateral tangent 2
145
140
140
145
Pitch, modulation factor and field width (cm) for the HT plans
Patient 1
Patient 2
Patient 3
Patient 4
Pitch
0.287
0.287
0.430
0.215
Modulation factor
2.4
2.4
2.0
2.8
Field width (cm)
5.0
5.0
2.5
2.5

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Table 3. Planning objective analysis of treatment plans for Patients 1 through 4.

Breast PTVeval
Heart
Ipsilateral Lung
Contralateral Lung
Contralateral Breast

Breast PTVeval
Heart
Ipsilateral Lung
Contralateral Lung
Contralateral Breast

Breast PTVeval
Heart
Ipsilateral Lung
Contralateral Lung
Contralateral Breast

3DCRT
Patient 1
Patient 2
D95% = 96.8% D95% = 96.7%
Max dose =
Max dose =
108.8%
106.4%
V16 = 2.8%
V16 = 5.0%
V8 = 5.0%
V8 = 7.6%
Mean = 2.1 Gy Mean = 3.0 Gy
V16 = 10.7%
V16 = 13.8%
V8 = 15.5%
V8 = 17.1%
V4 = 22.3%
V4 = 22.3%
V4 = 0.0%
V4 = 0%
Max Dose =
Max Dose =
0.8 Gy
0.9 Gy
TD
D95% = 99.8% D95% = 95.5%
Max dose =
Max dose =
105.4%
105.8%
V16 = 1.8%
V16 = 1.8%
V8 = 3.6%
V8 = 3.3%
Mean = 1.7 Gy Mean = 1.5 Gy
V16 = 6.6%
V16 = 8.1%
V8 = 9.6%
V8 = 10.6%
V4 = 14.4%
V4 = 14.6%
V4 = 0.0%
V4 = 0%
Max Dose =0.6 Max Dose =0.5
Gy
Gy
HT
D95% = 99.2% D95% = 98%
Max dose =
Max dose =
107.1%
108%
V16 = 1.1%
V16 = 0.5%
V8 = 2.5%
V8 = 2.3%
Mean = 1.7 Gy Mean = 1.5 Gy
V16 = 6.1%
V16 = 6.5%
V8 = 10.6%
V8 = 11.4%
V4 = 18.2%
V4 = 19.4%
V4 = 0.0%
V4 = 0%
Max Dose =
Max Dose =
1.2 Gy
1.8 Gy

Patient 3
D95% = 97%
Max dose =
108%
V20 = 1.0%
V10 = 2.4%
Mean = 2.1 Gy
V20 = 10.6%
V10 = 16.2%
V5 = 24.2%
V5 = 0.0%
Max Dose =
2.8 Gy

Patient 4
D95% = 97.5%
Max dose =
106.7%
V25 = 3.0%
Mean = 3.0 Gy

D95% = 100%
Max dose =
105%
V20 = 1.5%
V10 = 4.2%
Mean = 2.2 Gy
V20 = 6.0%
V10 = 11%
V5 = 16.1%
V5 = 0.0%
Max Dose =
1.3 Gy

D95% = 99.7%
Max dose =
112%
V25 = 2.2%
Mean = 2.5 Gy

D95% = 99%
Max dose =
109%
V20 = 0.89%
V10 = 4.1%
Mean = 2.7 Gy
V20 = 10.9%
V10 = 23.3%
V5 = 42.1%
V5 = 0.0%
Max Dose =
2.9 Gy

D95% = 98.3%
Max dose =
113%
V25 = 0.9%
Mean = 3.1 Gy

V20 = 12.7%
V5 = 0.0%

V20 = 9.0%
V5 = 0.0%

V20 = 6.7%
V5 = 0.0%

30

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