1

Comparison of VMAT vs. a 4-Field Technique for Post Mastectomy Irradiation of Barrel
Shaped Right Chest Wall Patients: A Case Study
Authors: Tayisiya Polishchuk, R.T.(T), Karen Krueger, R.T.(T), Michelle Rocque, R.T.(R)(T),
Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD, Ruth Ann M. Good, RT (R)(T), CMD, Alex
Whittington, CMD, Ashley Hunzeker, M.S., CMD
Medical Dosimetry Program at the University of Wisconsin La Crosse, WI
Abstract:
Introduction: This study aims to evaluate the dose variations of planning target volumes
(PTVs) and organs at risk (OR) between two treatment techniques for barrel shaped right chest
wall post mastectomy patients to determine which technique provides a more optimal plan.
Case Description: In the treatment of post mastectomy chest walls, some patients present with
chests that are thick anterior to posterior and somewhat resemble the shape of a barrel. Barrel
shaped right chest wall patients require involvement of additional volumes of the ipsilateral lung
in order to achieve adequate coverage of the chest wall and lymph node area. Increasing the
target volume increases the volume of the ipsilateral lung in the treatment fields, and therefore
increases the potential of higher toxicity to the ipsilateral lung volume and other OR.1 For the
purpose of this study; patients were selected based on 3.5 cm or greater ipsilateral lung depth
involvement, when evaluating tangential fields covering total nodal chest wall volumes. Two
techniques were performed to evaluate the ipsilateral lung dose. A 4-field plan utilizing extended
tangents with the supraclavicular (SCL) field and a posterior axillary boost (PAB) was used as
one of the chest wall treatment techniques. A volumetric modulated arc therapy (VMAT) plan
consisting of two coplanar arcs was utilized as the second treatment technique. A total of 6
patients were selected to evaluate doses to the ipsilateral lung and other OR for both treatment
techniques.
Conclusion: Obtaining data on PTVs and OR doses for three-dimensional conformal radiation
therapy (3DCRT) and VMAT planning techniques on 6 patients showed no significant preference
of one technique versus the other. Plan deliverability is ultimately at the discretion of the
prescribing physician and should be made on an individual basis with considerations of side
effects, the patients state of health, and age.
Key Words: Barrel shaped chest wall irradiation, 3DCRT, VMAT, radiation pneumonitis

2
Introduction
Radiation pneumonitis is the radiation-induced inflammation of the lungs caused when
delivering radiotherapy to intrathoracic malignancies.2 Despite the fact that radiation
pneumonitis is primarily caused while delivering lung cancer treatments, up to 5% of breast
cancer patients will experience radiation induced symptoms when receiving breast cancer
radiotherapy treatments.3 Symptoms may be acute or chronic and can require steroids to
resolve.4 Certain factors relating to radiation therapy treatments can increase the risks of postmastectomy patients developing radiation pneumonitis. These include the amount of lung
volume included in the tangential fields, the addition of a supraclavicular field, prior exposure of
certain chemotherapy drugs, and a history of smoking.
The National Comprehensive Cancer Network (NCCN) provides guidelines highlighting
the importance of including total nodal regions in the treatment fields when planning for chest
wall irradiation.5 Due to the higher possibility of nodal recurrence, it is strongly recommended to
consider treating the internal mammary nodes (IMN) when delivering chest wall radiation
therapy, especially if any of the following criteria was found during the mastectomy surgery:
positive margins, negative axillary nodes and tumor >5 cm, or the presence of positive axillary
nodes. An extended tangent technique is required when performing total nodal irradiation in
order to encompass all of the lymph nodes involved, in addition to including the chest wall
treatment volume. Increasing the field size in order to include all of the disease volumes can
increase the lung volume in the extended tangent fields. Increasing the lung volume in the
treatment fields of total nodal post-mastectomy barrel shaped chest walls could potentially
increase the risks of radiation pneumonitis.
Two treatment techniques were utilized when planning each of the 6 patients with the
total nodal barrel shaped right chest wall volume. A 4-field 3DCRT treatment plan with partially
wide tangential fields and parallel opposed SCL portals treatment plan was used as one of the
treatment techniques. Volumetric modulated arc therapy was the second treatment planning
method. Doses to the chest wall, SCL, axillary, and IMN, as well as heart, contralateral lung, and
contralateral breast were closely evaluated. In addition, dose to the ipsilateral lung was analyzed
for each patient in both 3DCRT and VMAT plans. A treatment prescription of 50 Gy in 25
fractions was applied to all of the treatment plans in the study. The plans were evaluated and
compared for acceptability against criteria in the National Surgical Adjuvant Breast and Bowel

3
Project (NSABP) B-51 protocol (also known as the Radiation Therapy Oncology Group RTOG1304 protocol).6
Case Description
Patient Selection & Setup
Patients with similar diagnoses and ipsilateral lung involvement were selected for
planning and evaluation of total nodal chest wall treatment in accordance with the NSABP B-51
protocol. The patients for the study were selected based on lung involvement consisting of
greater than 3.5 cm in the tangential fields. Five of the patients were diagnosed with invasive
ductal carcinoma and one patient was diagnosed with infiltrating ductal carcinoma. Each patient
underwent right-sided mastectomy and sentinel lymph node evaluation. A curative dose of 50 Gy
in 25 fractions was prescribed by the physician to the chest wall and the lymph nodes and
definitive radiation treatment following NSABP B-51 protocol was suggested.
Each patient was placed in the supine position with the head first into the CT scanner.
Four of the patients were simulated on the Phillips CT scanner and two patients were simulated
on the General Electric CT scanner. Patients 1, 2, 5 and 6 were simulated utilizing a breast board
with the right arm up, the left arm by patients left side, and the head slightly turned to the left.
Patient 3 and Patient 4 were simulated utilizing an inclined wingboard/breastboard with both
arms raised above the head and the head slightly turned to the left. In order to facilitate
contouring segmentation of the CT data-set, radio-opaque markers were placed on the patients
skin in the treatment position as external landmarks at the acquisition of the CT scan.5 These
markers identified the mastectomy scar, as well as the outline of the physicians clinical
assessment of the at risk chest wall which included postoperative changes and where the
ipsilateral breast was previously located.
Target Delineation
The Philips Pinnacle 9.6 treatment planning system (TPS) or the Varian Eclipse Version
11.0 TPS were utilized to outline targets in each of the selected patients. The chest wall Clinical
Target Volume (CTV) was delineated by the physician utilizing radio-opaque markers placed at
CT simulation identifying the clinical extent of the chest wall, surgical changes visualized by CT,
and consensus definitions of anatomical borders of the chest wall from the RTOG Breast Cancer
Atlas.7 The chest wall CTV was limited by the skin anteriorly and did not extend deeper than the
ribs to exclude the lung and heart. In addition, the chest wall CTV did not cross midline. The
CTV was expanded 7 mm (excluding the heart and not crossing midline) to form the chest wall
PTV. The chest wall PTV evaluation (PTV Eval) structure was created based on the chest wall

4
PTV with some limitations. The chest wall PTV Eval was limited anteriorly to exclude the
contour extending outside of the patient and the first 3 mm of tissue under the skin in order to
remove some of the buildup region for the dose volume histogram (DVH) analysis. In addition,
the chest wall PTV Eval was limited posteriorly to no deeper than the posterior rib surface and to
exclude the lung and the heart. The chest wall PTV Eval was the structure utilized for DVH
constraints and analysis and not for beam aperture generation. In addition, the SCL CTV was
outlined by the physician following the RTOG breast cancer atlas. The CTV was expanded 5 mm
in all directions to create the SCL PTV. The axillary CTV was created to include all three levels
of the axillary nodes. The CTV was then expanded 5 mm to create the axillary PTV. The IMN
CTV included the internal mammary/thoracic vessels in the first three intercostal spaces, and
then expanded 5mm medially, laterally, superiorly, and inferiorly to create the IMN PTV.
Contoured structures at risk included the ipsilateral lung, contralateral lung, heart, spinal cord,
and contralateral breast.
Treatment Planning
Philips Pinnacle 9.6 TPS was utilized when planning 2 of the patients and Varian Eclipse
Version 11.0 TPS was utilized when planning 4 of the patients. Each patient chest wall case was
planned utilizing VMAT and a 3DCRT 4-field technique using plan comparison to evaluate the
ipsilateral lung dose in both plans. In both planning techniques for patients 1, 3, 4 and 5, the
calculations were performed with a 3.0 cubic-millimeter dose grid resolution. For treatment
planning techniques on Patient 2 and Patient 6, the calculations were performed with a 2.5 cubicmillimeter dose grid resolution. A 4-field plan utilizing extended tangents with the SCL field and
a PAB was used as one of the chest wall treatment techniques. A 3 mm thick bolus was applied
every other day to the chest wall area. A VMAT plan consisting of 2 coplanar arcs with opposite
rotation (clockwise and counter-clockwise) was utilized as the second treatment technique.
According to the NSABP B-51 protocol, no bolus was necessary for the VMAT plan. The path
length of arcs and arc angles utilized for VMAT planning for each patient are displayed in Table
1. Both VMAT and the 4-field plans followed the prescription of 2 Gy for 25 fractions to a total
dose of 50 Gy without a boost to the post-mastectomy chest wall. In addition, both plans
encompassed the chest wall PTV, as well as the SCL, axillary and IMN targets. Although these
plans were designed for dosimetric comparison only, field arrangements for 3DCRT and VMAT
were at the discretion of the treating physician in order to produce optimal plans to meet the
DVH provided by the NSABP B-51 protocol. The goals of treatment planning were to

5
encompass the chest wall PTV and regional node targets, as well as minimize inclusion of the
heart and lung. Dose constraints and maximum point doses to chest wall PTV, SCL PTV,
Axillary PTV, IMN PTV were provided by the NSABP protocol.6 In addition, there were dose
constraints assigned for the heart, the ipsilateral lung, the contralateral lung, and the contralateral
breast. The NSABP B-51 provided per protocol and acceptable variations for all of the structures
in both the written and tabular formats.
Plan Comparison, Analysis and Evaluation
Sixteen dose constraints were utilized to evaluate 3DCRT and VMAT treatment plans for
6 patients. The NSABP B-51 protocol provided an acceptable, per protocol and not acceptable
variation for all of the structures being evaluated.6 The acceptable variation for the chest wall
PTV and the SCL PTV were to deliver 90% of the prescription dose to cover 90% of the PTV
volume per NSABP protocol. Both 3DCRT and VMAT were able to meet the criteria for all of
the 6 patients.
In order to compare the deliverability of the 3DCRT treatment plans versus the VMAT
plans, a scoring system developed by the NSABP protocol was used. The scoring system
assigned number 1 through 3 to the compliance criteria in order to evaluate a total of 16 dose
constraints for each plan and each patient. The score of 1 was assigned to the plan meeting
protocol criteria, the score of 2 was assigned to the plan meeting the acceptable per protocol
variation and the score of 3 was assigned to the unacceptable deviation. In the event the plan
could not meet the dose constraints and scored 3 for any unacceptable deviations, the plan would
not be acceptable for treatment delivery per NSABP protocol. Summary of the acceptable and
unacceptable treatment plans per NSABP protocol guidelines is displayed in Table 2. Evaluating
12 plans for 6 patients, two VMAT plans and three 3DCRT plans were acceptable per NSABP
protocol. Despite the fact that 7 treatment plans did not meet protocols criteria, it was important
to evaluate ipsilateral lung dose. Analyses of the ipsilateral lung dose are demonstrated in Figure
1. The dose of 20 Gy was evaluated by displaying the amount (in percent value) of ipsilateral
lung volume receiving 20 Gy. Comparison of lung doses in both treatment plans, 3DCRT and
VMAT, were displayed for each patient, and the values were evaluated based on the NSABP
protocol guidelines. According to the protocol, the acceptable variation for the ipsilateral lung is
35% of the ipsilateral lung to receive no more than 20 Gy. Nine out of 12 plans met the

6
acceptable lung dose variation guideline of the NSABP B-51 protocol. Six of the plans were
performed utilizing VMAT technique, and three were performed utilizing 3DCRT technique.
Overall 50% of the 3DCRT plans were unacceptable. Most of the plans did not pass the
acceptable criteria due to unacceptable ipsilateral lung dose most likely caused by the extended
tangents treatment technique. The 3DCRT plans had a mean V20 of the ipsilateral lung of
39.32%. The VMAT plans had a mean V20 of the ipsilateral lung of 31.72%. On average, the
VMAT plans reduced dose to the ipsilateral lung by 7.59%, however more than half (67%) of the
VMAT plans were also unacceptable. Most of the plans were unacceptable due to not meeting
contralateral breast/chest wall or lower ipsilateral lung dose constraints. For 4 of the plans, the
contralateral breast/chest wall volume was recorded at 3 Gy (V3), and for 2 of the plans the
volume was recorded at 4.1 Gy (V4.1). For the plans recorded at 3 Gy, the average V3 for 3DCRT
was 0.4% and the average V3 for VMAT was 30.98%, indicating an average increase of 30.58%
to V3 for VMAT plans. The average V4.1 for the 2 other patients was 2.35% for 3DCRT and
13.75% for VMAT, indicating an increase of 11.4% for V4.1 of the contralateral breast/chest wall
with VMAT. There was a higher dose in the contralateral chest wall due to utilization of dose
constraints to keep dose out of the ipsilateral lung. Dose also increased in the contralateral chest
wall due to increased integral dose from VMAT.8,9 The average mean dose to the heart was 2 Gy
for the 3DCRT plans and 4.33 Gy for the VMAT plans. On average the mean dose to the heart
was 2.22% Gy greater with VMAT. The lower dose constraint of the ipsilateral lung was to keep
5 Gy (V5) of the dose under 70% of the ipsilateral lung volume. The average V5 was 60.32% for
the 3DCRT plans and 73.25% for the VMAT plans. An increase of integral dose is evident by the
higher ipsilateral lung volume at the 5 Gy dose in the VMAT treatment plans.8 The average
increase in ipsilateral lung volume (V5) from VMAT planning was 12.93%, and was a result of
increased integral dose from VMAT planning.8,9
Conclusion
Dose variations were evaluated for PTVs and OR with 3DCRT and VMAT planning
techniques. On average, the VMAT plans reduced the V20 of the ipsilateral lung by 7.59%
compared to the 3DCRT plans. However, the VMAT plans resulted in an average dose increase
of 20.99% to the contralateral breast/chest wall compared to the 3DCRT plans. The increased
dose to the contralateral breast/chest wall is due to increased integral dose from the VMAT
technique.8,9 The contralateral breast/chest wall volumes ranged from 240.8 cc to 2589.47 cc.
Four of the 6 plans had an unacceptable contralateral breast/chest wall dose with the VMAT

7
technique. The two VMAT plans with acceptable contralateral breast/chest wall dose had
contralateral breast/chest wall volumes of 1257.45 cc and 2589.47 cc indicating that VMAT
planning might be more suitable for patients with larger contralateral breast/chest wall volumes.
In general, neither technique proved to be more optimal over the other in this study of
barrel chested right post mastectomy chest wall patients. Although no clear planning technique
was superior over the other plan deliverability is ultimately at the discretion of the prescribing
physician according to NSABP protocol criteria. This clinical judgement should be made on an
individual basis with considerations to include side effects, the patients state of health, and their
age.10 Due to the risk of secondary malignancies it may be more acceptable of an older patient to
receive a higher dose to the contralateral breast than a younger patient.9 Additionally, patients
with compromised lung function may benefit from a lower V20 dose achieved by the VMAT
plans.
A limitation to the study is the small number of patients included. A study that includes
more patients would provide more data for evaluation. A larger study, with further research into
other techniques, such as partially wide tangential fields with abutting electrons or a hybrid
IMRT, could lead to a more optimal method for the treatment of total nodal chest wall
irradiation.

8
References
1. Moran MS, Haffty BG. Radiation techniques and toxicities for locally advanced breast
cancer. Semin Radiat Oncol. 2009;19(4):244-255.
http://dx.doi.org/10.1016/j.semradonc.2009.05.007
2. Gagliardi G, Bjohle J, Lax I, et al. Radiation pneumonitis after breast cancer irradiation:
analysis of the complication probability using the relative seriality model. Int J Radiat Oncol
Biol Phys. 2000;46(2):373-381. http://dx.doi.org/10.1016/S0360-3016(99)00420-4
3. Marks L, Bentzen S, Deasy J, et al. Radiation dose-volume effects in the lung. Int J Radiat
Oncol Biol Phys. 2010;76(3):570-576. http://dx.doi.org/10.1016/j.ijrobp.2009.06.091
4. Agrawal, S. Clinical relevance of radiation pneumonitis in breast cancers. South Asian J
Cancer. 2013;2(1):19-20. http://dx.doi.org/10.4103/2278-330X.105885
5. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology:
breast cancer. http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Updated July
16, 2015. Accessed July 20, 2015.
6. Wolmark N. Standard or Comprehensive Radiation Therapy in Treating Patients With EarlyStage Breast Cancer Previously Treated With Chemotherapy and Surgery. Bethesda, MD:
U.S. National Library of Medicine; 2012. A Randomized Phase III Clinical Trial Evaluating
Post-Mastectomy Chestwall and Regional Nodal XRT and Post-Lumpectomy Regional Nodal
XRT in Patients with Positive Axillary Nodes Before Neoadjuvant Chemotherapy Who
Convert to Pathologically Negative Axillary Nodes After Neoadjuvant Chemotherapy.NIH
publication NCT01872975. https://clinicaltrials.gov/show/NCT01872975. Updated
November 26, 2012. Accessed June 6, 2015.
7. White J, Tai A, Arthur D, et al. Breast cancer atlas for radiation therapy planning: consensus
definitions. Radiation Therapy Oncology Group (RTOG).
http://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx. Accessed June 21,
2015.
8. Hall E. Is there a place for quantitative risk assessment? J Radiol Prot. 2009;29(2A):A171A184. http://dx.doi.org/10.1088/0952-4746/29/2A/S12
9. Zhang Q, Yu XL, Hu WG, et al. Dosimetric comparison for volumetric modulated arc
therapy and intensity-modulated radiotherapy on the left-sided chest wall and internal
mammary nodes irradiation in treating post-mastectomy breast cancer. Radiat Oncol.
2015;49(1):91-98. http://dx.doi.org/10.24778/raon-2014-0033
10. Emami B. Tolerance of normal tissue to therapeutic radiation. Reports of Radiotherapy and
Oncology. 2013;1(1):35-48.

10
Tables
Table 1. Path Lengths of Arcs and Arc Angles for Patients 1-6
Patient
Path length
Clockwise
CounterCollimator
Collimator
of an arc
arc angle
clockwise arc angle for the angle for the
angle
clockwise arc counterclockwise arc
Patient 1
135
75-210
210-75
5
335
Patient 2
180
180-360
360-180
90
180
Patient 3
210
330-120
120-330
30-150
30-210
Patient 4
210
330-120
120-330
30-150
30-210
Patient 5
135
75-210
210-75
5
355
Patient 6
225
315-105
105-315
25
25
Table 2. Deliverable and Undeliverable Treatment Plans for 6 Patients per NSABP Protocol
Guidelines
Patient
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6

3DCRT treatment plan

Unacceptable treatment plan
Unacceptable treatment plan
Acceptable treatment plan
Acceptable treatment plan
Unacceptable treatment plan
Acceptable treatment plan

VMAT treatment plan

Acceptable treatment plan
Unacceptable treatment plan
Unacceptable treatment plan
Unacceptable treatment plan
Acceptable treatment plan
Unacceptable treatment plan

11
Figure
Figure 1. Comparison of Lung Doses in 3DCRT versus VMAT Displayed to Evaluate the
Amount of Ipsilateral Lung Volume (in percent value) Receiving 20 Gy.

Ipsilateral lung dose comparison

35

Patient 1
32.5

Patient 2
Patient 3

28.6
31.3

Patient 4

29.5

26.2

48.7
3DCRT
VMAT

33.4
34.7

Patient 5
Patient 6

51.9

40.5

34

Ipsilateral lung volume in percent value receiving 20 Gy

12