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Abstract

Introduction

1) According to the American Society of Clinical Oncology (ASCO) guidelines, radiation


treatment of the internal mammary lymph nodes (IMN) is recommended for high-risk or
node positive, postmastectomy patients to control locoregional recurrence (LRR).
a) Radiation treatment to this area included the chest wall or reconstructed breast,
internal mammary lymph nodes (IMN), supraclavicular nodes, and axillary nodes
for patients post-surgery.
b) Such treatment has led to increased survival rates and decreased locoregional
recurrence (LRR) for post-mastectomy patients.
c) Three randomized trials have established the benefit of post-mastectomy radiation
therapy (PMRT).
i) For breast cancer stages I-III, these studies have demonstrated a 70%
decrease in LRR and proven advantageous for tumor local control and
patient survival.
ii) At 15 years PMRT has shown to decrease breast cancer mortality by 5%
for node-positive breast cancer patients.
iii) The objectives for treatment to the chest wall and regional lymph nodes
are complete dose coverage to the target volume (TV) and minimized dose
to normal tissue.
2) For chest wall and nodal irradiation, 2 of the major limiting organs at risk (OAR) are the
heart and ipsilateral lung.
a) Researchers such as Darby6, have proposed a mean heart dose of < 4Gy to avoid
increased cardiac morbidity.
i) Current literature has proven indications of increased mortality from heart
disease and induced lung cancer, 10-20 years post-radiotherapy.
ii) By incorporating current techniques such as field in field segments with
multi leaf collimation (MLC) and respiratory gating through deep
inspiration breath-hold (DIBH), decreased dose to healthy lung and heart
is achieved.
(1) The DIBH technique increases the separation between the chest
wall and heart, allowing dose sparing to the heart, without
compromising TV coverage.
3) Today, the standard treatment for PMRT patients is a three-dimensional (3D) tangential
field treatment technique.
a. This treatment has proven its success but falls short for patients presenting with
challenging anatomical features, specifically when IMN are involved in the
treatment field.
b. Inclusion of the IMN for tangential beams, can increase heart dose significantly
due to the location of the IMN that lie deep and medially in the sternum.
i) Concerns for anatomically complex treatments using tangential fields
include dose distribution inhomogeneity, poor conformity, high dose to
the heart, ipsilateral lung, and contralateral breast.
ii) Dose specific objectives, for limiting heart and ipsilateral lung doses, have
led to the investigation of inverse optimization, intensity modulated
radiotherapy (IMRT) and volumetric-arc therapy (VMAT) for more
complex breast cancer treatment.
4) Many studies have explored inverse planning techniques and discovered a trade-off
between improved target dose coverage and increased integral dose.
a. Detrimental effects of integral dose to surrounding tissue has not been proven but
continues to be investigated.
b. For IMRT and VMAT, less heart, ipsilateral lung, and contralateral breast doses
were reported and found superior to 3D tangential beams.
i. The most evident differences between IMRT and VMAT was less monitor
units (MUs) and treatment delivery time using VMAT.
ii. Continued research, however, is necessary to determine optimal beam
arrangements and techniques that will maximize TV coverage and
minimize dose to healthy tissue.
5) A hybrid technique, consisting of a VMAT and segmented 3D field in field plan was
researched to compare treatment outcomes with current treatment strategies for
irradiation to the chest wall and regional lymph nodes
a. This retrospective study was specific to post-mastectomy patients receiving
radiation treatment to the chest wall and regional lymph nodes including
supraclavicular, axillary, and IMN.
i. The objective of this study was to compare a hybrid VMAT and 3D
technique to VMAT alone.
ii. The dose homogeneity, PTV conformity, and dose to the heart, lung, and
contralateral breast were evaluated to determine if a hybrid VMAT with
3D field in field segments should be considered superior for treatment
planning over VMAT alone.

Methods and Materials


Patient Selection
1) All patients selected for this study were post-mastectomy breast cancer patients who
received radiation treatment at the same radiation oncology clinic.
a) The patients were female and between the ages of 29-72
b) Of these patients, 4 had received a mastectomy to the right-side and 6 to the left
side chest wall.
c) For the simulation, a CT scan of the patient was completed with a free-breathing
(FB) and DIBH technique.
i) Patients who were unable to successfully perform DIBH were not included
in the study.
2) Patients were positioned supine, with arms above the head on a breast board or Vac-lok
immobilization device.
a) The FB and DIBH scans were completed on a wide-bore Siemens Somatom
Definition AS scanner with 2 mm axial slice thickness.
i) The scanning parameters began at the elbows and ended below the inferior
aspect of the inframammary fold.
ii) The entire lung was included in the scan for accurate lung volume
statistics.
b) For the DIBH scan, a Varian Real-Time Position Management (RPM) system was
used to monitor patient breathing.
i) For daily treatment, an Optical Surface Monitoring System (OSMS) was
used to verify and replicate each patient's breath hold in reference to the
breath hold captured by the RPM at the time of simulation.

Contouring
1) Patient datasets from the CT simulation were imported into the Eclipse treatment
planning system (TPS) for delineation of the target and OAR volumes.
a) The contours were completed by the radiation oncologist and medical dosimetrist
on the DIBH scan.
i) The radiation oncologist completed contours for the TV, heart, coronary
arteries, esophagus, thyroid, and the brachial plexus.
ii) The medical dosimetrist contoured the spinal cord and lungs.
iii) The isocenter was placed by the medical dosimetrist inside the chest wall
near the center of the TV to maximize leaf travel.
b) The isocenter was placed by the medical dosimetrist inside the chest wall near the
center of the TV to maximize leaf travel.
2) The Radiation Therapy Oncology Group (RTOG) Breast Cancer Atlas for Radiation
Therapy Planning was used to define the clinical target volume (CTV) by the radiation
oncologist.
a) For the CTV, the chest wall was included which was considered 3 mm beneath
the skin surface, following along the inner edge of the ribs.
i) The medial border of the CTV was determined by the location of the
midsternal IMNs.
ii) The inferior border was considered 2 cm inferior to the inframammary
fold or the inferior border of an intact contralateral breast.
3) The regional lymph nodes included in the treatment field were the axillary lymph nodes
I-III, supraclavicular lymph nodes, and IMNs.
a) A 5 mm margin was added to the CTV to create the planning target volume
(PTV).
b) The PTV was cropped back 3 mm from the body and out of the lung contour to
exclude the dose buildup region.
c) Therefore, the overall PTV evaluated included the chest wall, axillary lymph node
levels I-III, supraclavicular lymph nodes, and IMNs.
i) The Boolean contouring tool was used by the medical dosimetrist to create
the PTV used to optimize the plan.

Treatment Planning
1) For this study, 2 treatment planning techniques were completed for 10 patients on the
Eclipse Version 15.1.15 TPS using the Analytical Anisotropic Algorithm (AAA)
calculation
a) The prescription for the patients was a daily dose of 200 cGy in 25 fractions, 5
days per week, for a total dose of 5000 cGy to the chest wall and regional lymph
nodes.
b) There was 0.5 cm of bolus added to cover the entire chest wall for daily treatment.
c) The treatments were completed on a Varian Truebeam linear accelerator that used
both 6 and 10 MV energies.
i) Using the beam's eye view (BEV) the medical dosimetrist determined the
appropriate gantry angles for the tangential fields and partial arcs.
ii) The location of the contralateral breast, heart, ipsilateral lung, and PTV--
specifically the medially located IMNs were considered-- when choosing
gantry angles.
2) The major priority for both treatment techniques was to achieve a dose distribution with
90% of the PTV receiving 90% of the prescription.
a) The medical dosimetrists ultimately aimed to cover 95% of the PTV receiving
100% of the prescription dose.
b) As for the IMNs, the goal was 90% coverage (45 Gy) to at least 90% of the IMNs.
c) A single isocenter was used for each planning techniques, because the VMAT
contributed to both the chest wall and regional lymph nodes.
i) The field width was always less than or equal to 20 cm to maximize
modulation for the VMAT techniques.
ii) With this field size, there was no matchline and therefore low dose
between the chest wall and regional lymph nodes was avoided, unlike a
typical mono-isocentruc set up with half beam blocking, commonly used
in 3D chest wall and nodal treatments.
3) The VMAT plan consisted of 4 partial arcs that moved between optimal tangent angles.
a) These arcs were typically 185 degrees apart but varied slightly based on patient
anatomy.
i) The first and second arcs used 5-15-degree complementary collimator
angles.
ii) The third and fourth arcs consisted of upper and lower arcs with a 2-3 cm
overlap at the chest wall and supraclavicular junction.
b) The collimator was turned to 90-degrees to improve conformity and carve out the
dose to the ipsilateral lung around the chest wall.
4) Similarly, the hybrid plan consisted of 4 partial arcs with 2 additional tangential fields.
a) The goal was to optimize the tangential beams and minimize heart dose.
b) The VMAT contribution was used to achieve a more conformal dose around the
PTV where the tangents were lacking conformity.
c) Optimal tangential gantry and collimator angles where chosen to include the
entire PTV while accommodating the slope of the chest wall to minimize dose to
the heart and ipsilateral lung.
i) At least 3cm of flash over the chest wall was used to assure maximum
coverage to the PTV surface and potential setup inconsistencies.
d) Subfields were added on each tangential field, open over the chest wall in the
planes of the heart (Figure 1).
i) The subfields provide a hard field edge blocking the heart. In the hybrid
planning, the segmented fields, collectively contributed approximately
80% of the total dose.
One hundred cGy was delivered from the field in field tangents and 100
cGy was delivered from the partial arcs.
e) For the VMAT planning, the tangential beam plan was used as the base plan, in
the optimizer.

Plan Comparisons

1) To evaluate the hybrid and VMAT treatment techniques, dose-volume histograms (DVH)
were generated to collect data for dosimetric analysis.
a) Three parameters used to compare the treatment techniques included dose
homogeneity, PTV dose conformity, and volume of healthy tissues irradiated.
b) For this study, the statistical data used to evaluate the plan quality were dose
maximum, V110%, V95%, D95%, D50%, D5%, the conformity index (CI), Healthy
Tissue Conformity Index (HTCI), and homogeneity index (HI).
i) The V110% is equal to the volume of the target receiving 110% of the
prescribed dose.
ii) The HI was calculated by, HI=D5%−D95%D50% where the D95%, D50%,
and D5% equal the dose to 95%, 50%, and 5% of the volume, respectively.
iii) The CI was calculated by, CI=V95%TV where V95%was the volume
included in the 95% isodose line and TV(cc) was the volume of the target.
iv) The HTCI was calculated by, HTCI=TVRIV95% where V95%was the
volume included in the 95% isodose line and TVRI was the volume of 95%
isodose line contained within the PTV5000.
c) The healthy tissue dosimetric parameters used for the comparison of dose to the
heart were (V4%, V25%, and Dmean) where V4% and V25% equal the volume of the
target that received 4% and 25% of the prescribed dose.
d) The Dmean refers to the average dose the TV received.
e) The dosimetric indices recorded for the ipsilateral and contralateral lung included
(V4%, V10%, V20%, and Dmean) where V10% and V20% equal the volume of the target
that received 10% and 20% of the prescribed dose.

Results

1) In comparing plan quality, OAR and PTV specific indices and parameters were used and
are displayed in (Table 1).
a) Dose volume histograms function as a valuable co-metric to compare plan quality
between hybrid and VMAT plans, which can be seen in (Figure 3).
b) Specific to dose conformality, the conformity index (Conformity IndexVMAT= 1.14
v. Conformity Indexhybrid= 1.21) and Healthy Tissue Coverage Index (HTCIVMAT=
0.86 v. HTCIhybrid= 0.81) indicate the.......

Discussion

1) The inclusion of regional lymph nodes for PMRT breast cancer patients is not a new
concept but is extremely important when discussing the likelihood of local recurrence.
a. The study by Strom et al20, reported that 50% of patients who did not receive
nodal irradiation presented with lymph node recurrence.
b. Adequate dose coverage of the regional lymph nodes therefore, cannot be
overlooked.
c. The goal of this study was to determine if a hybrid technique would sufficiently
protect the heart, lungs, and contralateral breast without compromising the PTV
when compared to a VMAT only technique.
2) Advantages of the hybrid technique were evident.
a. The hybrid VMAT partial arcs contributed dose to the low dose areas in the PTV
where the 3D tangents were unable to achieve the desired dose.
i. This could be done without increasing dose to the heart and lungs.
b. Another advantage of the hybrid plan was it did not add any complexity to the
treatment setup for radiation therapists, as a single isocenter was used.
i. As previously studied, the VMAT dose fall off occurred in all directions,
leading to a larger volume of healthy tissue receiving low dose.
ii. Therefore, a sharp dose gradient was not achieved for either planning
technique.
c. Some of the disadvantages of the hybrid technique included a higher difficulty
reducing the dose maximum, longer planning time, increased cost for patient, and
increased treatment delivery time.
d. The pure VMAT plans produced better PTV conformity, confining a larger ratio
of the prescription dose to the PTV while the hybrid plans displayed an advantage
in overall dose uniformity within the PTV.
i. Both pure VMAT and hybrid VMAT plans were able to adequately cover
95% of the PTV with 100% of the prescription dose, without
normalization.
3) The hybrid and VMAT alone techniques both produced plans with a Dmean below 4 Gy to
the heart.
a) As predicted, the hybrid VMAT was able to better spare the heart than the VMAT
plan alone, as the heart Dmean was an average of 0.5 Gy lower.
b) The ipsilateral lung Dmean and V20 were slightly higher for the hybrid plans while
the V5 and V10 low dose values were less for the hybrid.
c) Although the dose to the contralateral breast was not specifically recorded in this
study, the plans were evaluated by observing isodose distributions and approved
by a radiation oncologist to determine that contralateral breast dose was
acceptable.
4) After the evaluation of both planning techniques, there was not a clear indication as to
which treatment type was superior.
a. Ultimately, the hybrid and VMAT were both able to produce acceptable plans for
patient treatment.
i. The decision to treat with hybrid or VMAT alone became contingent on
anatomical factors.
ii. The most influential factor was the position of the heart.
b. Examples noted in this study include a patient case where the heart and IMNs
were directly abutting and another patient whose heart overlapped the PTV.
i. This anatomy posed challenges for both treatment techniques but
especially for the hybrid in limiting heart dose because the heart could not
be excluded from the tangent angles without blocking significant amount
of PTV.
ii. In these scenarios, the pure VMAT plans performed better in PTV
coverage and protecting the OAR.
5) The hybrid VMAT technique is a viable treatment option for patients with unusual
anatomic shape, unusual intrathoracic organs, multimodality therapy that causes
increased cardiac toxicity, or patients with pre-existing conditions that compromise
cardiac function.
a. For situations when it is difficult to achieve low dose to OAR with VMAT, a
hybrid plan can be considered.
b. Slight adjustments in beam arrangements can produce significant differences in
dosimetric outcomes.
i. Therefore, continual research to find optimal beam arrangements and
techniques for complex treatments such as chest wall and nodal
irradiation, remain relevant in the field of radiation oncology.
c. Overall, the ideal treatment method varied on a patient-to-patient basis.
d. Therefore, the final treatment technique chosen would be determined at the
discretion of the radiation oncologist and patient.

Conclusion
1) The purpose of this study was to compare hybrid VMAT with VMAT alone in the
delivery of external beam radiation for patients post mastectomy with nodal disease.
a) This retrospective study concluded that for most treatment scenarios a hybrid
VMAT technique can help achieve lower doses to the heart over VMAT alone,
depending on the location of the heart
b) Hybrid VMAT is not able to achieve better PTV conformity or dose homogeneity
over VMAT alone.
i) Hybrid VMAT was able to achieve appropriate PTV coverage in all
instances.
ii) On average the dose to the heart was 0.5 Gy less. For the contralateral
lung the hybrid VMAT delivered less low dose but for the ipsilateral lung
the pure VMAT V20 was ~3.38 Gy less than the hybrid VMAT.
2) Future Research
a) Study limitations
b) Ways to improve study has it been prospective.
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Figures

(still need to reference figures in text)

Figure. 1. Patient 10 - BEV of the subfield from the medial tangent of the hybrid plan.
Approximately 80% of the total dose is given through this field and it’s paired opposing subfield.

Figure 2. Patient 10 - cumulative DVH showing hybrid vs VMAT only plans for a left-sided
case.
Figure 3. Patient 10 - comparison of isodose line distributions on axial views for the VMAT
only (left) and the Hybrid (right) plans. The white line represents the 5000cGy isodose line, the
blue line represents the 4500cGy isodose line and yellow line is the 500cGy low-dose spillage.
Tables

Table 1. PTV5000 dose parameters and mean values for VMAT and Hybrid plan comparison.
VMAT Hybrid
Mean Minimum Maximum Mean Minimum Maximum T-test
PTV5000
D5% (Gy) 52.6 52.1 53.6 52.6 52.2 53.7 0.748
D50% (Gy) 51.2 50.9 51.8 51.1 50.8 51.4 0.076
D90% (Gy) 49.8 49 50.2 49.4 47.8 50.1 0.057
D95% (Gy) 49.1 47.5 49.7 48.4 44.6 50 0.11
Dmean (Gy) 51.1 50.8 51.7 50.8 50.2 51.2 0.03
V95% (Gy) 98.4 94.98 99.7 97.1 91 99.6 0.076
HI 0.069 0.047 0.113 0.082 0.049 0.179 0.232

Table 2. Lung dose parameters and mean values for VMAT and Hybrid plan comparison.
VMAT Hybrid
Mean Minimum Maximum Mean Minimum Maximum T-test
Total Lung
V5% 62.6 54.4 67.5 51 37 64.5 0.005
V10% 33.7 28.4 40.7 28.6 22.3 37.9 0.013
V20% 13 11.8 14.3 14.2 11.1 18.3 0.041
Dmean (Gy) 10.2 9.2 11.3 9.8 7.7 12.3 0.259

Contralateral
Lung
V5% 36.5 27.3 50.7 30.6 16.7 40.3 0.077
V10% 10.3 5.3 16.8 6.9 1.5 13.2 0.086
V20% 0.8 0 2.3 0.5 0 1.3 0.036
Dmean (Gy) 4.8 2.7 5.8 4 2.7 4.7 0.009

Ipsilateral Lung
V5% 84.3 71 95.6 71.6 58.2 85.2 0
V10% 54.9 43.7 70.2 50.5 43.5 63.4 0.058
V20% 24.6 22 27 28 23.7 33.6 0
Dmean (Gy) 15.1 13.4 17.1 15.6 13.4 19 0.193

Table 3. Heart dose parameters and mean values for VMAT and Hybrid plan comparison.
VMAT Hybrid
Mean Minimum Maximum Mean Minimum Maximum T-test
Heart
V4% 29.4 12.9 43.6 20.7 2.7 46.7 0.01
Dmean (Gy) 3.9 2.6 5.6 3.4 1.8 6.7 0.126

Table 4. Monitor units for VMAT and Hybrid plans.


VMAT Hybrid
Mean Minimum Maximum Mean Minimum Maximum
Plan MUs 673.3 564 812 674.9 579 823

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