1

Comparison of VMAT vs. a 4-Field Technique for Post Mastectomy Irradiation of Barrel
Shaped Right Chest Walls: 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
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 in order 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 of the ipsilateral lung
depth involvement, when evaluating tangent 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. The tangential fields were planned with a 3 mm thick
bolus to the chest wall area every other treatment. The volumetric modulated arc therapy
(VMAT) plan consisting of two coplanar arcs with opposite rotation (clockwise and counterclockwise) was utilized as the second treatment technique. A total of 6 patients were selected for
the study, in order to evaluate doses to the ipsilateral lung and other OR for both treatment
techniques.
Conclusion:
Key Words: Barrel shaped chest wall irradiation, 3DCRT, VMAT, radiation pneumonitis

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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
treatments.3 There are guidelines provided by the National Comprehensive Cancer Network
(NCCN) highlighting the importance of including total nodal regions in the treatment fields
when planning for the chest wall irradiation.4 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 for each of the 6 patients with the
total nodal barrel shaped right chest wall volume. A 4-field three-dimensional conformal
radiation therapy (3DCRT) treatment plan with partially wide tangential fields and parallel
opposed SCL portals treatment plan was used as one of the treatment techniques. A VMAT was
the second treatment planning method. Doses to the chest wall, SCL, axillary, and IM nodes, 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 Project (NSABP) B-51 protocol (also known as the
Radiation Therapy Oncology Group RTOG-1304 protocol).5
Case Description
Patient Selection

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The patients for the study were selected based on a large amount of lung involvement 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, head first into the CT scanner, and
simulated via free breathing. Four of the patients were simulated on the Phillips CT scanner and
two patients were simulated on the General Electric CT scanner. Patient #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.4 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 previously was 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 radiopaque 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.6 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
(Figure 1). The CTV was expanded 7 mm (excluding the heart and not crossing midline) to form
the chest wall PTV (Figure 2). The chest wall PTV evaluation (PTV Eval) structure was created
based on the chest wall PTV with some limitations. The chest wall PTV Eval was limited
anteriorly to exclude the part outside 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

4
surface and to exclude the lung and the heart (Figure 3). The chest wall PTV Eval was the
structure utilized for DVH constraints and analysis and not for beam aperture generation. In
addition, the supraclavicular CTV was outlined by the physician following the RTOG breast
cancer atlas. The CTV was expanded 5 mm in all directions to create the supraclavicular PTV
(Figure 4). 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 (Figure 5). 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 (Figure 6). 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 on patient #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
cubic-millimeter 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 any 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
encompass the Chestwall PTV and regional node targets, as well as minimize inclusion of the
heart and lung. Dose constraints and maximum point doses to Chestwall PTV, SCL PTV,

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Axillary PTV, IMN PTV were provided by the NSABP protocol (Table 2). 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
When evaluating 3DCRT treatment plan for patient #1, 2 of the dose constraints were
acceptable by the protocol variations, 2 of the dose constraints did not meet the acceptable
criteria, and the rest of 14 dose constraints were met as per protocol (Table 3). The acceptable
variation for the chest wall PTV and the supraclavicular PTV was to deliver 90% of the
prescription dose to cover 90% of the PTV volume per NSABP protocol. The criteria was met by
the 3DCRT plan delivering 90% of the prescription to the 94.3% of the chest wall PTV volume,
and 90% of the prescription to the 91.9% of the SCL PTV volume. The 3DCRT treatment plan
was not able to achieve 2 of the ipsilateral lung dose constraints. When evaluating VMAT
treatment plan for patient #1, 3 of the dose constraints were acceptable by the protocol
variations, and the rest of 13 dose constraints were met as per protocol (Table 4).
When evaluating 3DCRT treatment plan for patient #2, 3 of the dose constraints were
acceptable by the protocol variations, 1 of the dose constraints did not meet the acceptable
criteria, and the rest of 12 dose constraints were met as per protocol (Table 5). The criteria for
the chest wall PTV and the SCL PTV was met by the 3DCRT plan delivering 90% of the
prescription to the 99.4% of the chest wall PTV volume, and 90% of the prescription to the
95.9% of the supraclavicular PTV volume. In addition, all of the axillary PTV volume (100%)
received 95% of the dose. The 3DCRT treatment plan was not able to achieve the constraint for
the ipsilateral lung and instead 48.7% of ipsilateral lung received more than 20 Gy. Evaluating
the VMAT treatment plan for patient #2, 2 dose constraints were acceptable by the protocol
variations, 9 dose constraints did not meet acceptable criteria, and 5 dose constraints were met
per protocol (Table 6). The VMAT plan was unable to meet per protocol or variation acceptable
compliance criteria for the following target volumes: chest wall PTV maximum dose,
supraclavicular maximal point dose, 2 of the 3 heart dose constraints, 3 ipsilateral lung
constraints, contralateral lung, and contralateral breast constraints.
When evaluating the 3DCRT treatment plan for patient #3, 5 of the dose constraints were
acceptable by the protocol variations, none of the dose constraints were unacceptable, and 11

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dose constraints were met as per protocol (Table 7). The criteria for the chest wall PTV and the
SCL PTV was met by the 3DCRT plan delivering 90% of the prescription to the 95% of the
chest wall PTV volume, and 90% of the prescription to the 99.2% of the SCL PTV volume.
When evaluating the VMAT treatment plan for patient #3, 8 of the dose constraints were met as
per protocol, 5 of the dose constraints were acceptable by the protocol variations, and 3 of the
dose constraints were unacceptable variations of the dose criteria (Table 8). The VMAT plan was
unable to meet per protocol or variation acceptable compliance criteria for the following target
volumes: one of the ipsilateral lung constraints, contralateral lung, and contralateral breast
constraints.
When evaluating 3DCRT treatment plan for patient #4, 5 of the dose constraints were
acceptable by the protocol variations, and the rest of 11 dose constraints were met as per protocol
(Table 9). The criteria for the chest wall PTV and the SCL PTV was met by the 3DCRT plan
delivering 90% of the prescription to the 91.5% of the chest wall PTV volume, and 90% of the
prescription to the 97.9% of the SCL PTV volume. When evaluating VMAT treatment plan for
patient #4, 8 of the dose constraints were acceptable by the protocol variations, 3 of the dose
constraints did not meet the acceptable criteria, and the rest of 5 dose constraints were met as per
protocol (Table 10).
When evaluating 3DCRT treatment plan for patient #5, 2 of the dose constraints were
acceptable by the protocol variations, 3 of the dose constraints did not meet the acceptable
criteria, and the rest of 11 dose constraints were met as per protocol (Table 11). The criteria for
the chest wall PTV and the SCL PTV was met by the 3DCRT plan delivering 90% of the
prescription to the 91.6% of the chest wall PTV volume, and 90% of the prescription to the
97.6% of the SCL PTV volume. When evaluating VMAT treatment plan for patient #5, 4 of the
dose constraints were acceptable by the protocol variations, and the rest of 12 dose constraints
were met as per protocol (Table 12).
When evaluating 3DCRT treatment plan for patient #6, 6 of the dose constraints were
acceptable by the protocol variations, and the rest of 10 dose constraints were met as per protocol
(Table 13). The criteria for the chest wall PTV and the SCL PTV was met by the 3DCRT plan
delivering 90% of the prescription to the 93.2% of the chest wall PTV volume, and 90% of the
prescription to the 91.4% of the SCL PTV volume. When evaluating VMAT treatment plan for
patient #6, 5 of the dose constraints were acceptable by the protocol variations, 1 of the dose

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constraints did not meet the acceptable criteria, and the rest of 10 dose constraints were met as
per protocol (Table 14).
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 deliverable and
undeliverable treatment plans per NSABP protocol guidelines is displayed in Table 15.
Evaluating 12 plans for 6 patients, two VMAT plans and three 3DCRT plans were deliverable
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 Table 16. 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. Eight out of 12
plans met the acceptable lung dose variation guideline of the NSABP B-51 protocol. Five of the
plans were performed utilizing VMAT technique, and three were performed utilizing 3DCRT
technique.

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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. 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.
5. 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.
6. 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.

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Figures

Figure 1. The chest wall CTV (orange) is delineated according to the definitions of anatomical
borders of chest wall from the NSABP breast cancer atlas (patient 1).

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Figure 2. The chest wall PTV (blue) was expanded 7mm in all directions from the chest wall
CTV, excluded the heart, and did not cross the midline (patient 1).

11

Figure 3. The chest wall PTV Eval (red) was limited anteriorly to exclude the part outside the
patient and the first 3 mm of tissue under the skin, and posteriorly was limited to no deeper than
the posterior rib surface excluding the lung and the heart (patient 1).

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Figure 4. Supraclavicular CTV (purple) delineated according to the definitions of anatomical

borders of SCL CTV from the NSABP breast cancer atlas. The SCL CTV was expanded 5mm in
all directions to create the SCL PTV (pink), excluding the ipsilateral thyroid, trachea, esophagus,
vertebral body, and ipsilateral lung (patient 3).

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Figure 5. The axillary lymph node PTV (yellow) expanded 5 mm from the axillary lymph node
CTV (cyan) outlined according to definitions contained in the NSABP breast cancer atlas
(patient 3).

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Figure 6. Internal mammary node CTV (pink) delineated according to the definitions of
anatomical borders of IMN CTV from the NSABP breast cancer atlas. The IMN CTV was
expanded 5 mm medially, laterally, superiorly, and inferiorly to create the IMN PTV (green),
excluding the sternum, lung, and heart (patient 4).

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Tables
Table 1. Path lengths of arcs and arc angles for patients #1-#6.

Table 2. Objectives and dose constraints for 3DCRT and VMAT plans.

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Table 3. Dose constraint structures with the protocol doses and the collected data for the 3DCRT
treatment plan for patient#1.

Table 4. Dose constraint structures with the protocol doses and the collected data for the VMAT
treatment plan for patient#1.

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Table 5. Dose constraint structures with the protocol doses and the collected data for the 3DCRT
treatment plan for patient#2.

Table 6. Dose constraint structures with the protocol doses and the collected data for the VMAT
treatment plan for patient#2.

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Table 7. Dose constraint structures with the protocol doses and the collected data for the 3DCRT
treatment plan for patient#3.

Table 8. Dose constraint structures with the protocol doses and the collected data for the VMAT
treatment plan for patient#3.

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Table 9. Dose constraint structures with the protocol doses and the collected data for the 3DCRT
treatment plan for patient#4.

Table 10. Dose constraint structures with the protocol doses and the collected data for the
VMAT treatment plan for patient#4.

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Table 11. Dose constraint structures with the protocol doses and the collected data for the
3DCRT treatment plan for patient#5.

Table 12. Dose constraint structures with the protocol doses and the collected data for the
VMAT treatment plan for patient#5.

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Table 13. Dose constraint structures with the protocol doses and the collected data for the
3DCRT treatment plan for patient#6.

Table 14. Dose constraint structures with the protocol doses and the collected data for the
VMAT treatment plan for patient#6.

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Table 15. Deliverable and undeliverable treatment plans for 6 patients per NSABP protocol
guidelines.

Table 16. 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

51.9
57.8

Patient 2

Patient 3

48.7
28.6
31.3
VMAT

Patient 4

33.4
29.5
34.7

Patient 5

Patient 6

3DCRT

40.5
26.2
34
Ipsilateral lung volume in percent value receiving 20 Gy