1

Traditional Supraclavicular Treatment Field Versus Wedged Pair Treatment Field For
Treatment of Deep-Seated Nodes In Obese Breast Cancer Patients: A case study
Authors: Cinira Johnson, B.A, R.T. (R)(T), Nishele Lenards, M.S., R.T.(R)(T), FAAMD, Dale
Thornton R.T.(R)(T), CMD and Jennifer Backus B.S, R.T. (R)(T), CMD
Abstract:
Introduction: This study aims to determine if a single traditional angled supraclavicular (10 to
15 degrees) field or a wedge pair beam arrangement is a better treatment technique for 3 obese
patients with deep seated supraclavicular (SCV) nodes.
Case Description: Radiation treatment of deep seated SCV nodes in breast cancer patients
planned with a traditional SCV field technique can have undesirable side effects due to very
large hot spots created to overcome the lack of coverage. An alternative for this situation is to
use a wedged pair instead of the traditional approach when a field-in-field technique is not
enough to lower the global maximum dose.
Conclusion: An in depth dosimetric evaluation of both treatment approaches demonstrated the
wedged pair SCV fields offered superior coverage of deep-seated nodes while keeping the global
maximum dose values at an acceptable range.
Key Words: Wedged-Pair Fields, Supraclavicular Fields, Deep-Seated Supraclavicular Nodes,
Obese Patient.
Introduction
Irradiation of the supraclavicular fossa is generally recommended for breast cancer
patients with 3-4 positive axillary nodes.
1
It can improve long term locoregional control and
survival.
2, 3
The ever increasing obese population is a concern in the therapeutic management of
cancer requiring specific adaptations.
4


In the traditional approach, appropriate coverage is
achieved by normalizing the plan to as low as 80%, which impacts skins toxicity. Skin toxicity
is an issue while treating SCV fields even with the addition of a PA field.

The traditional
treatment approach was designed to irradiate lymph nodes located 3 cm deep under the skin
surface. In most, if not all, obese patients these lymph nodes are located much deeper.
5
A
2

wedged pair technique was originally used to treat shallow tumors but, more recently, it has been
used to treat deep-seated tumors due to dose uniformity.
6
Due to this characteristic, a wedged
pair technique can be a feasible option to treat obese patients with deep seated nodes.
Three obese patients with deep-seated SCV nodes were evaluated in this case study. For
each patient, 2 plans were generated: the traditional approach of a single field angled 10 to 15
degrees and second wedged pair technique. The data for all 3 patients were analyzed from a
dosimetric aspect to determine the best treatment option for patients with this profile.
Case Description
Patient Selection and Setup
The patient selection for this case study included patients being treated with chest wall
and SCV radiation with a BMI of 30 or higher. All patients were simulated in the supine position
on a breast board, with both arms up resting on the arm holders. A large knee sponge was placed
under the knees and the head turned to the contralateral treatment side. Radiopaque markers were
used to define medial border and the mastectomy scar. Radiopaque lead markers were placed
anteriorly for matchline identification. A Computed Tomography (CT) scan with 5 mm slices,
from mandible to the bottom of the lungs was performed with the patient head first into the
Philips Brilliance Big Bore CT scanner. A three point setup was tattooed on the patients skin
along with an anterior tattoo identifying the matchline.
Target Delineation
CT scan images were imported into Eclipse treatment planning system and the following
critical structures were contoured by the medical dosimetrist: ipsilateral lung, heart, spinal cord
and thyroid gland. The radiation oncologist delineated the clinical target volume (CTV) that was
named as Level 3/SCV.
7
For the purpose of this study an extra structure was created named 50%
ISDL (isodose line). This structured was created from the 50% ISDL of the traditional SCV field
(edge of the traditional field)

for each patient in the case study. It is used as a tool to help identify
the global maximum within the structure for the different techniques used in this case study.

3

Treatment Planning
For an even comparison of data most of the technical parameters were kept the same for
all treatment plans.
8
The prescription to be delivered was 50 Gy in 25 fractions at 2 Gy a day.
The coverage and normalization in both plans were 95% of Level 3/SCV volume receiving 95%
of the prescription dose. The target volume used was the Level 3/SCV, for deep seated SCV
nodes (Figures 1-3). For the wedged pair fields a 0.8 cm block margin around the level 3/SCV
volume was created with a half beam block located inferiorly at the matchline for the tangential
fields. The hinge angle was determined based on the best coverage of the volume for each case.
For the traditional supraclavicular treatment field, a half beam blocked single oblique field was
used with the following borders: medially, 1cm across or at midline extending upwards along the
sternocleidomastoid muscle to the thyrocricoid groove; laterally, vertical line at the anterior
axillary fold; inferiorly, at the matchline; and superiorly, extending laterally across the neck to
the acromial process.
9
The humeral head and spinal cord were blocked as much as possible
without compromising targeted lymph nodes. In all plans, 15x energy was used in order to
properly cover the target.
10
All plans were done using the Varian Eclipse Version 11.0 treatment
planning system (TPS) and AAA photon algorithm. Treatment parameters are demonstrated in
table 1 for traditional treatment fields and table 2 for wedged pair fields.
Plan Analysis & Evaluation
The traditional field plan was compared with the wedged pair plan for all 3 patients.
Three dosimetric aspects were observed in the study: the maximum dose, the mean dose and the
median dose of the PTV and 50% ISDL volume. When analyzing the PTV mean dose for all 3
patients, an increase in dose was observed in all traditional field plans compared to the wedged
pair. The mean dose of the traditional field were respectively 1%, 2% and 2% higher compared
to the mean dose of the wedge plans for patient 1, patient 2 and patient 3. The PTV global
maximum doses were 3.5 %, 2.5%, and 5% higher compared to the wedged pair plans
respectively (Table 3). The same trend is seen when comparing the dose volume histogram of the
50% ISDL structures for all patients (Figures 4 6). It is clearly noticeable on Figures 4 6, that
a large amount of tissue is being irradiated to a higher dose in the single SCV field technique.
The global maximum dose was higher in the traditional field for patient 1, patient 2 and patient 3
respectively 4.5%, 6% and 4.3% (Figures 7-9 and Table 4). Based on the results, skin toxicity
4

was lower with the wedged pair plans compared to the traditional approach. The thyroid toxicity
for all plans were also observed as seen in Table 5. Because this study aims to compare treatment
techniques, technical factors were kept the same, such as normalization and energy. With this in
mind, the thyroid toxicity (mean and maximum dose) is lower with the wedged pair approach for
all 3 patients consistently.
Conclusion
Based on the findings of this case study, the wedged pair technique is an adequate option
to treat SCV nodes of obese breast cancer patients, instead of the traditional approach. The
wedged pair techniques provides ideal coverage for deep-seated lymph nodes without increased
skin toxicity. A limitation of using wedged pair while treating deep-seated SCV nodes is the dose
to thyroid and spinal cord. Further investigation is recommended to assess thyroid toxicity in
wedged pair fields for SVC irradiation. For obese patients with deeper target volumes, the
traditional single field approach results in a higher global maximum dose in order to achieve the
dose coverage to the target volume. In any case, the technique to be used should be evaluated on
a case by case basis as determined by radiation oncologist.










5

References
1. Grills I, Kestin L, Goldstein N, et al. Risk factors for regional nodal failure after breast-
conserving therapy: regional nodal irradiation reduces rate of axillary failure in patients with
four or more positive lymph nodes. Int J Radiat Oncol Biol Phys. 2003;56(3):658-670.
http://dx.doi.org/10.1016/S0360-3016(03)00017-8
2. Yates L, Kirby A, Crichton S, et al. Risk factor for regional nodal relapse in breast cancer
patients with one to three positive axillary nodes. Int J Radiat Oncol Biol Phys.
2012;82(5):2093-2103. http://dx.doi.org/10.1016/j.ijrobp.2011.01.066
3. Chen S, Chen M, Hwang T, et al. Prediction of supraclavicular lymph node metastasis in
breast carcinoma. Int J Radiat Oncol Biol Phys. 2002;52(3):614-619.
http://dx.doi.org/10.1016/S0360-3016(01)02680-3
4. Hijazi H, Magne N, Levy A, et al. Features of cancer management in obese patients. Int J
Radiat Oncol Biol Phys. 2013;85(2):193-205.
http://dx.doi.org/10.1016/j.critrevonc.2012.06.003
5. Bentel GC, Marks LB, Hardenbergh PH, et al. Variability of the depth of supraclavicular and
axillary lymph nodes in patients with breast cancer: is a posterior axillary boost field
necessary? Int J Radiat Oncol Biol Phys. 2000;47(3):755-8.
6. Bentel G. Radiation Therapy Planning. 2nd ed. Columbia, SC: McGraw-Hill; 1996.
7. Li X, Tai A, Arthur D, et al. Variability of target and normal structure delineation for breast
cancer radiotherapy: an RTOG multi-institutional and multiobserver study. Int J Radiat
Oncol Biol Phys. 2009:73(3):944-951. http://dx.doi.org/10.1016/j.ijrobp.2008.10.034
8. Jephcott CR, Tyldesley S and Swift Cl. Regional radiotherapy to axilla and supraclavicular
fossa for adjuvant breast treatment: a comparison of four techniques. Int J Radiat Oncol Biol
Phys. 2004;60(1):103-10. Accessed June 29, 2014.
9. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3
rd
ed. St. Louis,
MO: Mosby-Elsevier; 2010.
10. Khan FM. The Physics of Radiation Therapy. 4
th
ed. Baltimore, MD: Lippincott, Williams,
and Wilkins; 2010.


6

Figures

Figure 1. Patient #1 deep seated lymph node.


Figure 2. Patient #2 deep seated lymph node.

7


Figure 3. Patient #3 deep seated lymph node.


Figure 4. Patient #1 DVH demostrating 50% ISDL structure.

Traditional Field
Wedged Pair
8


Figure 5. Patient #2 DVH demonstrating 50% ISDL structure.


Figure 6. Patient #3 DVH demonstrating 50% ISDL structure.
Traditional Field
Traditional Field
Wedged Pair
Wedged Pair
9


Figure 7. Patient #1 Global maximum dose axial slices. Blue line is 95% ISDL and red is 107%
ISDL.


Figure 8. Patient #2 Global maximum dose axial slices. Blue line is 95% ISDL and red is 107%
ISDL.


Wedged Pair Traditional Field
Wedged Pair Traditional Field
10

Figure 9. Patient #3 Global maximum dose axial slices. Blue line is 95% ISDL and red is 107%
ISDL.

Table 1. Traditional fields treatment planning details for patients 1-3

Patient 1


Patient 2

Patient 3

Target volume


Level 3/SCV

Level 3/SCV

Level 3/SCV

Prescription Dose


50 Gy in 25 fractions

50 Gy in 25 fractions

50 Gy in 25 fractions

Beam Energy


Varian True Beam
15x


Varian True Beam
15x

Varian True beam
15x

Gantry Angles


20 degrees

15 degrees

15 degrees

Technique


Traditional SCV field

Traditional SCV field

Traditional SCV field


Normalization

95% isodose line
covering 95% of
Level3/SCV volume

95% isodose line
covering 95% of
Level3/SCV volume

95% isodose line
covering 95% of
Level3/SCV volume



Wedged Pair Traditional Field
11

Table 2. Wedged pair fields treatment planning details for patients 1-3

Patient 1


Patient 2

Patient 3

Target volume


Level 3/SCV

Level 3/SCV

Level 3/SCV

Prescription Dose


50 Gy in 25 fractions

50 Gy in 25 fractions

50 Gy in 25 fractions

Beam Energy


Varian True Beam
15x


Varian True Beam
15x

Varian True Beam
15x

Gantry Angles


32 and 339 degrees

18 and 346 degrees

22 and 343 degrees

Technique


Wedged pair

Wedged pair

Wedged pair


Normalization

95% isodose line
covering 95% of
Level 3/SCV volume

95% isodose line
covering 95% of
Level 3/SCV volume

95% isodose line
covering 95% of
Level 3/SCV volume













12

Table 3. PTV mean and global maximum dose for all patients for both plans.

Patient 1


Patient 2

Patient 3

Technique

Wedged
Pair


Traditional
Field

Wedged
Pair


Traditional
Field

Wedged
Pair


Traditional
Field

Maximum Dose


5397 cGy

5556 cGy

5481 cGy

5623 cGy

5301 cGy

5546 cGy

Mean Dose


5106 cGy

5146 cGy

5010 cGy

5137 cGy

4985 cGy

5087 cGy

Median Dose


5129 cGy

5163 cGy

4998 cGy

5148 cGy

4985 cGy

5081 cGy

Table 4. 50% ISDL volume dose comparison in different planning techniques.

Patient 1


Patient 2

Patient 3

Technique

Wedged
Pair


Traditional
Field

Wedged
Pair


Traditional
Field

Wedged
Pair


Traditional
Field

Maximum Dose


5397 cGy

5643 cGy

5535 cGy

5855 cGy

5328 cGy

5559 cGy

Mean Dose


2119 cGy

3822 cGy

2316 cGy

4006 cGy

2286 cGy

3719 cGy

Median Dose


1363 cGy

3695 cGy

1970 cGy

3874 cGy

1828 cGy

3612 cGy





13

Table 5. Thyroid dose for all patients for wedged pair and traditional SCV field plans.

Patient 1


Patient 2

Patient 3



Wedged
Pair


Traditional
Field

Wedged
Pair


Traditional
Field

Wedged
Pair


Traditional
Field


Maximum Dose
of Thyroid





5350 cGy



5500 cGy



5279 cGy



5469 cGy



5216 cGy



5485 cGy