Group 8 Capstone Outline

I. Introduction
a. Research has not shown a direct comparison between three-dimensional (3D)
conformal field-in-field (FIF) and irregular surface compensator (ISC) or
electronic compensation techniques with modern planning technology. -go on
about old studies and new technologies that will be used. (many sources will be
used here, not sure which ones yet or what order)
b. Common post-treatment issues from whole breast radiotherapy have included
tumor recurrence, chest wall recurrence, contralateral breast tumors, heart
toxicity, and radiation pneumonitis.1
c. Target volumes, dose constraints, and treatment goals were defined by Radiation
Therapy Oncology Group protocol 1005 (RTOG 1005), as these guidelines were
used by Dr. Yu Chen who drew all the target volumes.6
d. Many studies are ridden with variables that could lead to findings that are not
entirely accurate. A goal of our study was minimize variables in the form of CT
datasets and the types of patients compared.
i. Side of breast treated
ii. Planning Target Volume (PTV) (breast tissue) treatment size
iii. Brands of machines and types within brands
iv. Types of dose algorithms
v. Tumor stage
e. If one study goes on to consistently have lower hot spots and organs at risk
(OAR) doses, further research will be called upon to confirm our findings.
f. The objective of this study was to perform a comparison between FIF and ISC
techniques in whole breast radiation therapy.2-5 -go on about what the study will
be comparing.
II. Patient Selection
a. In order to analyze breast tissue, heart, lung, and contralateral breast dose, the
research group chose to only plan left-sided breast patients.
b. The size or volume of breast tissue was taken into consideration. For the most
part, breast sizes avoided extremes to keep data more consistent and less variable.
c. All patients were limited to low stage disease. Any patients staged from ductal
carcinoma in situ (DCIS) to T2N0M0 with a lumpectomy procedure was a
candidate for the study.
d. To further lower variability, all patients were planned on 3D, free breathing CT
scans from a Phillips Brilliance large bore CT with 3mm slices.
e. The patients selected for this study were in the same, or very similar, treatment
position. All patients selected were simulated in the following position: Head first
supine, flat with both arms up with a T-grip on a wing board for the patient’s
hands, the head tilted to the right, a vacuum bean bag (Vac-Lok) used under the
head and arms while limiting bag under the thorax, and a knee cushion for patient
comfort.
III. Target Delineation
a. To allow for quantitative analysis of treatment plan quality, both breast tissue
(PTV) and the lumpectomy site (gross tumor volume [GTV]) were contoured
according to RTOG 1005 guidelines by Dr. Chen.6
b. Organs at risk included the contralateral breast, ipsilateral lung, contralateral lung,
total lung, and heart which were all drawn in accordance with RTOG 1005.6
c. The treatment planning system (TPS) used in the study was Eclipse version 13.6
utilizing the Analystical Anisotropic Algortihm (AAA) for photon energies.
IV. Treatment Planning
a. The prescription and fractionation in the study were consistent with Arm 1
(Standard Whole Breast Irradiation with Sequential Boost) of RTOG 1005 in
delivering 50Gy in 25 fractions of 2Gy.
b. Due to the variability of boost treatment modalities and inconsistent volumes, the
study did not include a boost plan to solely focus on the effectiveness of the two
treatment methods in treating the whole breast.
c. Both FIF and ISC techniques were planned for treatment of a TrueBeam linear
accelerator with an equal number of 0.5cm and 1.0cm MLC leaves used in
collimation. Field in field had 6MV, 10MV, and 15MV available while ISC used
6MV and 15MV beams.
d. Beam angles were determined by the medical dosimetrists to best suit their
coverage needs based on external patient contours, RTOG guidelines, and visual
analysis of a reviewing physician
e. Collimator angles were consistent with 0 or 90 degrees for the primary treatment
beams but had the option to be modified in FIFs or ISC.
f. For the sake of comparing both treatment methods, plans were normalized to
reach 1 of 2 constant coverage specifics with a plan hot spot maximum of 115%.
Additionally, 95% of the breast tissue PTV was covered by 95% of the dose, and
100% of the lumpectomy site-GTV was covered by 99% isodose. –dosimetrist
can choose either of these normalization methods as long as the both specs are
met-(to Ashley, this is a reminder to myself (ryan) to make sure I explain this in
this paragraph)
g. Organs at risk constraints were all determined by RTOG 1005 and were evaluated
by use of dose volume histograms (DVHs) and the ClearCheck third party
software. –all constraints will be in the draft-6
h. Not all constraints were met on each plan as there was no modification of target
coverage doses allowed in the study. In good faith, the group trusted that the
research dosimetrists lowered hot spots and OAR doses as much as possible
within the limitations of their respective treatment method.
V. Plan Analysis and Evaluation
a. Every patient had a sentence or short paragraph simply describing the planning
done for both FIF and E-comp
 b. Plans were evaluated for overall dose conformality, hot spots, and OAR dose
constraints.
c. The average doses to the targets in both FIF and E-comp were described. Charts
showing dose statistics for targets were shown with averages and different metrics
for each method here.
d. Average hot spot and hot spot location in each plan following the same visuals as
above.
e. Each OAR dose constraint, value, and whether the specs passed or failed for each
treatment technique for each plan was shown the same way as above.
f. Both planning methods were compared in terms of target doses, dose
conformality, hot spots, and OAR doses. (This paragraph and discussion will be
long)
g. Describe if one method of planning was better than the other and to what degree.
If the information shows one method better than the other, statistics were used to
determine if the findings are significant.
h. Explain and determine whether visual analysis identified trends or variables in
treatment planning. Ex: Did FIF work better on smaller PTV volumes... Did E-
comp work better on smaller GTV volumes... Did e-comp provide better GTV
coverage when the GTV was further away from the center of the breast?..
VI. Conclusion
a. Of all identified variables in the introduction and from previous studies, the study
only included a few small variables like the FIF dosimetrist being able to use
10MV and the fact that different dosimetrists did the planning.
b. One planning method was or was not better than the other regarding hotspots or
dose constraints when normalization methods were consistent.
c. Described that the patient population was limited, but the population was selected
to represent a vast number of different tissue volumes and lumpectomy sites
(GTV) in different regions of the breast.
d. The research was consistent (or not) with prior research. We found that when
variables are limited, and normalization methods are consistent between planning
techniques, our research shows that FIF or E-comp could be a more effective
treatment planning technique for free breathing, left-sided breast patients across a
variety of patients.
e. Was heart dose a factor? If not, we predicted that this study would also be
reflected on the right side... Was lung dose a factor, if so, did we think the study
should be done with deep inspiration breath hold (DIBH) to further research.
f. Since our findings showed one method to be more proficient in the other to some
regard (whether significant or not), we call upon further research to be done on a
larger population.
References
1. Fragkandrea I, Kouloulias V, Mavridis P et al. Radiation induced pneumonitis following
whole breast radioterapy treatment in early breast cancer patients treated with breast
conserving surgery: A single institution study. Hippokratia. 2013;17(3):233-238.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872459/.

2. Koivumaki T, Fogliata A, Zeverino M, et al. Dosimetric evaluation of modern radiation

therapy techniques for left breast in deep-inspiration breath-
hold. Physica Medica. 2018;45:82-87. https://dx.doi.org/10.1016/j.ejmp.2017.12.009

3. Emmens DJ, James HV. Irregular surface compensation for radiotherapy of the breast:
Correlating depth of the compensation surface with breast size and resultant dose
distribution. Br J Radiol. 2010;83(986):159–165. http://dx.doi.org/10.1259/bjr/65264916

4. Friend M. An overview of electronic tissue compensation (ECOMP) for breast

Radiotherapy. CSM. 2014;R-0170. http://dx.doi.org/10.1594/ranzcr2014/R-0170.

5. Al-Hammadi N, Torfeh T, Sheim S, Petric P, Paloor S, Hammoud R. Indications for

intensity modulated radiation therapy using field-in-field and electronic compensator for
the treatment of large left breast volumes. Phy Med. 2016;32(3):322-
323. https://dx.doi.org/10.1016/j.ejmp.2016.07.213

6. Vicini FA. A phase III trial of accelerated hole breast irradiation with hypofractionation
plus concurrent boost versus standard whole breast irradiation plus sequential boost for
early-stage breast cancer. Radiation Therapy Oncology Group (RTOG).
http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?action=openFile&Fi
leID=9366. Updated 2014. Accessed May 27, 2018.