Dose/Tech Boob

Question 1

You are shown a DDR image of a breast plan. Outline format for commentary and give examples:

Answer 1

What: e.g. “The DDR image shows a tangent plan for the breast (comment on side)”
Cover: E.g “On this image the breast appears to be well within the field” (e.g if being treated prone look at medial border - often poor cover).
OARS: E.g “On this view there appears to be a considerable volume of Lung (or heart) within the field. SAY “**I would review DVHs””
Improve: E.g IMRT/VMAT Technique for OARS, Ask planner to re-plan/optimise more for variable of concern.

Answer to “would you accept this plan”
- Consider tumor location (e.g for lateral tumor, medial compromise may be ok).

Question 2

Treatment issues/factors for large/pendulous breasts:

Answer 2

Treatment:
1) Reproducibility - tend to move laterally
2: May require more lateral fields increasing treatment volume and dose to OARS.
3) Energy may need to be higher
4) Larger skin fold - hotspots/more dermatitis

Question 3

Treatment options for large/pendulous breasts:

Answer 3

1) Treat Prone
2) Breast prothesis to improve reproducibility
3) VMAT or DIBH to improve OAR doses
4) Higher energy photons to decrease hotspots.

Question 4

CTV for bolus to tumor bed:

Answer 4

I would use pre-operative imaging, scar tissues and clips on planning imaging, scar and examination finding (including wired scar) to deliniate my bolus CTV, I would expand this by 0.5cm to PTV (or to departmental guidlines),