Bootstrap Framework 3.3.6

[jadyn_pretty]

At our facility we have treated a handful of supraclav/chestwall patients with BOLUS using DIBH technique monitored by VisionRT.  At least two of those patients also had electron IM match fields.  We have found these treatments to be extremely cumbersome for both the therapists as well as the patient.  Are there any other facilities out there with doctors who plan this way?  Tips?

[amanda_moreira]

Hi Jadyn,

At my centre we generally treat these patents with an IMRT plan that includes the IMC.  They usually end up being about 9 Fields.
As to patient set up, we use the standardly recommended set up in FB and DIBH.  I think our main learning curve for this patient group was the Bolus.  Even though we use a Flab that does have a certain shine to it, we have found that the system can still see enough to correctly gate the treatment.  I think this has to do with our ROI, which we draw to include chest wall inferior to the treatment area and well across the patient's midline. After set up in FB and DIBH we use an additional DICOM surface that is the body contour in DIBH including the Bolus for imaging and treatment.
Our standard imaging for an IMRT breast treatment in DIBH would be AP-LAT Kvs and an additional tangential KV.  We did some extra imaging on the first few bolus patients just to double check everything, but I think the best thing to do is remember to take your time.  It is a lot of breath hold for the patient, so training on CT is also important!

Hope this is helpful, and if you want more info about how we set our beams/constraints for an IMRT IMC plan let me know,
Amanda

[michael_tallhamer_msc_dabr]

Jadyn,

We used to do these types of treatments with matching electron IMN fields but they have fallen out of favor with our docs as they now would rather use "deep tangents" to treat these IMNs. The BH treatments with matching e- IMN fields were always challenging but we don't find much issue with standard bolus CW and matched SC fields.

As far as the BH with IMN e- fields go the easiest thing we found that worked well (again while we were still doing these) was to set your patient up to the FB surface then have them breath to the BH DICOM surface. If everything looks good we would switch to our monitoring field (or bolus field if you have had the VRT training) where we would have them breath into the BH DICOM and when it matches place the bolus and snap a reference. Under this field you have 2 ROIs one standard ROI for monitoring the tangents with bolus and one over the contralateral aspect of the chest to use for monitoring during the IMN e- field so we had something to look at outside of the e- cone. Before we would start treatment all we would do is again have them breath into the reference BH with the bolus and then check both the ROI for the tangents and the ROI on the contralateral side for use during the IMN field to make sure they correlated well (they should). They both had to be within tolerance before treatment could continue. If your docs like to check the match line (as ours did) we would draw the Med boarder prior to placing the bolus under BH and then when we switched to the IMN e- field we would have them BH to the contralateral ROI position and check the e- light field against the previously drawn Med boarder.

Hope that helps. Deep tangents are the way to go IMO!

Mike

[chris_mcguinness]

Hi Amanda,

Would you be willing to share your beam setup and constraints for IMRT IMN plans?  We are considering using IMRT for some of our challenging patients with IMNs. And we are also looking into APBI treatments which would further motivate us to implement IMRT planning for those breast patients.

Thanks,

Chris