Breast Fields

Matching tangential fields with the Supraclavicular field

3field

A) The superior edge of the tangential beams can be made perfectly vertical by means of the "hanging block" technique
B) The superior edge of the tangential beams can be made perfectly vertical by avoiding rotation with the use of a rotating beam splitter.

PMRT w/o AXILLARY BOOST (based on SWOG 9927)

Supraclavicular Field

Supraclav
Top cricothyroid membrane but do not flash the shoulder
Inferior inferior clavicular head
Medial 1 cm contralateral to anterior midline
Lateral bisect coracoid process
Gantry 10-15 degrees to avoid trachea, esophagus and spinal cord.

Note: this does not treat the "axilla"
1/2 beam block the SC field to avoid divergence to tangent fields

Chest Wall Fields

CW_T
Medial 5 cm into the ipsilateral chest wall from the med-stermun
Lateral Mid-axillary line
Superior Mached to Surpaclavicular field
Inferior 1 cm inferior to inframammary fold

Technique A (Tangents + IM Fields)

Medial_Strip

Internal Mammary Electron Field
Medial-lateral

  • 1 cm contral-lateral of the midline to tangent field. ||

Superior-inferior

  • length of the tangent field
  • Interspace 1-3 should be marked and the IMC field can be split into two field so that separate electron energies can be used to cover the depth of the IMN.

Internal Mammary Photon Field

  • Anterior photon field can be used up to 5 treatment to spare the skin
  • Inferior border is at the tip of the xyphoid otherwise same as IM electron field.

Technique B (Partial Deep Tangents)

Wide_T

Superior Tangents
Cover IMN 1-3
Limit lung to 3.0 cm. If this is not possible use alternate technique.

Inferior Tangents
Eliminate incidental cardiac irradiation
electrons to inferior medial and/or lateral aspect may be needed

Technique C (Electrons)

CW_E

90% of isodose line should encompass the nodes
6-12 MeV should be used for the IMN
6-9 MeV are sufficient to cover chest wall.
If energies in excess of 12 MeV are needed alternate plan need to be used due to concerns of pneumonitis.

Technique D (IMRT)

Bolus

  • Photon field should be bolused every other day with 1 cm or 0.5 cm.
  • Reconstructed breasts should also receive bolus.
  • Electron field should not require bolus.

Dose

  • 50 Gy in 2 Gy fractions
  • 50.4 Gy in 1.8 fractions
  • 10 Gy boost in 2 Gy fractions

IRRADIATION OF REGIONAL LYMPHATICS

Supraclavicular Lymph Nodes

SCsmall.tiff
Top cricothyroid membrane but do not flash the shoulder
Inferior inferior clavicular head
Medial 1 cm contralateral to anterior midline, following the medial border of the sternocleidomastoid muscle
Lateral bisect coracoid process Lateral to Humoral Head
Gantry 10-15 degrees to avoid trachea, esophagus and spinal cord.

Note: this does not treats the "axilla"
1/2 beam block the SC field to avoid divergence to tangent fields
(AP/PA) supraclavicular/axillary fields may be reasonable when the axillary and supraclavicular nodes are deep.

Posterior Axillary Boost

PABsmall.tiff
Top split the clavicle
Inferior match supraclavicular field
Medial 1.5-2.0 cm of lung
Lateral posterior axillary fold
Gantry 10-15 degrees to avoid trachea, esophagus and spinal cord.
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