Tom Goffman MD, Abstract Co-Author: Nothing to Disclose

Vladimir Ioffe MD, Presenter: Nothing to Disclose

Jason Linefsky MD, Abstract Co-Author: Nothing to Disclose

Michael Gilgrest, Abstract Co-Author: Nothing to Disclose

Claire Carman MD, Abstract Co-Author: Nothing to Disclose

Christine Laronga MD, Abstract Co-Author: Nothing to Disclose

Roger Perry MD, Abstract Co-Author: Nothing to Disclose

et al, Abstract Co-Author: Nothing to Disclose

Purpose/Objective: In a geographic region of known excessive obesity, we were presented with the problem of large breast relaxation back to the posterior axillary line. Over a four-year period we utilized an aquaplast 'bra' with a specially contoured shelf near the anterior axillary line, which permitted alignment of the posterior tangential fields with significantly less heart and lung within the irradiated volume. The shelf kept the breast from slipping down. In all but three cases in which the heart was situated very anteriorly, the maneuver permitted less or no heart to be treated and routinely reduced the volume of lung as measured at the central axis from irradiation. Materials/Methods: Cases were test simulated routinely when the breast position suggested uncertain lung volumes but changed if needed to aquaplast if needed, and consistently when the breast volume and position suggested overwhelming chances of excessive thoracic cavity irradiation. We failed in 3 of 15 cases to avoid the edge of the myocardium entirely due to anterior geography of the heart but succeeded routinely in lung volume reduction. With the advent of increased use of taxanes, lung volume reduction showed promise in reducing pneumonitis. Scatter from the aquaplast-as much as 15%-was offset by breast size requiring mixed 6 and 18 MV beams due to size and separation. The majority of our patients were D cup to cup sizes that had to be ordered specially by mail. No patient desquamated but 7 of 15 noted a generalized 'sunburn' effect. No patient requested removal of the aquaplast. For Afro-American women whose skin often tended to darken, we used 3% white vinegar and lava soap two weeks post radiation. Results: Overall we found this simple methodology to be routinely effective in reduction of lung volumes and very frequently effective in avoiding cardiac irradiation and may as well have been an aide in treating severe asthmatics and one cardiac transplant recipient. 3D or IMRT planning of such cases reduced 'hot spots' but failed to significantly reduce vital organ irradiation. Pre and post aquaplast shelf use documented changes as large as 4.5 cm central axis lung dose dropping to 2 cm and with training both simulator technologists and therapists were able to help set up these 'shelf' fields and treat them consistently. Simulation pictures and 3D plans documented the efficacity of the method and the treatment of the entire breast in over 30 consecutive cases. Finally, 3 professionals are required at the time of shelf construction or there will be breast tissue extending superiorly or inferiorly out from under the aquaplast or an unnatural air gap formed in the medial portion of the breast without several pairs of trained hands. Fixation time is reduced using a wet cold towel and the procedure now takes us no more than an extra 5 minutes during simulation. Construction of the shelf requires very firm compression of the aquaplast against the chest wall with the patient moved to the edge of the simulator table and was done by the same physician in all cases. Conclusions: We offer this technique as an addition to 3D or forward IMRT planning of breast irradiation. A few patients could not be CT planned due to girth or weight constraints. The technique proved ineffective in patients with prior mammoreduction as the breast tissue appeared surgically fixed to the lateral chest wall, as opposed to simply overhanging it. Reduction in lung volumes without compromise in treatment of breast tissue was 100%; avoidance of the myocardium was 80%, although in several cases the beams posterior edge sat just off the myocardium, suggesting some dose to the rather superficial coronary arteries. Women were simulated and treated with 1/2-2/3 full lungs, but permitted to take shallow breasts during both simulation and treatment. We found this added modestly to cardiac avoidance.

Goffman, T, Ioffe, V, Linefsky, J, Gilgrest, M, Carman, C, Laronga, C, Perry, R, et al, , Repositioning of Large Lax Breasts with an Aquaplast Shelf.  Radiological Society of North America 2004 Scientific Assembly and Annual Meeting, November 28 - December 3, 2004 ,Chicago IL. http://archive.rsna.org/2004/4417792.html