A multidisciplinary approach to improving the quality of tangential chest wall and breast irradiation for carcinoma of the breast.

Physicists, radiotherapists and radiographers have worked together to enhance the quality and accuracy of radiotherapy for tangential irradiation of the chest wall and breast. Each stage of the process has been reassessed and improved. A technique has been developed on the treatment simulator which determines the required beam directions and sizes in a straightforward manner. A computerised tomography facility has also been developed on the simulator and this provides one or more slices for planning through the treatment volume, thus allowing accurate determination of external contour and lung position with the patient in the treatment position. The beam edge entry points and the isocentre position can be seen from radiation opaque markers placed on the skin surface, allowing accurate reproduction of the treatment beam positions as set on the simulator. A photon beam algorithm that corrects for the changes in scatter dose in a 3-dimensional (3-D) inhomogeneous situation has been developed and applied to tangential chest wall irradiation. This has shown large differences (up to 10%) in dose compared to a conventional 2-dimensional algorithm. The changes in dose distribution due to the accurate determination of lung position have also been investigated. A method has been developed of measuring the volume of ipsilateral lung irradiated. Dose-area histograms are used to evaluate the fraction of the lung area irradiated in the central slice, and an estimate of the volume irradiated can be made using a beam's eye radiograph and the simulator CT image.