ALPHA CRADLE® FOR TREATMENT OF THE BREAST PATIENT

Eddie W. Scott, BSRT, RT
Nashville Memorial Cancer Center
Madison, Tennessee

Over the past twenty years, there have been a great number of improvements in the field of radiation therapy. Since the early seventies, this field has acquired the use of sophisticated computed tomography and magnetic resonance scanners to better serve physicians in tumor diagnosis. This field has witnessed the onset of very sophisticated isocentric simulators and planning computers to better potentiate the entire treatment planning process of radiotherapy. The availability of these diagnostic and therapeutic tools have made it possible to achieve a high degree of precision in the field of radiation therapy.
Although there are many new tools that offer new approaches to precision radiotherapy, one weak link that poses a threat to the overall treatment planning process is the problem of patient positioning.
Regardless of how modernized and sophisticated our diagnostic and therapeutic tools are or how knowledgeable our radiation oncologists are, if the daily treatment cannot properly be administered, then all is to no avail. Therefore, correct patient positioning is critical and must be viewed as such by the radiation therapy technologist.
In this field, patient positioning is crucial. For the proper treatment to be delivered, it is necessary that the patient be placed such that the exact position can be maintained and reproduced each day. The quality of patient care provided by the radiation therapy technologist is dependent upon precisely administered treatments. Therefore, optimal treatment requires a conscientious daily effort to minimize any variations from the selected treatment plan.
Through my experiences over the past several years, I have found that by using the ALPHA CRADLE® devices from Smithers Medical Products, Inc., the risk of error due to patient positioning is greatly reduced. I have used ALPHA CRADLE® devices as an aid to treat various parts of the anatomy. Set-up for the breast and chestwall regions is enhanced by the use of the cradles. The ALPHA CRADLE® device is a simple tool that is commonly used in many institutions for treatment to this region of the body. By using the ALPHA CRADLE® device I have found that it enables the technologist to duplicate the daily treatment with much consistency.
The breast or chestwall patient can very often be difficult to obtain correct positioning. Radiotherapy of the breast and adjacent nodes involves the most complex geometric and field matching situation for the average radiation oncology department. The treatment position for the patients with breast carcinoma varies somewhat depending on the treatment technique employed. It should however, remain the same during the entire course of treatment and during the treatment of each field each day. Once positioned in the ALPHA CRADLE® device each day, the patient’s position should remain constant until the treatment is complete.
The basic technique for the treatment of breast carcinoma is opposed medial and lateral tangential fields directed across the chestwall or breast and in many cases an anterior field to include the supraclavicular an axillary lymph nodes. The inferior field border of the supraclavicular field should be matched against the superior field border of the tangential field to avoid an underdosage in the area between the two fields. Some physicians choose to use a small gap between these two fields to prevent an overdose or hot spot to this region.
Achieving coincidence of these three diverging beams is a problem never easily solved. When treating the small breast one may find that it is quite easy to get field sizes to coincide and field borders to match and line up correctly. On the other hand, treating the large pendulous breast often requires manipulation of the upper thorax and arm to properly align fields.
It cannot be over emphasized the importance of NOT overlapping the tangential and supraclavicular fields. The ALPHA CRADLE® device which provides a great deal of stability for this particular treatment set up, is the most effective tool in controlling this problem. Since the ALPHA CRADLE® device is formed to the patient’s contour, it allows for minimal involuntary movement of the patient’s body. This enables the technologist to duplicate each field daily with very little discrepancy. By using the ALPHA CRADLE® device for this treatment, I have found the consistency of this treatment set up to be unmatched by other methods.
The ALPHA CRADLE® device is prepared for this technique just prior to the simulation process. Upon pouring the foaming agents in the ALPHA CRADLE® liner, the foam will begin to rise and proceeds to inflate the polyform bag in the position that the patient is to be treated in each day. This now allows the mold to conform to the contour of the patient’s body. After the mold has hardened, the field parameters are set and measurements are taken with the patient being in what is now the actual treatment position. This now allows for consistency between the simulation table and the treatment couch.
Both the chestwall and the breast setup requires extension of the arm for entry and exit of the radiation beam. The arm position must be reproduced each day since skin marks move over underlying tissue as the arm position changes. By using the ALPHA CRADLE® device, this problem is eliminated. The ALPHA CRADLE® device forms a hardened foam resting surface below the shoulder and extending the numeral shaft. This allows for the shoulder and arm to be in the exact position each day. This, in turn greatly enhances the match line accuracy between the tangential and supraclavicular fields. The ALPHA CRADLE® device eliminates the need for using an armrest to extend the arm away from the torso. Unlike an adjustable arm rest, the ALPHA CRADLE® device allows for much greater precision in the treatment since the arm is lying in a flat pre-molded cast rather than hanging from an adjustable bar that allows the elbow to swing freely. This will provide more consistency in aligning the supraclavicular – tangential match line.
This junction line between the supraclavicular and tangential field is a very critical region. The treatment to this area must be precise in order to prevent ‘hot’ or ‘cold’ areas as this junction site. By using the ALPHA CRADLE® device, this problem is virtually eliminated. Since the patient’s arm is placed in a premolded form, no change in the arm position will likely occur from day to day.
The thorax which rests flatly in the ALPHA CRADLE® device is also in a very comfortable and stable position. The thorax is held secure on each side by the hardened ALPHA CRADLE® device which has inflated to create a rim-like wall on each side of the upper torso. Therefore, lateral movement of the thorax is not possible while in the ALPHA CRADLE® device. However, the technologist must be careful to assure that the patient is lying flat in the form during simulation when the ALPHA CRADLE® device is being formed.
On occasions, treatment plans for breast of chestwall patients will include a boost (an additional radiation field) to the posterior axillary region. If this is indicated, modifications can be made to the ALPHA CRADLE® device without causing any effects on the patient’s position. In this instance, a small opening can be cut out just over the auxiliary region. This will allow a posterior radiation beam to treat the axillary nodes without attenuation from the ALPHA CRADLE® material.
Many physicians prefer using a breast board as an aid in treating this region of the body. The breast board is basically an angle board that the patient lays on to level the upper and lower chestwall. This technique can be used very successfully in treating breast and chestwall region. However, for this technique there are several variables that make reproducibility each day difficult (i.e. obtaining the exact position on the breast board each day). The ALPHA CRADLE® device does not reduce the slope of the chestwall as nicely as does the breast board. However, it compensates for this in reproducibility, stability, and patient comfort. Many physicians who prefer the breast board have not had the opportunity to use the ALPHA CRADLE® device and experience their versatility.
Many institutions use elaborate casting techniques to immobilize patients during treatments. Some of these techniques have been quite effective in minimizing patient motion. However, patients are known to move within a cast especially if the fit is not good. One of the benefits to using the ALPHA CRADLE® device is that the hardened rim that forms the top and sides of the cradle secure the patient from moving in any direction. Another advantage is that after lying in the ALPHA CRADLE® device for a few treatments, the patient will be able to tell if they are in the correct position within the ALPHA CRADLE® device.
The ALPHA CRADLE® device does provide a great deal of stability for the breast and chestwall set up. It can also be used very effectively for other treatment set ups (i.e. mantles, head and necks, and extremities).
There are many different immobilization techniques that are used for treatment of the breast and chestwall region. I have found the most effective of these methods are those in which the patient is positioned lying relaxed and comfortable. Some treatment set ups for the breast region place the patient in cumbrous positions which often results in an ineffective treatment plan.
I feel the ALPHA CRADLE® device meets the needs for all involved in the treatment of carcinoma of the breast. It provides the technologist with security in knowing that the treatment set up is correct. It helps provide the physician an optimum treatment plan for the breast region and it provides the patient a stable and comfortable resting surface in which to be treated.