When treating whole breast, how do you minimize contralateral breast dose without sacrificing coverage and lung/heart dose?

In terms of minimizing contralateral breast dose, it starts in simulation for me. I try to make sure the contralateral breast is as far away from where medial tangent will enter. If contralateral breast is close, you can consider taping it away.

For tangents only or tangents with SCV (without IMN):

I typically don't run into issues with contralateral breast dose in these cases as long as contralateral breast is positioned well at sim. Heart and lung doses can be kept low with DIBH.

For tangents...

This is a great question and poses a unique situation both in the intact breast setting as well as the PMRT setting. Since the former was addressed in the answers yesterday, I would like to quickly share some thoughts on the latter.

Patients who require PMRT and who present to our clinics with large reconstructions (somewhere > 300-400 ccs) face a tradeoff dilemma between irradiating too much ipsilateral lung vs. too much of the contralateral side while trying to cover the entire chest wall and...