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Eyob Mathias Clinical Case Study March 13, 2013 Adenocarcinoma of the Rectum History of Present Illness: Mr. PR is a 74-year-old Caucasian male who was diagnosed with malignant neoplasm of the rectum on February 27, 2013. He had not seen a doctor in at least 5 years. In the past two years the patient was consistently losing weight. Mr. PRs family noticed him losing weight, becoming more sedentary and spending long periods of time in the bathroom. After losing 45 pounds over 2-years period and having diarrhea which started at least one year ago, his family finally took him to a local hospital. He is also unable to control his bowel movement at times. The physician ordered several laboratory tests and found him to be severely anemic, requiring blood transfusion. His hemoglobin count was as low as 7 grams/deciliter. He received blood and underwent an upper as well as lower endoscopy study. The upper endoscopy only showed some reflux esophagitis, but the lower endoscopy revealed an obstructing mass in the rectum measuring between 6 and 10 centimeters (cm) from the anal verge. The scope could not be advanced past the lesion. Biopsies were obtained showing a moderately differentiated rectal adenocarcinoma. He underwent staging studies including a computed tomography (CT) scan of the head which showed some vascular changes. Magnetic resonance imaging (MRI) scan of the brain did not show any evidence of malignancy. CT scan of the chest, abdomen, and pelvis revealed a small pulmonary nodule measuring about 6-8 mm in the posterior right mid lung field, adjacent to the vertebral body, at the level of the tracheal bifurcation. A CT scan of the abdomen showed some enlargement of the pancreatic head and some pancreatic duct dilatation as well as thickening of the colonic wall near the distal sigmoid and rectum. An MRI scan of the abdomen did not demonstrate any pancreatic abnormality and confirmed the presence of a lesion in the rectum. The patient had an echocardiogram and cardiac catheterization at another hospital which showed a diminished ejection fraction and a complete occlusion of the right coronary artery with collateral arterial formation. The staging study was done using Positron Emission Tomography (PET) scan and CT scan. The results showed an area of PET scan avidity in the rectum but no other PET scan avid lesions in the lung or abdomen. It appears clinically that he has a T3NXM0 fixed rectal lesion. Due to his near obstructing presentation, Mr. PR would benefit from chemoradiation treatment prior to surgical resection.

Pasty Medical and Surgical History: Patient has a history of arteriosclerotic cardiovascular disease and chronic obstructive pulmonary disease (COPD) caused by long-term smoking. He had a tonsillectomy and adenoidectomy as a child, but he has had no other surgical procedures. Other than those medical histories mentioned above, the patient has never been ill or hospitalized. Family History: Mr. PRs brother died at the age of 17 and cause of death (COD) is unknown. Patients sister died due to lung cancer, at the age of 50. Patients mother died because of cerebrovascular accident when she was 88 year old. Patient does not know anything about his biological father. Social History: Mr. PR has smoked one pack of cigarettes per day from age 14 to the present, for about 60 years. He used to drink alcohol but he has had none for the past 3 or 4 years. He worked as a carpet installer. Medication: His current medications include one Toprol-XL 25 milligram (mg) per day. He also uses Symbicort twice a day and Ventolin as necessary. He has been taking iron 325 mg daily and some Ensure. Diagnostic image studies: The patient had a variety of imaging studies including a chest X-ray on 01/25/2013 and on 02/07/2013 that showed no pulmonary abnormalities other than the COPD. A CT scan of the chest on 01/30/2013 showed COPD and 6 millimeter (mm) nonspecific, posteromedial, mid-right lung lesion. CT scan of the brain on 01/30/2013 showed no metastases. He had a CT scan of the abdomen and pelvis on 01/30/2013 which showed a large, lobulated head of the pancreas. An MRI of the abdomen on 02/04/2013 was negative and showed no pancreatic abnormalities. An MRI of the head on 02/04/2013 showed no evidence of metastatic disease. He also had a barium enema study on 02/08/2013 that showed narrowing of the rectum to the proximal sigmoid colon. A PET scan/CT scan showed increased uptake involving the distal sigmoid and rectum within the diffuse thickening and narrowing noted on CT scan. Recommendations: Mr. Prs diaAs noted above, this is not strictly a rectal cancer due to its recto-sigmoid involvement. PR has had a colonoscopy in the past and the colonoscopy could not be passed beyond the mass. He had a PET scan which suggests involvement of the recto-sigmoid

as did a barium enema study. Unfortunately, he has a significant level of obstruction and he is at risk for complete rectal obstruction. PR does not appear to be a surgical candidate at this point and given his poor clinical status and marked weight loss, he will not be able to tolerate the necessary surgery. The only recommended plan is to give him combined neoadjuvant radiation with chemotherapy which includes capecitabine at a dose of 1000 mg twice per day (BID), on days 1 through 5 of each week of radiation therapy. This will possibly shrink the tumor to a point where it can be surgically removed keeping his cardiac status under control. The Plan (prescription): A radiation dose of 5040 centigray (cGy) is anticipated at 180 cGy per fraction, to be delivered in 28 fractions, using 6 megavoltage (MV) photon energy beams, per the generated dosimetric plan. This prescription was planned using intensity modulated radiation therapy (IMRT) technique. IMRT is being requested over conventional or 3D planning for optimal dosimetry which will result in maximization of dose to planned target volume, while minimizing dose to critical structures at risk including distal rectum, bladder, small and large bowel, hips which may incur unacceptable morbidity with conventional external beam radiotherapy. IMRT would significantly decrease the probability of radiation toxicity when compared to conventional external beam radiation. A 7 - 9 field plan with inverse planning was prescribed to meet the dose constraints and prevent excess dosage of the critical structures. This particular technique involves multiple volumes receiving different dose per fraction. Depending on the tumor response to the treatment and patients treatment tolerance level, addition boost dose may be given to any residual tumor. Patient Setup / Immobilization: The patient was placed in supine treatment position and radiation borders were obtained on the skin. Reference point (BBs) was placed and verified via CT scout films. CT scan was then performed of the target area without contrast. Measurements were taken and marks were placed. The CT images were sent to Digital Imaging and Communication in Medicine (DICOM) server, where it can easily be downloaded to the Phillips Pinnacle 9.2 treatment planning system. Anatomical Contouring: The gross tumor volume was contoured by the radiation oncologist. Then the dosimetrist outlined the small bowel, bladder, right femoral head, left femoral head and other surrounding organs at risk (OR). The physician reviewed the outlined critical normal

organs at risk. After the necessary contouring adjustments were made, the physician recommended 0.5 cm margin as a planning target volume (PTV). Beam Isocenter/Arrangement: The isocenter was placed in the center of the gross tumor volume. A nine beam IMRT arrangement was utilized for this plan with gantry angles of 2200, 2600, 2900, 3300, 350, 750, 1050, 1400 and 1800. The gantry angles were set to adequately cover the PTV while sparing the contoured critical structures. The collimator angle also played an important role to avoid portions of the bladder and small bowel. The treatment couch angle remained at zero for all the beams. The dosimetrist used 6MV photon energy for all nine beams. The objectives were added into the IMRT module and the treatment planning system (TPS) was set to optimize the appropriate field sizes and monitor units for all the beams. Treatment Planning: Our institution uses ADAC Pinnacle 9.2 treatment planning system. The PET/CT scan was fused with the treatment planning CT to assist the radiation oncologist with contouring the GTV. There are hot script objectives in the TPS that are particularly used for rectal cancer IMRT planning. The dose constraint to the ORs was set with reference to the tolerance doses of radiation table published by cancer network website. The physician wanted to achieve 98% GTV coverage. After the TPS optimized the dose and the adjusted objectives was satisfied, the plan was submitted to the medical physicist department for dose calculation and IMRT quality assurance (QA). Monitor unit calculation: After the plan was approved by the radiation oncologist, the dosimetrist transferred the plan to Mozaiq electronic medical record and verifies system. The medical physicist was able to access the treatment plan from Mozaiq and double check for any inconsistencies or errors. Monitor unit calculations were performed using a second check computer program. Finally, our institution performs QA process only on IMRT plans. The physicist use Matrix to conduct QA procedure. All beams from the plan are computed on the matrix QA device in the TPS and all beams are also measured on the machine with all the beams delivered to tissue equivalent solid water phantom. The QA software records the dose and exports it into the QA analysis computer program. The physicist compares the planar dose from the Pinnacle 9.2 with the fluence map from the machine. The treatment plan passed this criterion within under 3% tolerance dose.

Conclusion: I was hesitant to work on this plan when I first saw the size of the gross tumor volume the physician drew. The gross tumor volume was relatively larger than any other plans I have seen so far. But after I started working on it, I realized the TPS does most of the treatment planning process. The major responsibility that a dosimetrist have when planning IMRT is setting the correct objectives and accurate dose constraints for all the objectives. According to American Cancer Society website,1 brachytherapy (internal radiation therapy) is recommended for people with rectal cancer, particularly sick or older people who would not be able to go through surgery. This technique is also useful for some patients who have a lot of spread to the liver but little or no spread to other distant parts of the body. The physician can inject tiny radioactive beads (yttrium-90) through the artery that goes to the liver.1 These beads block some of the small blood vessels that feed the tumors and their radioactivity helps kill the cancer cells. I believe brachytherapy would have been a better treatment method for Mr. PR to limiting the radiation effects on nearby healthy tissues, downsize the tumor volume, making surgery possible in the future. Currently, Mr PR is under treatment and expects to complete his treatment on April 25, 2013.

Figure 1 AP simulation setup

Figure 2 Right lateral simulation setup.

Figure 3 Isodose lines

Figure 4 Dose Volume Histogram (DVH)

Figure 5 Setup window

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Figure 6 Monitor Unit Sheet

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Figure 6 Monitor Unit Sheet (continued)

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Figure 6 Monitor Unit Sheet (continued)

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Figure 7 Digitally Reconstructed Radiograph (DRR)

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Reference 1. Colorectal Cancer Overview. American Cancer Society, Inc. http://www.cancer.org/cancer/colonandrectumcancer/overviewguide/colorectal-canceroverview-treating-radiation. Accessed March 22, 2013.