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Nick Piotrowski Clinical Practicum II June 3, 2013 3 Site Metastatic Bone Cancer History of Present Illness: JR is a 51 year old female with recently diagnosed metastatic bone cancer. While they are not positive of her primary, it is most likely from a previous lung carcinoma. She presented with pain in her left abdomen as well as her right leg and hip. A nondiagnostic liver biopsy also helped to determine a benign lesion in her liver. The rib biopsy revealed a poorly differentiated pleomorphic carcinoma. All of the metastatic disease has been the main reason for the use of radiation therapy treatment alone. Past Medical History: JR has a very thorough previous medical history with a variety of operations. Besides minor arthritis, a birth defect, heartburn, a slight heart murmur, she also had some surgeries performed. A tubal pregnancy, where the egg attaches in the fallopian tube,1 lead to an abdominal surgery in 1993. Later in 1993 JR also had a hysterectomy, as well as a tonsillectomy in 1973 and again in 1990. Social History: JR is married with two children whom she does not communicate with very often. This stress as well as the lack of understanding of her diagnosis has made this a difficult situation for her. While she does not consume alcohol or any drugs, she has been smoking one pack per day for almost 30 years. Medications: She is currently taking 150 milligrams (mg) of Bupropion H as well as 40mg of Prilosec daily. She also takes 12 micrograms (mcg) of Fentanyl every 3 days, 1 tablet of Hydrocodone every 6 hours and 0.5mg of Lorazepam every 8 hours as needed. She has not yet discovered any drug allergies. Diagnostic Imaging: Within the last month JR has received a variety of scans to help diagnose her most recent disease. Liver and gallbladder ultrasounds were taken to determine the extent of her disease. A suspicious heterogeneous mass on the left liver lobe required her to get a biopsy completed as well which came back benign. A magnetic resonance image (MRI) of the brain helped to reveal nothing abnormal in that region. A whole body bone scan showed activity in the left rib, and right hip to the shaft of the femur. Finally, a computed tomography (CT) scan with contrast of the abdomen and pelvis revealed the same liver lobe mass and lesions as the bone scan.

Radiation Oncologist Recommendations: With such extensive disease and most of it being inoperable, the physician suggested doing radiation therapy alone. The treatment would be completed within one week as it would only consist of 5 fractions. The lesion on the iliac crest as well as the proximal femur were in regions that would not affect other critical structures. The Plan (prescription): To finish her relatively quickly, the plan was only to receive a total of 5 fractions for each site. While there were three separate plans, each site was prescribed to 2000 centigray (cGy) at 400cGy per fraction. Due to her pain levels and the fact that there were three separate sites, it was important the plans be relatively simplistic. Two of the three sites had only 2 fields and the right hip was created with 3 fields. Patient Setup/Immobilization: During the treatment planning CT the radiation therapists attempted to make JR as comfortable as possible. She was able to lie supine on a wingboard with her arms above her head. The isocenter for the left rib was set in the simulator by the physician, and marked by the therapists. Not knowing whether the other two lesions would fit in one field, the second isocenter was placed and marked halfway between the hip and the femur lesion. Anatomical Contouring: As both the femur and hip tumors were not near structures of great importance, there was little contouring to be completed. In both plans I contoured the right femur from acetabulum to the end of the scan. For the left rib however, the left lung and spinal cord were considered critical structures. While the spinal cord didnt receive substantial dose, the left lung needed the most attention. In addition, with the use of a posterior beam in each plan, it was necessary to contour the couch as it does absorb and scatter radiation. Beam Isocenter/Arrangement: Using a Varian iX linear accelerator JR will complete treatment to all three sites within the week. Using the isocenter set in the simulator and contours drawn by the physician, the plan was conformed to the clinical target volume (CTV). The CTV for the rib consisted of a 0.7 centimeter (cm) margin on the lung side of the tumor, and a 1.5 cm margin elsewhere to the block edge. It was planned using a wedge pair technique, requiring a collimator rotation of 90 degrees for both fields. As the isocenter for this was set during simulation, there was no need for shifts. (Figure 1) The right thigh field also used a wedge pair, but included a mixed energy technique as well. The gross tumor volume (GTV) plus a margin of 2cm to the block edge was used to set my field borders. To eliminate a portion of the hot spot, the lateral field used an 18 megavoltage (MV) energy while the posterior anterior (PA) beam was 6MVs.

With the isocenter being set in the simulator between the two leg lesions, this plan also required some shifts. The right thigh shifts completed on the first day were 5.8cm inferior, and 3.5cm right. (Figure 2) Finally the right pelvis was planned using a 3 field technique conformed to the GTV with a 2cm margin. It was originally tested anterior posterior (AP)/PA but a third field became necessary to split up some of the dose. The fields were weighted 2:3:3 AP, PA, and the right anterior oblique (RAO) respectively. Again the use of wedges required a 90 degree collimator rotation and an open field design. This plan also required shifts from the initial isocenter, resulting in a 9.6 cm superior and 5.9 cm right shift. (Figure 3) Treatment Planning: The ultimate goal for JRs plan was to reach a dose of 2000 cGy to the tumor volume while sparing the critical structures surrounding it. The planning system Eclipse 10.0 was used to create the plans and do the initial calculations for each. With there being no real concern of surrounding structures, the physician didnt leave me with any constraints for these plans. While the physician did suggest keeping the dose to the femur low on the thigh plan, and the lung dose low on the rib plan, he wasnt worried about possible overdosing. When verifying the plans, the physician did use the dose volume histogram (DVH) to assess the lung dose in which 20% of the volume received 15% of the dose. (Figure 4) With tolerances not being an issue, it was most important to try and get the best possible coverage while keeping the hot spots to a minimum. In order to do this, a wedged pair technique with 45 degree wedges was utilized. The calculation point was set near the lung in an attempt to bring some of the coverage deeper and avoid cold regions. (Figure 5) For the right thigh treatment plan, another wedged pair technique was used in an attempt to increase the coverage of the tumor and bring some of the dose off the superficial region. (Figure 6) The 30 degree wedges also helped to bring the centralized hot spot down to 102.3%. The final editing of the plan was to assess the weighting of the two fields. The RAO field required 60% of the dose in order to keep some of the exit dose from entering the femur. Lastly, the right pelvis plan ended up being slightly more labor intensive. Unlike the previous 2 plans that were simply 6MV energies, the right pelvis plan required a mix of energies, weights, and wedges. As the lesion on the iliac crest was relatively anterior, the PA beam needed an energy of 18MV to reach the tumor without depositing too much dose posteriorly. It also used a 30 degree wedge with the heel laterally to compensate for sloping of the tissue. On the AP beam, a similar technique was used with the 30 degree wedge, but because the lesion was more superficial, a 6MV beam was ideal. Finally, a RAO beam with

a 10 degree wedge was put in place to improve the tumor coverage and decrease some of the existing hot spot. With the margin directly next to the block edge, there was a limited build up region before reaching the tumor. Fortunately with the variety of angles and wedges, the coverage of the tumor was excellent and the hot spot was kept to 104.8%. (Figure 7) Quality Assurance / Physics Check: Before printing, the monitor units that were calculated by Eclipse were double checked using RadCalc. Once the numbers were found to be within the 2% tolerance, the plan was checked and signed off by both the medical physicist, as well as the attending physician. Conclusion: Being 5 months into the clinical rotation this plan was not the most challenging of the plans that I have worked on. However, having a multiple site treatment with two isocenters and 3 treatment sites forced me to be extremely organized. With the physician leaving the beam arrangement up to me, I was able to try a variety of plans and techniques to see what worked the best for each site. While the plan wasnt strenuous, I found excitement in having the time to experiment with different ideas and methods to cover the tumor volume. Ultimately it was the patient comfort and ease on the therapists that made my decisions on this plan. With it being three separate sites I had to take into account that the patient would be on the table for a long period of time. While extra beam angles may have slightly improved my coverage, if the patient was on the table too long there was an increased probability of motion. While this plan may not have pushed my dosimetry skills as far as other plans, I felt as though I was acting as a true dosimetrist. I recognized that a plan needed to be completed, communicated the appropriate questions with the physician, and got the patient ready to be treated in plenty of time. While it may not have happened overnight, I do feel as though I am becoming a competent dosimetrist.

Figures

Figure 1. Isocenter set in simulation for left rib lesion.

Figure 2. Placement of field with MLCs for right thigh lesion.

Figure 3. Placement of field with MLCs for right pelvis lesion.

Figure 4. DVH summary of the left rib plan.

Figure 5. Left rib lesion isodose line coverage with reference point labeled left rib

Figure 6. Isodose line coverage of the right thigh with a hot spot of 102.3%

Figure 7. Three field right pelvis plan dose distribution.

References 1. Mayo Clinic Staff. Ectopic pregnancy. Mayo Clinic. 2012. Available at: http://www.mayoclinic.com/health/ectopic-pregnancy/DS00622. Accessed June 3, 2013.