1

Ashley Pyfferoen January Case Study January 21, 2013 Conformal Treatment for Basal Cell Carcinoma and Squamous Cell Carcinoma of Lower Right Leg and Foot History of Present Illness: Patient SG is an 87 year-old male that has an extensive history of precancerous and cancerous skin lesions throughout his body. This history predates electronic medical records with dermatological treatments beginning 25 years prior to the patients initial consultation with the radiation oncologist in December 2012. Patient SGs dermatologist has been treating these non-melanomatous skin lesions on a monthly basis with chemotherapy (5Fluorouracil), cryosurgery and excision since 2008. Generally, the patient has been asymptomatic with these skin lesions understanding that the goal of these treatments is palliation. In September 2008, the dermatologist first noted a troublesome area on the lower right leg approximately 13 centimeters (cm) superior to the right medial malleolus. He treated this area with 5-fluorouracil mixed 50/50 with 1% Xylocaine and epinephrine. The area was continuously monitored and treated via chemotherapy in subsequent appointments. In April 2009, this area was excised and the pathology report indicated residual squamous carcinoma in situ with a small area of superficial infiltrating squamous cell carcinoma. At the time of this report, margins were free of disease. In a follow-up appointment, the physician excised an area of the same tissue and revealed well differentiated squamous cell carcinoma of the keratoacanthoma type. In August 2010, the dermatologist noted a second more troublesome area as well. It appeared that the dorsal surface of the patients right foot was now becoming difficult to control with chemotherapy and cryosurgery alone. This area was excised and pathology results confirmed well differentiated squamous cell carcinoma. Similar chemotherapy and cryosurgery treatments continued on both areas until late 2012 when the physician noted the difficulty he was having keeping these areas under control. The physician noted these areas were not healing as a result of continuous infections and contained either squamous cell carcinoma in situ or invasive cancer. The dermatologist suggested that the patient should consider radiation therapy to control these areas and was referred to a radiation oncologist. At the time of referral, both areas were positive for basal cell carcinoma and squamous cell carcinoma.

In December 2012, the radiation oncologist met with SG to discuss treatment options for both regions of interest. The physician discussed the possibility of superficial palliative treatment and side effects associated with radiation therapy. After this appointment, the patient chose to proceed with radiation treatments to the lower right leg and dorsal surface of the right foot. Past Medical History: The patient has a past medical history of squamous cell carcinoma, pterygium, nuclear cataract, choroidal nevus, basal cell carcinoma, actinic keratosis, unspecified peripheral retinal degeneration, unspecified ectropion, blepharitis, tear film insufficiency, vitreous degeneration, and actinic skin damage. The patient was also diagnosed with early stage laryngeal cancer approximately 15 years ago that was treated and successfully eradicated with radiation therapy. Patient SG also indicated ectropion surgery to his left eye in February 2009. The patient has no known allergies. Social History: Patient SG presents himself as a retired widow and has denied ever smoking or using smokeless tobacco. The patient reports no alcohol or drug use and is not currently sexually active. The patient also reported that his mother had glaucoma and is deceased. Medications: The patient uses the following medications: CefaDroxil, Cholecalciferol, Hydrochlorothiazide, Multivitamin Niacinamide, Silver Sulfadiazine cream and Soriatane. Diagnostic Imaging: This patient has no diagnostic images because lesions are visible. Radiation Oncologist Recommendations: The radiation oncologist reviewed the information documented from the dermatologist and after the consultation with SG, he decided to proceed with external beam radiation therapy to the lower right leg and dorsal surface of the right foot. This patient had been receiving consistent chemotherapy injections and excisions to this area on a regular basis for a number of years, as recommended for non-melanoma skin cancer.1 The decision to proceed with radiation treatments came after both areas became infected, preventing the dermatologist to proceed with further injections and incisions after the skin lesion continued to spread. While it is not recommended that individuals infected with non-melanoma skin cancer over 50 with cancerous areas of the lower extremities receive external beam radiation therapy, the patient had exhausted all other factors for fighting the disease.1 The oncologist chose to treat the right leg with a 6 megavoltage (MV) photon beam 3-Dimensional (3D) conformal treatment plan and the right foot with a 6 million electron volts (MeV) electron beam clinical setup that didnt require a treatment plan. Generally, while treating superficial lesions such as skin cancer, low energy photon beams are used because of a superficial maximum dose (dmax) keeping the

hottest dose distribution near the surface.2 In contrast, the 6MeV electron beam has a skin sparing effect when compared to higher energy electron beams. Therefore, when treating with a lower energy electron beam, it is essential that bolus is used to bring the skin-surface dose to 100%.2 With this combination of treatment energies, the goals were achieved. The Plan (prescription): The radiation oncologists plan to treat the right leg consisted of a basic photon beam conformal treatment plan at 6MV. This plan consisted of two oblique parallel opposed fields to spare unaffected skin posteriorly. In addition, two modulated fields were added to improve dose homogeneity. The right leg was prescribed to 50Gy at 2.5Gy per fraction for 20 fractions. The right foot was treated with an en face 6MeV static electron beam with a 15x15cm cone. The prescription to this lesion was 50Gy at 2.5Gy per fraction for 20 fractions as well. The oncologist did not recommend a boost since the area is diffuse and palliative. Patient Setup/Immobilization: In early January 2012, the patient presented for a computed tomography (CT) simulation scan in the radiation oncology department. The patient was placed on an elevated Vac-Lok bag supine on the simulation couch and inverted so he would enter the scanner feet first for scanning purposes (Figure 1). He was then marked to align with in-room lasers for treatment. The patients leg was wrapped with an 8x12 inch, 1 cm deep bolus from the medial to lateral side of his right leg. A smaller 1cm piece of bolus was placed anteriorly and bonded to the larger bolus with medical tape (Figure 2). A wire was wrapped around the pretibial region to locate field edges on the axial images. The patient did not undergo a simulation for the right foot since the clinical setup required no treatment planning. However, clinical setup was documented on the first day of treatment. Patient SGs foot was placed with sole flat on the simulation table and secured with tape. Custom lead shields were designed to cover the patients toe nails and medial portion of the foot (Figure 3). One cm of bolus was placed on the entire dorsal surface of the patients right foot to increase dose to the surface (Figure 4). Setup photos were taken and the patient was measured and marked for reproducibility accordingly. Anatomical Contouring: In conclusion of the CT simulation, the axial images were uploaded into the Philips Pinnacle3 8.0m radiation treatment planning system (TPS). Because this patient was being treated for superficial skin lesions, the physician did not place a tumor volume in the scanned extremity. The leg and the wire were contoured to define the bolus outline and field borders. There were also no organs at risk in the area of treatment, therefore, no other structures

were contoured. The physician reviewed the leg and wire structures contoured. The structures were suitable for planning and the dosimetrist was given a prescription to begin planning. Beam Isocenter/Arrangement: This patient was treated on a Varian Clinac 21EX machine. The isocenter was placed centrally in the patients leg, at approximately 4cm posterior to the anterior skin surface and 5cm lateral from the medial portion of the leg. The isocenter was placed exactly midpoint to the wire contours placed during simulation and was used as the calculation point as well (Figures 5-7). In treating the right leg, the gantry angle of the right anterior oblique (RAO) field was determined to be 295 and the gantry angle for the left posterior oblique (LPO) field measured to be 115, proving them to be exactly parallel opposed beams. In addition, this treatment plan did not require the changing of couch angle and remained at 0. The field size apertures were determined by the wire that was placed on the leg for simulation (Figure 8). Since the wire represented the exact area of skin the radiation oncologist wanted to treat, the field sizes were determined accurately. This area was treated with a 6MV photon beam. For the clinical set up of the right foot, isocenter was determined differently. Because the lesion on the foot was visible, the physician manually determined where to place isocenter by mapping out a treatment area on the skin with a maker. He drew an X to theoretically determine where isocenter was located on the foot (Figure 9) and the gantry was placed at a static 25 angle with a 15x15cm cone. The couch was rotated to a 270 angle. As mentioned before, this field will be treated with a 6MeV electron beam. Treatment Planning: Considering the patients extensive history with recurrent and diffuse precancerous and cancerous lesions, aggressive palliation was the objective of this treatment regime for both regions of interest. With this information, the dosimetrist attempted to achieve the best dose uniformity to the superficial surface of the leg and there were little constraints that made that goal difficult. The daily fractionated dose was weighted approximately equal between the RAO and LPO beams to deliver the prescribed dose to the right leg via isocenter. While discussing constraints, the radiation oncologist requested as low as reasonably achievable (ALARA) for the soft tissue area to avoid treating any area deeper than the surface to a high dose. In addition, he requested that the posterior portion of the leg be spared to allow for lymphatic drainage. After initial calculations, the skin received the appropriate prescribed dose; however, there was significant dose distribution beyond the skin surface and into soft tissue. To correct for this, a modulated field was created for each beam to block out hot spots and keep

significant dose distribution near the skin surface and lesions (Figure 10). Both of these modulated fields were weighted equally and the plan was recalculated. After these changes, the hot spots were minimal and the highest doses were kept superficially. These four fields combined treated the patient with a dose of 250cGy per day and the isodose lines were suitable (Figure 11-12). Using the DVH, the dosimetrist was able to confirm the treatment area was receiving adequate dose (Figure 13).The physician viewed this plan and accepted with a normalization of 98% of the prescribed dose for daily treatment. While the right foot wasnt simulated for treatment, a plan was still created to determine the amount of monitor units (MU) need to give the appropriate dose prescribed by the physician. The radiation oncologist provided the dosimetrist with the appropriate dose per fraction, field size, percentage of prescribed dose that will be used for treatment, and patient setup (100 source to skin depth). Using a manual MU calculation, the dosimetrist was able to determine the treatment required 278 MUs to administer per fraction. He also verified this calculation with a MU calculation computer program. Quality Assurance/Physics Check: The MUs were reviewed for both treatment areas. To check MUs for the right leg, an MU calculation program was used. All of the MUs for the treatment plan were within tolerance (5%) of the calculations computed by the program. The physicist also verified prescription, Digitally Reconstructed Radiographs (DRR), treatment fields, and treatment calendar to ensure that the dosimetry was precise. The MUs for the right foot were verified by calculation via a department physicist. He checked the prescription, dose, cone size, cutout, SSD, monitor units and isodose percentage. Conclusion: While the treatment plan presented few difficulties for the medical dosimetrist, the reproducibility for administering treatment daily has a high degree of difficulty. Firstly, the patient has numerous skin lesions in the treatment area that have become tender and weepy. It is difficult to accurately place the bolus without causing serious pain to the patient. Another struggle is the patients inability to keep the alignment markers on his skin. The radiation therapists have to realign the patient weekly. Thirdly, because the treatment to the right foot is a clinical setup without any reusable immobilization devices, reproducibility while treating the foot is the biggest struggle of all. The radiation therapists spend several minutes adhering SGs foot to the table and attempting to draw a coordinate system to help align the extremity the next day.

One difficulty that did present itself to the medical dosimetrist was keeping the dose superficial. Dose was spread to soft tissues posterior and lateral to the skin surface. Modulated fields adjusted for the areas of hot spots accordingly. The 3D conformal treatment plan and the static electron beam were excellent options to treat the skin lesions presented. This case significantly extended my view of the typical radiation treatments delivered at this clinic. I learned the importance of treating to dmax especially in this patient to keep the dose distribution superficial. I also learned that clinical setups are necessary and that manual MU calculations are needed in cases such as this.

Figure 1. Patients leg is immobilized on a Sivco Inc. Vac-Lok bag.

Figure 2. Dose to skin surface was optimized with 1 cm bolus surrounding treatment lesion.

Figure 3. Lead shields on the medial surface of right foot.

10

Figure 4. 1cm bolus covering dorsal surface of patients right foot.

11

Figure 5. Isocenter placement in axial view.

12

Figure 6. Isocenter placement in sagittal view.

13

Figure 7. Isocenter placement in coronal view.

14

Figure 8. Wire contoured to determine treatment field size.

15

Figure 9. Treatment field determined with central axis location represented by the X.

16

Figure 10 Beams eye view DRR for fields LAO, LAO modulated, RAO and RAO modulated.

17

Figure 11. Isodose distributions on varying slices.

Figure 12. Isodose distributions on varying slices.

18

Figure 13. Dose Volume Histogram (DVH).

19

References 1. Neville J, Welch E, Leffel D. Management of non-melanoma skin cancer in 2007. Nat Clin Pract Oncol. 2007;4(8):462-469. 2. Veness M, Richards S. Role of modern radiotherapy in treating skin cancer. Aust J Dermatol.2003;44:159-168.