1 Spencer Arnould July Case Study July 8, 2013 Distal Esophageal Adenocarcinoma History of Present Illness: Patient B is a 55-year

old women who has been recently diagnosed with stage IIIB Tumor 3 (T3), Node 0 (N0), Metastasis 0 (M0) distal esophageal adenocarcinoma. Patient B was in overall good health besides the newly diagnosed cancer within the esophagus. Although she had no prior reflux symptoms, in December 2012 she began to notice the sensation to burp more often than usual. She was referred to a cardiologist but declined to seek out further help in a gastrointestinal (GI) consultation. On April 16, 2013 she underwent an esophagogastroduodenoscopy (EGD), which showed a 1.5-centimeter (cm) mass at the gastroesophageal (GE) junction. The biopsy revealed poorly differentiated carcinoma favoring adenocarcinoma of the lower esophageal tract. After this initial test was complete, Patient B was sent for a computed tomography (CT) scan on April 19, 2013 which showed mild circumferential thickening of the wall of the distal esophagus and medial fundus. She was then sent for another EGD test on May 23, 2013, which indicated a mass of 3 cm circumferentially at the distal esophagus and 39-42 cm from the incisors. The tumor extended through the muscle layer (T3), but did not indicate any aortic invasion or lymphadenopathy. The patient was then referred to radiation oncology for treatment of the distal esophageal adenocarcinoma. Past Medical History: Patient Bs medical history was entirely negative prior to this esophageal cancer diagnosis. She did have minimal eyelid surgery and a bunionectomy. Social History: Patient B has been married for 22 years and worked as an elementary school music teacher. She smoked one quarter of a pack of cigarettes daily for 20 years but discontinued this habit in 2010. She also stated that she rarely drinks alcohol. Medications: Patient B used the following medications: aspirin, Atenolol, Simvastatin (Zocor), multivitamin, Pantoprazole (Protonix). Diagnostic Imaging: After the initial assessment and consultation with the GI physician, Patient B was sent for an EGD on April 16, 2013, which showed the 1.5 cm mass at the gastroesophageal junction. The biopsy and results from this exam prompted a referral to have a CT and barium swallow exam on April 19, 2013. This exam showed thickening within the walls of the distal esophagus and slight mucosal irregularity at the GE junction. From these findings,

2 Patient B was sent for a positron emission tomography (PET) scan on May 24, 2013, which showed an increased uptake at both the GE junction and distal esophagus, similar to previous exams. Most malignant tumors of the esophagus metabolize glucose at a higher rate than normal tissue which in turn causes an increased accumulation of the glucose analog flourodeoxyglucose (FDG) in malignant tissues.1 In addition to these procedures, Patient B also had an endoscopic ultrasound. Although this test demonstrated a 3 cm long GE junction tumor 39-42 cm from the incisors, there was no lymph node involvement indicated. Radiation Oncologist Recommendation: After review of Patient Bs distal esophageal and GE junction adenocarcinoma, the radiation oncologist recommended that she receive preoperative radiation therapy and chemotherapy, prior to an esophagectomy. In patients who are medically and surgically fit, either chemoirradiation alone or preoperative chemoirradiation followed by surgery can be considered.1 Patient B had already met with both the medical oncologist and thoracic surgeon in attempts to clarify a sound plan of action towards treating the esophageal cancer. After a complete discussion about the risk and benefits associated with treatment, as well as the logistics, planning, and treatment schedule, the radiation oncologist recommended that Patient B receive 5.5 weeks of daily radiation treatments, or 28 treatment sessions given 5 days a week, in addition to the chemotherapy which would most likely be scheduled around the normal treatment sessions. The Plan (Prescription): The radiation oncologist treatment recommendation to Patient B was to treat the distal esophagus and GE junction to a total dose of 50.4 Gray (Gy) in 1.8 Gy fractions daily. The use of all three modalities chemotherapy, radiation therapy, and surgery has the potential to increase survival by decreasing distant metastasis and eliminating residual local disease with surgery after chemoradiation.2 Patient Immobilization: On June 28, 2013 Patient B underwent a CT simulation scan for radiation therapy. She was placed on a Civco Thorax board (Figure 1), which included her arms above her head, resting within adjustable arm cups for support. An egg crate cushion and knee cushion were placed underneath her back and knees for additional support. Before the actual CT scan was taken, the radiation therapist gave Patient B some barium solvent (in a liquid shake form) before they scanned the thorax region. This barium solution was enhanced on the CT scan and highlighted the entire esophageal passage and entrance into the stomach, making the localization much easier. After the scan was complete, the radiation therapists placed a reference

3 tegaderm mark on the patient 15 cm below the superior sternal notch (SSN) (Figure 2) and side levels at the same reference point (Figure 3). The radiation therapist also placed straightener marks on the patient (one superior and one inferior of the CT reference mark) to make sure that she would be straight on the table. Anatomical Contour: After the scan was completed, the images were sent to the Digital Imaging Communications of Medicine (DICOM) conquest server, which can import and export images to the necessary treatment planning stations. The images from Patient Bs scan were transferred to the Eclipse contouring station for the physicians and residents to contour volumes. The residents typically contour the gross tumor volume (GTV), and sometimes the clinical target volume (CTV), while also contouring the necessary anatomic structures that need to be avoided. After this process, the residents and the attending physician review volumes and discuss an adequate expansion volume known as the planning target volume (PTV). In this specific case, the physicians decided that they wanted to expand the GTV by 1 cm circumferentially and radially in order to delineate a suitable PTV for planning margins. After the physicians came to a sound conclusion on the tumor volume expansions, a planning directive was dictated for the medical dosimetrist to follow. Depending on the location of the PTV, the medical dosimetrist contoured the normal structures that included the external body, spinal cord, heart, lungs, kidneys, and some of the liver. Beam Isocenter/Arrangement: After the contours had been drawn and the volumes expanded, the CT scan was then exported back to the conquest server, and re-imported into UMPlan treatment planning software. Once this process was complete, it was up to the medical dosimetrist to come up with an adequate treatment plan according to the treatment-planning directive. The medical dosimetrist began designing a four-field box technique plan. They inserted one field from the anterior to posterior (AP), and one from the posterior to anterior (PA) (Figure 4). They also accented these two fields by adding in an additional two lateral beams from the right and left side of the patient (Figure 4). This 4-field box technique will form a boxlike conformity around the PTV, providing coverage while sparing dose to critical structures. (Figures 4, 5, and 6). Although the esophagus and GE junction on this patient was fairly wide and elongated, the medical dosimetrist did not need to use segments or more than four fields to adequately cover the tumor volume.

4 Treatment Plan: The planning system used to calculate the treatment plan was UMPlan. When starting to plan a four-field box technique, the medical dosimetrist usually starts out with 6 megavoltage (MV) beam energy, and evaluates for anything higher energies. In this specific distal esophageal case, the PTV is directly within the center of the body, therefore requiring the use of 16 MV beams in order to get dose to conform around the target. As Figures 7 through 10 demonstrate, all of the fields for this plan had a 0.8 cm blocking margin around the PTV, which provided enough coverage to conform and distribute dose around the target volume. The medical dosimetrist also weighted the fields based on the dose around the spinal cord, heart, and lungs. Since the AP and PA fields did not encompass as much lung tissue, they were given a higher weighting capacity. The two lateral fields are decreased because of the lung tissue dose, and are normally planned to treat off cord to prevent high doses to the spinal cord. The Normal Tissue Complication Probability (NTCP) for this case was 9.72%, which falls within our clinics tolerance level of 15%. The overall maximum dose to the PTV treatment volume was 55.3 Gy, with the spinal cord receiving a maximum dose of 37 Gy and the heart receiving a mean dose of 24 Gy (Figure 11). Quality Assurance: The monitor unit calculation and monitor unit check were completed in both the download (through UMPlan) as well as the second check through a medical physicist. A medical physicist checks the plans through a specific software system that checks both the monitor units and back-up time to make sure that the plan agrees with each tolerance that was set. The monitor units on this 4-field distal esophagus technique were within tolerance and within the back-up time associated with our departments tolerance of +/- 5%. Conclusion: Although this distal esophageal case fell within the standards of planning with a four-field box, not all cases would be this forward. Many cases can include special circumstances that do not allow for this method of treatment, which can make treatment planning much more difficult. One of the things most enjoyable about this plan was the ability to help expand and draw volumes with the physician. This process is normally left alone for the residents within the clinic to learn, but was given to me in order to help understand and gain some knowledge on how physicians decide on expansions. Working with the physicians on this process has really given me a look into the practice of tumor delineation when it comes to the treatment planning process. Although this plan was straight forward (only containing 4 total fields), I think I struggled a bit in weighting the fields correctly. Since the tumor volume was

5 very deep within the center of the body, I had to plan each field with a different weight in order to completely encompass the target. I think that although I struggled a bit with this technique, I learned that weighting the fields even slightly could completely change the look of your treatment plan. Overall, this case was a great learning opportunity for me to use some critical problem solving skills, and come up with something that agrees with the planning directive targets. I feel that I did a great job with this plan and look forward to learning from future distal esophageal cases.

Figures

Figure 1. Patient B on a Civco Thorax board with a knee cushion and eggcrate under her back.

Figure 2. Patient B with side level tegaderm.

Figure 3. Patient B with CT mark and superior straightener.

Figure 4. Axial view of isocenter on Patient B. The different color lines indicate different isodose levels around the PTV.

Figure 5. Coronal view of Patient B. The different color lines indicate different isodose levels around the PTV.

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Figure 6. Sagittal view of Patient B. The different color lines indicate different isodose levels around the PTV.

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Figure 7. The BEV of the PA field.

Figure 8. The Left Lateral (LLAT) BEV.

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Figure 9. The BEV of the AP field.

Figure 10. The Right Lateral (RLAT) BEV.

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Figure 11. Dose Volume Histogram (DVH) showing the various structures in the plan.

14 References 1. Chao K, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2011:357-371. 2. Heath E, Heitmiller R, Forastiere A. Esophageal Cancer. In: Hall L, ed. Clinical Oncology. Atlanta, GA: American Cancer Society; 2001:331-343.