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1 Eyob Mathias Case Study September 29, 2013 Stereotactic Body Radiation Therapy for Adenocarcinoma of the Lung

History of Present Illness: Patient GJ is a 77-year-old, white male with a long list of medical comorbidities including coronary artery disease, hypertension, chronic obstructive pulumonary disease (COPD), carotid stenosis, diabetes and peripheral vascular disease. About a year ago he was diagnosed with a right upper lobe pulmonary nodule. He had a computed tomography (CT) scan of the chest performed on June 2012 which showed a 1.7 centimeters (cm) irregular density in the right lung apex. Subsequently he underwent a positron emission tomography (PET) scan and the result showed slightly increased uptake in the right paratracheal lymph node, the subcarinal lymph node and the pulmonary nodule which measured 8 x 13 millimeters (mm). The subcarinal nodes were difficult to assess. The patient subsequently underwent an EBUS (endobronchial ultrasound) biopsy. The paratracheal and subcarinal lymph nodes were biopsied and these were both benign. The tumor size measured 1.9 cm and was located in the very apex of the right upper lobe adjacent to the pleura laterally near the chest wall (T1). No lymph node involvement was reported (N0). He was felt to have a T1N0M0 lesion but due to his medical comorbidities, it was determined that he was at a poor risk for anesthesia and lobectomy or wedge resection. The options of radiofrequency ablation were also discussed, but this is also an invasive procedure and carried with it a risk of pneumothorax. The case was discussed at the tumor board meeting and it was elected to pursue stereotactic body radiotherapy (SBRT). Stereotactic body radiation therapy refers to an emerging radiotherapy procedure that is highly effective in controlling early stage primary and oligometastatic cancers at locations throughout the abdominopelvic and thoracic cavities, and at spinal and paraspinal sites.1 The major feature that separates SBRT from conventional radiation treatment is the delivery of large doses in a few fractions, which results in a high biological effective dose.1 In order to minimize the normal tissue toxicity, conformation of high doses to the target and rapid fall-off doses away from the target is critical. 1 Past Medical History: GJ has a history of chronic COPD secondary to long-term cigarette smoking, diabetes mellitus type 2, coronary artery disease, status post 4-vessel coronary artery bypass grafting in 2004, hypertension, dyslipidemia, osteoarthrosis, history of T1 carcinoma

2 within a colonic polyp that was completely excised and asymptomatic moderate carotid

stenosis. He has had repair of an inguinal hernia in the past, also thoracoscopy with a wedge resection of the lung in August of 2010, common femoral endarterectomy and iliac artery revascularization with angioplasty. Social History: GJ was a former smoker, 2-3 packs a day for 30 years, quitting in 1982. He drinks alcohol infrequently. He and his son served in the military. He also have a daughter. He is a retired construction worker. Medications: GJ uses the following medications: Lisinopril, Atorvastatin, Ventolin inhaler, Gabapentin, NovoLog insulin, Levemir, potassium chloride tablets, Meclizine, Clopidogrel, Metoprolol, isosorbide mononitrate, vitamin C, Bumex, vitamin D, aspirin, Ranexa, multivitamin, and B complex vitamin. Diagnostic Imaging: On June 21, 2012, GJ underwent a PET scan which revealed an enlarged right upper lobe nodule. On August 09, 2012, GJ underwent CT guided biopsy which revealed benign paratracheal and subcarinal lymph nodes. Further study determined the surgical margins were negative. The pathology report of the biopsy confirmed a diagnosis of T1N0M0, poorly differentiated carcinoma of the right upper lobe with squamous differentiation. Radiation Oncologist Recommendations: After assessing GJs surgical history and pathology reports, the physician recommended radiation treatment to the right upper lung lesion using SBRT technique. The radiation oncologist discussed with GJ and his daughter about the diagnostic studies findings and explained the recommended radiation treatment as well as its side effects. The Plan (prescription): The radiation treatment plan was designed for the patient to receive a total of 5000 centigray (cGy) at 1000cGy for 5 fractions using SBRT technique. In this case, the physician scheduled to reevaluate the tumor after 5000 cGy was administered. Patient Setup / Immobilization: On Oct 10, 2012, GJ was simulated in a supine position aligned to lay straight on a wing board (Figure 1). His hands were raised above his head holding the wing board bar. A large wedged sponge was also placed under his knees. A large bore GE Light Speed CT scanner was used for the simulation process. The radiation therapists put BB markers on the patient using the sagittal and lateral laser beams (Figure 1 & Figure 2). The CT images were exported to the Digital Imaging and Communication in Medicine (DICOM) server. Anatomical Contouring: The dosimetrist downloaded the CT simulation images into Philips

3 Pinnacle3 9.2 radiation treatment planning system (TPS). After localizing the treatment couch and creating a BB point, the DICOM images were transferred to deformable fusion software, where the CT scan was fused with the PET scans. Positron emission tomography scans are usually taken on a curved couch in a non-treatment position, so obtaining an accurate Gross Tumor Volume (GTV) using PET image can be difficult due to the subjective nature of visual delineation. However, Medical Image Merge (MIM) version 6 software can fuse multiple modalities in less than 10 seconds, and contours can be created from any plane on any modality.2 Using this software the medical dosimetrist localized the position of the tumor and the radiation oncologist contoured the GTV on the PET-CT fused image. Subsequently, the medical dosimetrist added organs at risk (OR) contours which included the right and left lungs, esophagus, heart and spinal cord. Beam Isocenter / Arrangement: The medical dosimetrist placed an isocenter in the right upper lung approximately 4.0 cm right from the vertebral body (Figure 3). A Varian trilogy linear accelerator (Linac) machine was used to treat the patient. Gantry angles of 2050 with couch angle 2900, 2400 with couch angle 00, 2900 with couch angle 3500, 3200 with couch angle 400, 300 with couch angle 3300, 300 with couch angle 2700, 1500 and 1800 were used in combination with collimator angles of 300, 00, 00, 400, 3000, 00, 00 and 00 respectively (Figure 4). Each field consisted of 6 mega voltage (MV) photon energy beams. The placement of the isocenter corresponded approximately to the mid-plane depth of the target volume (Figure 3 and Figure 5). Each of these field apertures had a multi-leaf collimator (MLC) blocking pattern to define the treatment field. The field size apertures of all the beams were approved by the radiation oncologist and designed to spare the greater portion of the healthy lung as well as other ORs. Treatment Planning: The radiation oncologist outlined the GTV and specified the dose prescription. The objective was to reduce tumor size using SBRT technique and achieve adequate dose distribution to the GTV while significantly minimizing the dose to the surrounding critical structures. The dosimetrist reviewed the digitally reconstructed radiograph (DRR) view of each field to make sure the collimator angle and the gantry angle was positioned properly before initiating the optimization process. The objective goals were entered in the inverse planning window according to each ORs tolerance dose limit (Figure 6). Then the computer calculated the beam weight, isodose distribution and proper dynamic multileaf collimator (MLC) motions according to the defined objectives dose limits. After the plan was

4 completed to the medical dosimetrists satisfaction, it was saved for the radiation oncologist to evaluate. The radiation oncologist reviewed the dose volume histogram (DVH) and evaluated the dose coverage to the GTV as well as doses to the OR (figure 7 and figure 8). The physician approved the treatment plan and selected the 80% isodose line for treatment. The challenge was observed when the tumor presented slight motion during respiration. The variation in CTV size and position due to respiratory motion or organ filling is generally accounted for by an internal margin added to the CTV, resulting in the internal target volume (ITV). Typical SBRT margins for defining the minimal distance separating the CTV and PTV surfaces are 0.5 cm in the axial planes and 1.0 cm in the inferior/superior directions for treatments that were performed in conditions that suppressed respiratory motion.1 Dose prescriptions in SBRT are often specified at low isodoses e.g., 80% isodose and with small or no margins for beam penumbra at the target edge, as compared to traditional radiation therapy. The rationale is to improve dose fall-off outside of the targeted volume and help spare nearby organs at risk. This practice increases dose heterogeneity within the target.1 Quality Assurance/Physics Check: The monitor units were reviewed and a second check was completed with a quality assurance (QA) computer program known as Radcalc. A 3% deviation in MU is the tolerance for IMRT treatment plan. The complete SBRT treatment plan was reviewed by a medical physicist before treatment date was scheduled. Conclusion: This treatment planning case presented minimal challenge for the medical dosimetrist. The major drawback of using this technique for lung cancer treatment is respiratory tumor motion.


Figure 1. Simulation patient setup on a wingboard

Figure 2. Patient position on a Wing board.

Figure 3. Digitally reconstructed radiograph (DRR), Isocenter position.

Figure 4. Treatment plan summary sheet.

Figure 5. Field beam arrangement 3 dimensional view.


Figure 6. Inverse planning window. Dose constraints to the PTV and each OR


Figure 7. Isodose distribustion (Aqumarine = 102%, Green = 95%, Blue = 90%, Yellow = 80%, Orange = 50%, Forest green = 20%)


GT Adjacent Ribs V


Rt. Inf. Brachial plexus

Total lung - PTV

Figure 8. Dose Volume Histogram

13 References 1. Benedict S, Yenice K, Followill D, et al. Stereotactic body radiation therapy: The report of AAPM Task Group 101. Med. Phys. 2010: 37(8) 4078-4101. 2. MIM Maestro. MIM software. http://www.mimsoftware.com/products/maestro/. Accessed on June 6, 2013