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Eyob Mathias October Case Study October 20, 2013 Right lung irradiation using 3D CRT History of Present Illness: Patient JH is a 79 year-old male who was diagnosed with stage IIIB squamous cell carcinoma of right upper lobe with mediastinal lymphadenopathy and left adrenal uptake. He underwent a biopsy of the tumor in the lung which showed squamous cell carcinoma. The left adrenal biopsy was negative for metastatic disease. He was treated with chemotherapy, induction with 3 cycles of carboplatin and Taxotere followed by chemoradiation to a dose of 5940 centigray (cGy) completed in November of 2008. Post-treatment he did well until October of 2011 when he had a Positron emission tomography (PET) scan showing increase in the right perihilar area and upper lobe parenchymal densities. Subsequent re-biopsy of the right upper lobe lesion showed recurrent squamous cell carcinoma (Figure 1). Lesion of the adrenal gland was re-biopsied in June of this year and was again negative for metastatic disease and was felt to be consistent with adrenal adenoma. He has also been seen by a thoracic surgeon and was felt that he would not be able to tolerate a pneumonectomy, which is what would be required and possibly even a lobectomy, and therefore is not a surgical candidate. In early August 2013, the patient was referred to the radiation oncology department for consultation of palliative radiation treatment. The radiation oncologist reviewed the patients record and recommended 3 Dimensional Conformal Radiation Therapy (3D CRT) to the right lung target volume. The results of clinical investigations have shown that 3D treatment planning has significant potential for improving RT planning for lung cancer, both for adequate tumor coverage to high doses and for minimizing normal tissue dosage.1 The physician discussed the benefits and possible side effects of the radiation treatment with the patient. The patient verbalized his understanding of the procedure process and agreed to proceed with the treatment. Past Medical History: JH was initially diagnosed with squamous cell carcinoma of the lung in 2008. JH also has a past medical history of type II diabetes mellitus, angioplasty with stent, pneumonia, fractures of the upper limb due to osteoporosis and urinary tract infection. Patient is allergic to tetracycline. Social History: JH was heavy cigarette smoker until 08/18/06 when he had aneurysm surgery. He drinks a couple of Manhattans a day. He was a manufacturing engineer in the metal industry.

He had 6 sisters, 1 is still alive and the other 5 died from heart disease. He has no brother. His mother died at 80 year old age and his father died at 50 due to cerebral hemorrhage. Medications: JH uses the following medications: Lipitor 40 mg daily, Furosemide 40 mg as needed, Amiodarone 200 mg daily, Metoprolol 50 mg twice daily, Combivent 2 puffs 4 times a day, Oxybutynin 10 mg daily, Lorazepam 0.5-1 mg as needed, multivitamin and aspirin 81 mg daily. Diagnostic Imaging: On June 8, 2013, JH underwent a PET scan which revealed an enlarged right upper lobe nodule. On June 26, 2013, LM underwent video-assisted thoracic surgery, mini thoracotomy, and right upper lobe wedge resection. Further study determined the surgical margins were negative. The pathology report of the resected right upper lobe tumor confirmed a diagnosis of T2N2M0, squamous cell carcinoma (Figure 1). Lung adenocarcinomas are histologically aggressive and often manifest at a high stage in nonsmokers and frequently metastasize to the contralateral lung, mediastinal lymph nodes, bone, and adrenal glands, with high mortality.2 Radiation Oncologist Recommendations: After assessing JHs medical history and pathology reports, the physician recommended radiation therapy to the right lung using 3D CRT technique. The Plan (prescription): The radiation oncologists treatment recommendation to JH was a 3D CRT plan that consisted of anteroposterior (AP), right anterior oblique (RAO) and posteroanterior (PA) beams. The prescription dose was 45 gray (Gy) at 1.8Gy per fraction for 25 fractions. Patient Setup / Immobilization: On August 30, 2013, JH underwent a computed tomography (CT) simulation scan for radiation therapy treatment. The patient was placed in supine position with both of his arms raised and positioned above his head (Figure 2-3). The patients head was supported with a pillow (Figure 4). Knee sponges were also provided for comfort. The therapist marked the anterior and lateral regions using radiopaque markers. Immobilization devices were reviewed by the physician and 133 simulation images were transferred to the Digital Imaging and Communications in Medicine (DICOM) server. Anatomical Contouring: The dosimetrist downloaded the CT simulation images into Philips Pinnacle3 9.2 radiation treatment planning system (TPS). After localizing the treatment couch and creating a BB point, the medical dosimetrist imported another set of PET images to perform rigid fusion. 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 images can be difficult due to the subjective nature of visual delineation. In the year 2008, deformable fusion softwares were not widely used in most facilities and dosimetrists were using rigid fusion technique to fuse multiple modalities. After fusing the two modalities, the dosimetrist localized the position of the tumor and the radiation oncologist contoured the GTV. Subsequently, the 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 lung approximately 5.0cm right from the vertebral body (Figure 5). The placement of the isocenter corresponded approximately to the mid-plane depth of the target volume (Figures 6-8). A gantry angle of 2900 was used for the RAO beam. Due to the patient thickness and tumor location, the dosimetrist employed 6 megavoltage (MV) photon energy for the AP/PA beams and 15 MV for the RAO beam. The AP beam had a 900 collimator angle and the other two beams had a 0 collimator rotation. There was no couch rotation associated with any of the beams. The field size apertures of all the 3 beams were determined by the radiation oncologist and designed to spare greater portion of the healthy lung as well as the spinal cord. In addition, each of these field apertures had a multi-leaf collimator (MLC) blocking pattern to define the treatment field. Treatment Planning: The radiation oncologist outlined the dose prescription. The objective was to control local tumor recurrence using 3D CRT irradiation technique and achieve adequate dose distribution to the GTV while minimizing the dose to the critical structures. The challenge was observed when the tumor presented slight motion during respiration. This obstacle limited the dosimetrist to accurately deliver the prescribed dose exactly to the assigned target volume without expanding the treatment field and encompassing more lung tissue. A margin of approximately 1.5 centimeters (cm) was given in order to account for breathing motion as well as patient setup variation. Moreover, the medical dosimetrist encountered some challenge when trying to avoid previously treated radiation fields (Figure 9). Once the old fields were reconstructed and the target volume was drawn by the physician, the dosimetrist was able to easily produce 3D CRT treatment plan in a short period of time. The prescription dose for all three fields was assigned to the isocenter point. Parallel opposed AP/PA beams that consisted of 35.3% and 31.37% weighting respectively were assigned to the isocenter point and another beam with 33.33% weight was selected for the RAO field. The medical dosimetrist assigned one

prescription to all the 3 beams and employed the collapsed cone convolution superimposition (CCCS) algorithm calculation method to generate a treatment plan. Finally, the dosimetrist reviewed the dose volume histogram (DVH) (Figure 10). The patient received a total of 180cGy per day with a total of 262 monitor units (MU) for 25 fractions. The OR mean dose constraints are as follows: heart was 84.6cGy, cord was 88.3 cGy, total lung (doesnt include the GTV) was 750.7cGy and the esophagus was 258.3cGy (Figure 10). The radiation oncologist also reviewed the plan and picked the 98% normalization line for the treatment plan. 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 (Figure 11). The treatment plan passed the allowed tolerance which is under 3%. The complete 3D CRT 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. In most similar cases, patients are usually in pain or have shortness of breath and would like to receive their treatment as soon as possible. The treatment time required for 3D CRT technique is relatively shorter than the time needed for Intensity Modulated Radiation Therapy (IMRT) treatment. The benefit of using this planning technique saves time and enables the dosimetrist to quickly generate a treatment plan as needed.

Figures

Figure 1. Squamous cell carcinoma of the lung

Figure 2. Patient position supine on Wing board.

Figure 3. Patient position from CT simulation.

Figure 4. Wing Board / TIMO headholder

Figure 5. Isocenter placement.

Figure 6. Isodose distribution transverse view.

Figure 7. Isodose distribution sagital view.

Figure 8. Isodose distribution coronal view.

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Gross Tumor Volume (GTV)GTV

Right Lung Esophagus Heart Total dose lung - GTV

Left Lung

Spinal Cord

Figure 9. Dose Volume Histogram.

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Figure 10. Previous treatment plan.

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Figure 11. Radcalc Monitor Unit Calc Sheet.

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References 1. Wu K, Jiang G, Qian H, et al. Three-Dimensional conformal radiotherapy for locoregionally recurrent lung carcinoma after external beam irradiation: A prospective phase I-II clinical trial. Int J Radiat Oncol Biol Phys. 2003;57(5)1345-1350. 2. Squamous cell Carcinoma of the Lung. Center for Genomic Pathology. http://ctrgenpath.net/wp-content/uploads/2011/06/GP11-0035-A-HE-x20-RJM-SCC-lungscaled.jpg. Accessed on October 20, 2013.