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Asim Farooki
February Case Study



ARC Radiation Therapy for Bladder Metastasis following Colon AdenoCarcinoma


History of Present Illness:
Patient LD is a 61 year old caucasian male who was initially diagnosed with recurrent metastatic
colon carcinoma (2012) and bladder carcinoma (2013). In July 2012, the patient underwent left
hemicolectomy including the sigmoid for an adenocarcinoma of the sigmoid region, which pre-
sented as a sigmoid mass. During the excision of colon cancer, a cytoscopy and a bladder bi-
opsy along with a liver biopsy was performed. The surgical pathology showed the sigmoid
mass had a margin of 5cm both proximally and distally and extended to the serosal surface,
which showed a benign bladder mucosa. The bladder biopsy showed invasive adenocarcino-
ma, rare benign urothelial mucosa. It was concluded by the pathologist that the tumor was
morphologically compatible with colonic primary, but the primary adenocarcinoma of the bladder
cannot be completely excluded. The liver biopsy showed necrotic cellular debris suspicious for
tumor and the histology showed moderately differentiated adenocarcinoma with less than 5%
mucinous component with 1 of 32 positive lymph nodes. The patient was offered chemothera-
py, but he declined. In November 2012, the patient was readmitted with hematuria and the new
cytoscopy showed presence of an ulcerating mass in the bladder. In November 2013, the pa-
tient was referred to the Radiation Oncology department for consultation after another PET-CT
showed evidence of a growing mass involving the bladder.

Past Medical History:
LD suffered a left-sided stroke due to an AVM rupture in 1988. The rupture was sealed with
neurosurgery and reported of no neurological symptoms. Following the stroke, the patient dis-
played memory loss with short-term memory being affected and the long-term memory intact.
Also, the patient has limited mobility with a cane, otherwise has been dependent on a motor
scooter for the past 25 years following paralysis. Going further back in his medical history, the
patient had unrelated gallbladder surgery several years ago as well as a hernia surgery.

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Social History:
LDs family history shows that his grandfather had throat cancer and that his father, died with
lung cancer. LD is married with two children. The patient was a truck driver before the stroke
but has become fully disabled since the stroke. The nursing and progress notes had no infor-
mation related to recreational drugs/ alcohol/ tobacco usage.

Medications:
While continuing concurrent chemotherapy, the patient list of medications includes: Oxybutynin
(Ditropan) 5mg oral BID, Pantoprazole (Protonix) 40mg oral daily, tamSULOSIN (Flomax)
0.4mg oral daily, and Metoprolol.

Diagnostic Imaging:
In October 2012, an outpatient PET-CT was performed that showed amorphous plaque sheaths
of FDG avid tissue in relation to the ascending colon at the inferior aspect of the right hepatic
lobe. Tracking on the surface of the right lower abdominal wall measuring approximately 15.5,
SUV 10.3 may represent a combination of tumor implants and post-surgical inflammation, in the
mid abdomen, two additional smaller bands of FDG avid tissue in the central mesentery demon-
strating SUV of 4.2. Other FDG avid masses were described in the peritoneum and in the liver.
On November 12, 2013, a CT without contrast showed evidence of a mass involving the bladder
extending as high up as the iliopubic junction and this merging after that with loops of the large
bowel. On November 20, 2013 a whole-body PET-CT scanning was performed from the skull
vertex down to the thighs with an intravenous administration of 16.1mCi FDG. Compared to the
previous study (October 2012), there had been development of an approximately 2.6cm AP x
2.4cm wide metatstatic lesion along the lateral dome of the right hepatic lobe demonstrating
SUV max 8.2 with an estimated tumor volume of 22cc. Also seen was an increase in the size of
supravesical mass and FDG avidity now now extended over a vertical distance of 6cm and
measured 4.3cm wide x 6.0cm AP with SUV max 16.0 and the estimated tumor volume of 40cc.
It was marked as unclear in regards to the exophytic tumor extending rostrally from the bladder
dome or metastatic tumor implant to the pelvic mesentery and bladder. Intracranially, reduced
activity in the right cerebral hemisphere compared to the left due to the chronic hemispheric in-
farct was noticeable.


Radiation Oncologist Recommendations:
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After reviewing LDs medical history, which consisted of surgical, pathology, and oncology re-
ports, the Radiation Oncologist suggested a combination of chemotherapy and radiation as the
best course for treatment. The recommended radiation treatment was to utilize conformal plan-
ning, which ensures satisfactory PTV coverage
1
. IMRT and volumetric intensity-modulated arc
therapy have demonstrated increased conformality and potential dosimetric improvements to
the organ at risk in comparison with conformal planning
2
. The benefit of using arc therapy over
the traditional four-field box (AP/PA and laterals) is that the radiation is delivered only to the in-
tended area, thus allowing us to try to spare more surrounding healthy tissue and better avoid
any nearby critical anatomy
3
. For this particular case, the organs at risk included rectum, femo-
ral heads, and the small bowel.

The Plan (Prescription):
The Radiation Oncologists treatment recommendation for LD was dual rapid arc therapy for the
pelvis. The plan utilized two VMAT ARC rotations using 6 MV photon beam energy. The pre-
scription dose for the bladder site was 5400 cGy, which was to be delivered in 30 fractions at a
daily fraction dose of 180 cGy.

Patient Setup:
The patient was simulated via CT on November 25, 2013 in the radiation oncology department
for radiation therapy treatment planning. The patient laid supine on the CT couch to mimic the
treatment position with a pillow under his head and arms on his chest. To hold the position for
treatment, an aquaplast was created to immobilize the pelvis treatment region. Using bbs and
lasers in the room, the patient was straightened and aligned, and finally tattooed with ink to
make permanent marks to prevent erasure.

Anatomical Contouring:
After the CT scan was complete and the images were okd by the physicist, the CT data set was
transferred to the Treatment Planning System (TPS) by Varian Eclipse version 8. After the
transfer, the radiation oncology resident contoured the images to highlight the PTV, CTV, Or-
gans At Risk (OAR) which included the included rectum, femoral heads, and the small bowel.
The Multi Leaf Collimator (MLC) was VMAT based.

Beam Isocenter/Arrangement:
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The physicist placed the isocenter in the geometrical center of the highlighted PTV. The plan
consisted of 2 complete VMAT arcs of the gantry. The energy utilized on the Varian 2300IX
was 6 mega voltage (MV). The first arc was counterclockwise (CCW) 179.0 degrees to 181.0
degrees, meanwhile the second arc rotated 181.0 degrees to 179.0 degrees. The collimator
rotation for arc 1 was 45.0 degrees, meanwhile for arc 2, it was 315.0 degrees. The physicist
used the treatment planning software to determine field sizes and their weightings to me meet
the prescribed dose needed to be delivered.

Treatment Planning:
The treatment planned laid out by the Radiation Oncologist was to focus on the bladder treat-
ment site with 5400cGy being the desired prescription dose, which was to be delivered in 30
fractions. The daily dose delivered was 180cGy, which was divided into the two arc rotations,
where arc 1 delivered 101.9cGy and 78.1cGy delivered via arc 2. The isocenter was placed in
the PTV and Volumetric Modulated Arc Therapy (VMAT) was chosen to deliver radiation to the
intended area to try to spare as much surrounding healthy tissue and the organs at risk (OAR)
in the vicinity.

Quality Assurance (QA) / Physics Check:
Quality Assurance (QA) was carried out following the creation of the treatment plan by verifying
the monitor units generated by the QA program RadCalc by Sun Nuclear Corporation. They
also were reverified by hand and the monitor units were within the facilitys tolerance require-
ment of less than 3% difference. After the plan was finalized, it was verified by another physicist
and the Attending Radiation Oncologist.

Conclusion:
By reading up on the treatment protocol, I saw first hand how technology has evolved and to
provide safer radiation treatments, we have moved away from the traditional three/four-field
techniques to better spare the healthy tissue and surrounding organs at risk. As I went through
this care, I got a better understanding of when VMAT treatments can be more beneficial, as in
this case, the gantry rotates around the patient delivering focused beams of radiation. The arc-
based delivery reduces the dose of radiation to normal tissue while increasing the dose to the
cancer in a lesser time period, thus making it easier for patients to stay still during treatment.
This was very much important in the case here, as LD was paralyzed on the left side, thus stay-
ing still and being comfortable during treatment was a major area for concern. This was a good
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example of a medical team working together to help provide the best level of care for the pa-
tient, as we saw open lines of communication between the oncologist and the radiation oncolo-
gy department. Also following the trail from the first contact with the radiation oncology depart-
ment to the entire treatment planning to delivery of radiation, this was a good learning lesson to
see how treatment plans are created and how we cannot solely base the treatment on that, but
in fact hand calculations ands all final plans are reverified by the head physicist and radiation
oncologist before initiating any treatment.























Images


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Figures 1 - 4: Patient Positioning during CT Simulation using the Aquaplast mold
to hold the patient firmly in place during treatment.







CT Images
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used for simulation and planning

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References:
1. Bentel G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996
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2. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St Louis,
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MO: Mosby-Elsevier 2010
3 Discussion with N. Penigrahi, Medical Physicist at NYM Hospital. January 28, 2014
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