Tsai 1 Kevin Tsai April Case Study April 23, 13 Atypical Meningioma History of Present Illness: Patient LJ is a 47-year-old

female diagnosed with stage WHO (World Health Organization) grade II atypical meningioma. The 1979 WHO classification of central nervous system (CNS) is the most widely accepted system for classifying CNS tumors.1 The histopathologic grade of brain tumors is important because benign lesions have better prognosis and can be cured or controlled by surgery or irradiation.1 The WHO classification has 3 grades for meningioma: I (benign), II (atypical), III (malignant/anaplastic).1 Meningiomas are the most common benign intracranial tumors (approximately 35% of primary brain tumors) in the United States. It has an overall 5-year survival rate of 69% (70% benign and 55% malignant).2 The meningioma was discovered when patient LJ started complaining about dizziness and black out episodes. She would lose consciousness for a period of 1 to 5 minutes. On 11/28/2012, a magnetic resonance imaging (MRI) scan was performed on the patient which revealed a 1.7 to 2 centimeter (cm) meningioma located in the posterior lip of the tuberculum sellae and expanding halfway over into the tuberculum sellae and into the diaphragmatic sellae area. Past Medical History: Patient LJ has a past medical history of orthostatic hypotension and a history of depression. Her previous surgery history is a C-section in 2007. The patient has no known drug allergies. Her family history is noncontributory. Social History: Patient LJ is a 47-year-old female that works in bond sales. She is married and currently lives with her husband. She denies any tobacco and recreational drug uses. The patient occasionally has 3-4 glasses of wine per week. Medications: LJ uses the following medications: Inderal 60 milligrams (mg) daily, multivitamins daily, vitamin b12 daily, and fish oil 1000 mg daily. Diagnostic Imaging: Patient LJ underwent a brain MRI with and without contrast on 11/28/12. The exam identified the suprasellar mass, which splays the optic chiasm and abuts the proximal optic nerves. The mass is separated from the pituitary gland and infundibulum. On 12/6/12, a computed tomography (CT) scan of the head without contrast was performed shortly after the supraorbital craniotomy performed earlier that day. The next day on 12/7/12, another MRI of the

Tsai 2 brain with and without contrast was performed to compare with the previous MRI on 11/28/12 and CT from 12/06/12. The postoperative changes involving the right craniotomy and resection of the suprasellar meningioma were visualized. There were no new mass lesions or abnormal contrast enhancements. Radiation Oncologist Recommendations: Adjuvant radiation therapy was also recommended after surgery to eradicate any microscopic tumor cells left behind. The patient discussed the options with her family and ultimately decided to undergo surgery and adjuvant radiation therapy. Therefore, she signed the informed consent after the risks and benefits were explained. On 12/06/12, patient LJ underwent a right-sided lateral supraorbital craniotomy for resection of tuberculum sellae meningioma with use of microscope and intraoperative image guidance. The tumor removed consists of a 1.7 x 0.9 x 0.6 cm piece of tan-brown, rubbery, and soft tissue with cautery effect. After the surgery, patient LJ was referred to our radiation oncology department for consultation with the radiation oncologist. After reviewing LJs surgical history and pathology reports, the oncologist recommended adjuvant radiation therapy to the tumor bed using an intensity modulation radiation therapy (IMRT) plan. The advantages of using IMRT plan for brain tumors are to reduce doses to critical organs and a more conformal dose around the target volume. The patient agreed to the radiation treatment and came in on 1/16/13 for a CT scan for treatment planning. LJ began her radiation therapy treatments on 1/24/13. The Plan (Prescription): The radiation oncologist recommended LJ receive adjuvant radiation therapy to the brain using IMRT technique. The principle of IMRT is to treat a patient using multiple gantry angles with beams of non-uniform fluences, which have been optimized to deliver a high dose to the target volume and low dose to the surrounding critical organs.3 The prescription dose for patient LJ is 54 Gray (Gy) at 1.8 Gy for 30 fractions. For accurate treatment setup, daily kilo-voltage (kV) images will be taken prior to treatment and checked by the radiation oncologist. Patient Setup / Immobilization: On 1/16/13, LJ underwent a CT simulation for radiation therapy. The patient was scanned head first supine with her arms on the side of her body. A small knee sponge was placed under her knees for comfort. An Aquaplast mask was made for the patients head to immobilize her as much as possible and also for repositioning (Figure 1). Fiducial markers and cranial array balls were placed on the mask. The cranial array balls are used for the ExacTrac imaging system for daily setup.

Tsai 3 Anatomical Contouring: Once the CT scan was completed, the images were exported to our Varian Eclipse version 10 treatment planning system (TPS). From there our radiation oncologist contoured the planning target volume (PTV) and the dosimetrist contoured all the critical organs near the target volume. The brain has many critical structures within it making it difficult at times to avoid certain structures. The normal structures contoured for patient LJ were the brain stem, spinal cord, whole brain, left eye/lens/nerve/lacrimal gland, right eye/lens/nerve/lacrimal gland, and optic chiasm. The medical dosimetrist was given a prescription and constraint list for this patient. Beam Isocenter / Arrangement: Once all the normal structures and PTV were contoured, the medical dosimetrist placed the isocenter very close to the center of the PTV (Figure 2). The patient was treated using the IMRT technique with a total of 6 fields at a gantry angle of 200, 240, 280, 80, 120, and 160 degrees (Figure 3). Once the gantry angles were determined, the treatment planning program divided each beam into a large number of beamlets and determined optimum setting of their fluences or weights (Figure 4).3 All the fields in the plan used a 6 megavoltage (MV) energy which is common for IMRT technique. Treatment Planning: The isocenter was placed in the center of the PTV as you can see in figure 3 but the prescription dose was prescribed to a calculation point above the isocenter. The isocenter was near a bone, which had the potential to alter the dose, therefore the dose was prescribed to another point. The patient will receive 54 Gy at 1.8 Gy per fraction for 30 fractions. The organs at risk (OR) dose constraints given by the doctor were: the optic nerve, optic chiasm, and brain stem maximum dose to be less than 50 Gy, and max dose to the spinal cord and eyes to be less than 45 Gy. A shell of 2 cm was created around the PTV to control peripheral dose. Another structure called Skin-PTV was also created by subtracting the PTV from the body and was used to reduce dose to all other normal tissues. The normal tissue objective does not have to be used to control peripheral dose if a shell is created. The Eclipse TPS optimization was run to accomplish the best possible plan for the patient. Once the prescription dose was achieved from optimization, the OR were reviewed by looking at the dose volume histogram (DVH). The DVH for this plan can be seen in figure 5. The optic chiasm (54 Gy), optic nerve (52 Gy), and brain stem (53.8) all had max doses over the doctors recommendations. The radiation oncologist looked over the plan and decided that the PTV coverage is more important than the OR. After reviewing the plan, the radiation oncologist prescribed 95% of the dose cover 100% of the

Tsai 4 treatment volume. In figure 6 and 7, the images display 50% and 95% dose coverage in color wash. Quality Assurance / Physics Check: The monitor units (MU) from the plan were double checked with another software named RadCalc. The plan was exported to RadCalc for comparisons and the MUs difference were less than 3%, which was within tolerance. The dosimetrist would then create a verification plan so that the physicist can run an IMRT QA on the machine to test the fluences. The IMRT plan was then reviewed by the medical physicist for a final check before treatment. Conclusion: This case presented with a lot challenges for the medical dosimetrist because of the location of the PTV. The entire optic chiasm and parts of the optic nerves were sitting inside the PTV. It was impossible to reduce the dose to the optic chiasm and optic nerves therefore the radiation oncologist had to decide whether to trim the PTV or not. The radiation oncologist decided that covering the entire PTV was more important than saving the optic chiasm, optic nerve, and brain stem. The max doses for the critical structures were: optic chiasm at 53.43 Gy, right and left optic nerve at 52 Gy, and brain stem at 53.8 Gy. The doses were a bit higher than what the oncologist wanted and may lead to vision problems in the future. From this case study, I learned that we cant always save all the critical organs. If a normal structures lies within a PTV, the doctor has to make the hard decision of deciding which is more important.

Tsai 5 Figures

Figure 1: Patient position with Aquaplast mask during CT simulation

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Figure 2: Isocenter on transverse, coronal, and sagittal slices.

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Figure 3: Gantry angles.

Figure 4: Field created from optimization for gantry angle 200 degrees.

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Figure 5: Dose Volume Histogram (DVH).

Figure 6: 50% dose distribution.

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Figure 7: 95% dose distribution.

Tsai 10 References 1.) Chao C, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd ed. PA: Lippincott Williams and Wilkins; 2011:145-177. 2.) Meningiomas. American Association of Neurological Surgeons Web Site. http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/Meningi omas.aspx. Accessed April 24, 2013. 3.) Khan FM. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams and Wilkins; 2010:481-506.