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Pat Sheil
April Case Study
April 9, 2017
Hybrid Technique for Malignant Neoplasm of Right Lung

History of Present Illness: Patient is a 63-year-old male with distant smoking history, episode
of pneumonia in 2/2016. In 1/2017 he had similar symptoms with increased cough and
congestion that led to him going to the ER and having a chest x-ray done on 1/07/2017. The x-
ray showed abnormal large right upper lobe opacity consistent with lobar pneumonia. He was
treated with antibiotics however his symptoms and condition did not improve and he returned to
the ER on 1/28/2017. A CT scan of the chest was done which showed a 7cm volume within the
right upper lobe approximately 6cm in length and another extending along the right hilar region.
Patient then underwent an endobronchial ultrasound, transbronchial needle aspiration 4R on the
right paratracheal node on 1/31/2017. Biopsies from 4R revealed malignant cells present
consistent with poorly differentiated carcinoma. Diagnosis stated to be T3N3M0 non-small cell
carcinoma of the right upper lobe/hilum without squamous differentiation. MRI of brain
performed on 2/5/17 with results showing no presence of metastatic spread.
Past Medical History: JP has a past medical history of obesity, sleep apnea, essential
hypertension (benign), arrhythmia (A-Fib), diabetes mellitus type II, depression, renal disease,
and strabismus. The patient reported an extensive surgical history consisting of the following:
Eye surgery (1960,1982), Finger surgery (2x), Right knee surgery (1991), Right Rotator cuff
repair (2014), Biceps tendon repair (2015). In addition, the patient reported an allergy to Talwan.
Social History: JP currently works as a martial arts instructor. JP is married and lives at home
with his wife; they have no children of their own. JP reported that he quit smoking 17 years ago
after 20 years of smoking. Never used smokeless tobacco. Reports he rarely drinks alcohol,
about 2 times per year. His mother suffered a heart attack and father had history of arrhythmia
and wore a pacemaker. Patient also reported that his brother and sister both have diabetes.
Medications: JP uses the following medications: hydroxyzine, calcium carbonate (vitamin D3),
insulin glargine, carvedilol, fenofibrate, warfarin, furosemide, insulin needles (nano pen), blood
glucose test strips, albuterol, atorvastatin, lancets, spironolactone, cholecalciferol/D3, and

Diagnostic Imaging: In early February 2016, JP had an episode of pneumonia. In January 2017,
he had similar symptoms of pneumonia, which led him going to the ER where a chest x-ray was
performed. The x-ray showed an abnormal large upper lobe opacity consistent with lobar
pneumonia. After being treated with antibiotics the symptoms did not improve and again he
returned to ER on January 28th where a CT scan of his chest was performed. The scan revealed a
7cm mass within the right upper lobe, with 6cm mass extending along the right hilar region. A
5mm nodule was also found in the right lower lobe. Airway exam revealed abnormal splayed
RUL carina and narrowed right upper lobe bronchi without evidence of endobronchial invasion.
After the findings, the patient then underwent an endobronchial ultrasound and transbronchial
needle aspiration on the right paratracheal node on January 31st. Biopsies revealed malignant
cells present consistent with poorly differentiated carcinoma. Biopsy favored non-small cell
carcinoma without squamous differentiation. An MRI of the brain performed on February 5th
showed no evidence of metastatic disease. A PET scan was performed on February 9th and it
showed right and left supraclavicular positive lymph nodes involved. Also found were right
upper lobe mass with central cavitation in the right hilar region, enlarged mediastinal lymph
nodes including left prevascular space, precarinal and subcarinal region. Final diagnosis
determined to be T3N3M0 non-small cell carcinoma of the right upper lobe/hilum.
Radiation Oncologist Recommendations: After careful assessment of JPs pathology reports,
the radiation oncologist recommended JP to undergo concurrent chemotherapy and radiation
therapy to the right lung applying a hybrid technique. The other option presented was
chemotherapy alone; however; given his young age, performance status, and local symptoms, the
physician advised that concurrent chemo and radiation would be beneficial. The hybrid plan
consisted of AP/PA beams combined with two full dynamic arcs. By implementing the hybrid
technique, dose uniformity to the target volume is increased and dose to the heart, lung,
esophagus and spinal cord are decreased compared to a strictly RapidArc or AP/PA parallel-
opposed plan.1
The Plan (prescription): The radiation oncologists prescription for the right lung treatment was
6000cGy at 200cGy per fraction for 30 fractions using the 3D conformal hybrid technique with
all 6MV beams. This plan was decided upon due to the VOI being irregular and in close
proximity to the normal structures that must be protected. After 1st day of treatment, patient was
sent to ER for breathing complications. Per request of the doctor, the plan was altered so that the

patient would immediately receive 2 fractions at 300cGy to help alleviate complications and
symptoms and continue on with the original prescription of 200cGy per fraction with the total
fraction count being reduced to 29 and total dose still being 6000cGy.

Patient Setup/Immobilization: In mid-February 2017, JP completed a computed tomography

(CT) simulation scan. The patient was placed in the supine position on the CT simulation table
with both arms raised above his head clasping his hands (Figure 3). Wedge cushions were placed
under his shoulders to provide comfort. A custom upper body vac-loc mold was formed over a
wing board and headrest to aid in patient immobilization and treatment reproducibility. Black
pad was placed abutting vac-loc bag with a knee sponge to alleviate pressure and provide needed
comfort (Figure 2). Once the patient was aligned on the table, the simulation scan was completed
and reviewed by the radiation team. The therapist then placed BBs on the patients sides and
chest. The BBs were used to help determine isocenter placement and aid the dosimetrist in
establishing a reference point prior to planning. The BBs also verify correct patient positioning
due to the right side having two BBs instead of one. Once the CT scans with BBs were
complete, the BBs were removed and replaced with cross-shaped Sharpie markings. The vac-loc
bag was also marked with tape and Sharpie markings in order to ensure the patient is in the same
position in correlation to his body marks. These markings also assist the therapists in daily setups
by aligning the patient to the treatment room lasers. Once marking was complete, a picture of the
setup was taken for future reference. The CT images were then pushed to the treatment planning
system for the dosimetrist to import. Earlier PET scan imported in the TPS and fused with CT to
improve target delineation
Anatomical Contouring: After completion of the CT simulation scan, the CT data set was
transferred into the Varian Eclipse treatment planning system (TPS). The radiation oncologist
contoured the right mass found in the right lung and labeled it GTV. The medical dosimetrist
added 0.8mm margin to the GTV to create a clinical target volume (CTV). A 1cm margin was
added to the GTV as well to create the planning target volume (PTV). The PTV margin was
created to account for organ movement, respiration, and daily setup errors.2 The medical
dosimetrist then contoured all of the organs at risk (OR) for the treatment plan including the
esophagus, spinal cord, heart, liver, brachial plexus, and both of the lungs. These ORs were the
normal structures in close proximity to the GTV whose radiation sensitivity may significantly

influence treatment planning. Once all structures were contoured, the dosimetrist was ready to
begin planning using the prescription given by the doctor.
Beam Isocenter/Arrangement: After contouring was complete, the dosimetrist chose to place
isocenter so that it was in the middle of the PTV (Figures 4, 5 and 6). The 6MV AP/PA fields
were the first be implemented and their respective beam angles were entered. AP beam at 0 o and
PA at 180.1 o so that the gantry rotated on the right side of the patient. Next the dynamic
conformal arcs had to be implemented. The first arc started at 180.1 o and rotated clockwise to
179.0 o. The second arc started at 179.0 o and rotated counter clock wise to 180.1 o. The two
conformal dynamic arcs also used 6MV energy due to the lung volume being irradiated. There
was a 90 o collimator applied for the AP field in order to apply a dynamic wedge. No couch
rotations were needed for any of the fields. The MLC blocking pattern for each field was created
by fitting the MLCs to the PTV and placing a 0.8cm margin around the PTV. The TPS
automatically adjusted the field sizes for each beam after the MLC adjustment.
Treatment Planning: Treatment planning was done using Varians Eclipse. Before planning was
done, the radiation oncologist gave the dosimetrist the script with constraints for organs at risk
and reviewed margins for GTV. After much discussion and multiple plans were exercised, the
hybrid technique of AP/PA beams and dynamic conformal arcs proved to be the best suited plan
for this specific patient. The dosimetrist chose this plan due to its superior coverage and lack of
unnecessary dose to OR. Originally, solely a RapidArc plan was done but dose to the lung was
excessive and did not meet the constraints given by the physician. An AP/PA with obliques was
not possible due to the close proximity of the tumor volume to the esophagus and spinal cord.
There was no way to avoid the structures while maintaining conformal dose to the GTV. The
hybrid technique takes care of both flaws from the sole RapidArc and AP/PA technique. By using
hybrid technique, the dosimetrist was able to fit and shield the spinal cord through the full
rotation of the dynamic conformal arcs, which lowered the dose to spinal cord and esophagus.
The dosimetrist altered beam weighting to move the hot spot to be contained within the PTV. The
final weighting for each field was the following: AP (24.1%), PA (32.9%), CW ARC (21.0%),
and CCW ARC (22%). The AP field collimator was rotated to 90 degrees so that a 15-degree
dynamic wedge could be implemented in the field. The wedge was placed in the AP field to push
dose to the left aspect of the patient where dose was lacking, as well as to reduce some of the hot
spot in the right inferior portion of the field. The dynamic conformal arcs also varied dose

intensity greatly, which helped conform the isodose lines to the PTV and avoid greater dose to
OR.3 The dosimetrist made it so that the dynamic MLCs moved to shield the spinal cord during
the full rotation, altering the dose absorbed which created the conformal isodose lines shown in
the plan. Reference point location was critical in this plan and for the homogenous dose
distribution seen as the end result. The isocenter placement was tricky for it could not be placed
to close to the edge of the field, in an air cavity, or on the edge of different densities within the
field. Poor isocenter placement could throw off the MU calculation and over or under dose the
plan. After the dosimetrist was satisfied with the overall layout of the plan, it was time to check
the dose volume histogram and make sure the physicians constraints were met. For this plan the
patients lung V20 had to be less than 37% and the mean dose was to be under 0Gy. The mean
dose to the esophagus was to be less than 34Gy. Maximum dose allowed to spinal cord was
50Gy. Heart dose for V40 was to be less than 100%, V45 less than 67%, and V60 less than 33%
volume. Liver dose for V35 was to be less than 40% and mean dose less than 20Gy. The brachial
plexus was to remain under 66Gy. The dose constraints for this plan were achieved, as can be
seen by the DVH (Figure 10). After review from the doctor, the plan was approved and ready for
QA and RadCalc.
Quality Assurance/Physics Check: The monitor units to be delivered for this specific plan were
double-checked using RadCalc software. The department standard discrepancy tolerance
between the Varian Eclipse TPS and RadCalc is 2% for photons. After running RadCalc the
tolerance difference was below 2% for all four fields (Figure 9). Our physicist then completed
QA by running a mock treatment plan on a designated phantom. The phantom used by our
physicist is the Scandidos Delta4. The standard tolerance for phantom dose versus calculated
dose is more lenient than RadCalc with a 5% discrepancy. After clinical hours, the physicist
was able to run QA and upon completion the results found that the phantom and calculated dose
discrepancy was within 5% tolerance. The physicist gave the final approval and the plan was
ready to be carried out for the patients first day of treatment.
Conclusion: When treating a case as complicated as this one due to tumor location, it is
imperative as a dosimetrist to exhaust all treatment plans and ideas in order to find the plan that
achieves constraints best and minimizes dose to OR. The dosimetrist made more than five plans
before coming to the conclusion that the hybrid technique would be best suited for this specific
case. This goes to show how important it is as a dosimetrist to explore and evaluate every

possible option. The biggest challenge for this plan was the close proximity of the tumor to the
spinal cord. The location eliminated multiple treatment planning options and forced the
dosimetrist to think outside the box. This case helped me to understand that it is ok to try new
techniques and create multiple fields in order to see the pros and cons of each. I struggled with
contouring the brachial plexus. This case also helped me to understand the importance of
contouring. Many structures had to be contoured for this specific case and if any of the contours
would have been done inaccurately, the plan would not be accurate. I also learned the importance
of reference point placement. I often struggle finding the ideal placement. The isodose line
coverage and accurate MU calculation is dependent on precise placement. Placing the reference
point too close to block edge or in air space could drastically alter the entire plan. Lastly, I
learned that communication amongst the radiation team is of the utmost importance. The
physicians guidance and the dosimetrists input and ideas helped put this plan into motion and
helped perfect it. The hybrid technique using AP/PA fields with dynamic conformal arcs created
the perfect blend to create a homogenous and highly conformal plan to a tumor volume in a very
hard location.


1. Soyfer V, Meir Y, Corn B; et al. AP-PA field orientation followed by IMRT reduces lung
exposure in comparison to conventional 3D conformal and sole IMRT in centrally located
lung tumors. Radiation Oncology. 2012. 10.1186/1748-717X-9-28

2. Washington, Charles M. and Leaver, Dennis T. The Principles and Practice of Radiation
Therapy. 4th ed. St. Louis, MO: Mosby Year Book Incer

3. Khan FM. Intensity-Modulated Radiation Therapy. In: Khan FM. The Physics of
Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams and Wilkins; 2010

Figure 1. Lateral reference mark placed on patients skin during sim. Two marks
on vac-loc bag showing ISO and lower level to be aligned with lateral skin marks
for daily positioning.

Figure 2. Patient positioned in the supine position, with wedge cushions under
arms for supports and comfort

Figure 3. Anterior reference mark on patients skin. Arms raised above head
with hands clasped.

Figure 4. Isocenter placement in transversal view. Red line indicates GTV and
thick pink line indicates PTV

Figure 5. Isocenter placement in frontal view. Thick Red line indicates GTV.

Figure 6. Isocenter placement in sagittal view. Thick Red line indicates GTV.

Figure 7. Beams eye view of AP view. Pink contour is GTV and purple contour is

Figure 8. Beams eye view of gantry angle 149 of dynamic arc. MLC leaves
shielding spinal cord during gantry rotation.

Figure 9. RadCalc showing discrepancy % difference.


Figure 10. Dose volume histogram