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Charity Rogstad
April Case Study
April 6, 2017
Sarcomatoid Lung Cancer
History of Present Illness: PL is a 53 year old male who presented in the Emergency
Department on 12/17/2016 with stabbing chest pain for three nights. An EKG was done and
results were in normal range. His chest x-ray was also unremarkable. He began having a cough
with hemoptysis, which was a dark red in color. The physician gave him a prescription for
Augementin and he was being treated for Bronchitis. On 1/19/2017 a CT of the chest was done
without contrast. It showed left pleural fluid extending into the major fissure. There as a left
lower lobe atelectasis with no central airway obstruction. Also a CT of the chest was done with
contrast that showed peripheral enhancement of the abnormal left lower lobe with necrotic
changes. These were consistent with neoplasm versus abscess formation. On 1/24/2017
interventional radiology performed a CT guided aspiration of the pulmonary abscess with left
pleural drain placement, the drain was also placed into the left for empyema. There was 150 mL
of red-brown pasty liquid that was aspirated from the mass and an additional 50 mL of red-
orange pus was aspirated from the area suspicious for empyema. Pathology for the left lower
lobe aspiration showed suspicion for non-small cell lung cancer (NSCLC) and the pleural fluid
was negative for malignant cells. This represents a sarcomatoid carcinoma due to the
pleomorphism. The World Health Organization (WHO) has established a histologic
classification of lung cancer that includes at least 12 primary tumor types with several subtypes.
For a clinical perspective lung cancer is divided into two main groups small cell lung cancer
(SCLC) and NSCLC.1 Sarcomatoid lung cancer falls under the NSCLC category. In 2004 WHO
classification sarcomatoid carcinomas of the lung are classified into 5 subtypes: pleomorphic
carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma, and pulmonary
blastoma.2 PL was discharged from the hospital on 1/28/2017 only to return to the Emergency
Department on 1/29/2017 with severe air hunger at rest, he was discharged recommending CPAP
and lorazepam for anxiety. On 1/31/2017 a CT angiography showed a left lower lobe mass
measuring 7.6 x 6.1 x 9.4 cm which was enlarged from the 1/19/2017 scan measurements of 7 x
5.5 x 8.1 cm. Also noted was a new small right pleural effusion. An MRI of the brain was done
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on 1/31/2017 and did not show any metastatic disease. PLs diagnosis stage IV Sarcomatoid
Lung Cancer.
Past Medical History: PL has a past medical history of psoriasis, vertigo, sinusitis, obstructive
sleep apnea, gastric esophageal reflux, neck pain, plantar fasciitis, tobacco use, benign prostatic
hyperplasia, hyperlipidemia, and cervical spine degenerative joint disease. PL has a past surgical
history of negative cardiac catherization in 2013, tonsillectomy, colonoscopy, and trigger point
injections in the cervical spine. PL has no known drug or food allergies.
Social History: PL is currently working in Mandan with the Police Department. He and his wife
have lived in Mandan for over 20 years. PL has a family history of father with colorectal cancer,
mother with breast cancer and also two sister with breast cancer. He has a 30 pack year smoking
history and rarely uses alcohol.
Medications: PL uses the following medications: acetaminophen, aspirin, vitamin D3,
ibuprofen, multivitamin, omega-3 fatty acid, vitamin B6, vitamin C, Wellbutrin, meclizine.
Diagnostic Imaging: PL had a chest xray in mid-December 2016 which was unremarkable.
Chest CT with and without contrast in mid-January 2017 which showed an abnormal left lower
lobe. CT guided aspiration was also done in January 2017 results were positive for poorly
differentiated non-small cell lung cancer. In late January 2017 a CT angiography was done
showing that the size of the mass had significantly increased in a matter of less than two weeks.
MRI of the brain was also completed in late January 2017 showing negative brain metastasis.
Radiation Oncologist Recommendations: After review of PLs medical history and pathology
the diagnosis of stage IV sarcomatoid lung cancer was determined. Based on multiple pleural
involvement and contralateral hilar adenopathy he is not a surgical candidate. After discussion
with medical oncology curative intent is not likely a possibility. Sarcomatoid cancer has a poor
prognosis especially with a large volume of disease. Sarcomatoid cancer is diagnosed in men
more often than women, predominant in smokers versus nonsmokers, is stage IV in 43.5% of
cases and chemoradiotherpay is used in 5.5% of these cases. Median survival of stage IV patients
that did not undergo Surgery is 3 months and most die of cancer progression.3 Medical oncology
and radiation oncology agree that immediately beginning palliative intent chemoradiation is PLs
best treatment plan. Radiation intent will be to control the pleural effusion as rapidly as possible
since a chest tube will be in place until the effusion is under control. Advantages of concurrent
chemoradiation are quicker tumor response and local control.
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The Plan (prescription): The radiation oncologists treatment recommendation for PL was to
start treatment as soon as possible with an IMRT plan that encompasses the treatment volume
and spares the right lung, heart, airway, and esophagus. Initial prescription is 30 Gray (Gy) at 2
Gy per fraction for 15 fractions using two Vmat partial arcs. Daily Image Guided Radiation
Therapy (IGRT) will be used to check position and tumor response. On the first day of treatment
orthogonal port films were also taken. IMRT was chosen over a 3D plan in an effort to reduce
radiation dose to the organs at risk (OR) including the heart and right lung. The radiation
oncologist also believes that with an IMRT plan there will be better tumor coverage in
comparison to a 3D plan.
Patient Setup/Immobilization: On 2/2/2017 PL came from the hospital to the Bismarck Cancer
Center for his initial computed tomography (CT) planning simulation using a Phillips Big Bore
CT scanner, a 4D lung scan was done. He was placed on the table in the supine position with
both of his arms up on a Civco Monarch wingboard, a red Civico head rest was used under his
head and his hands were holding at the G9 position with a grip placement on the top of the bar. A
red Civco knee cushion was placed under his knees and indexed to the table, his toes were also
banded to ensure reproducibility every day for treatment. PL was aligned to be anatomical
straight and was given superior, inferior, central axis and lateral marks that were also marked
with a Beekly CTSpot marker. These marks are also the setup marks that are used for radiation
treatment so after the CT scan a small tattoo was also given in each of the five positions.
Anatomical Contouring: Once the CT simulation scan was completed the 4D scan and standard
CT images were fused in Philips Pinnacle version 9.1 treatment planning system (TPS). The
medical dosimetrist contoured all the organs at risk (OR) which included the right and left
normal lung, spinal cord, airway, heart, esophagus, and combo lung volumes. The radiation
oncologist reviewed and approved OR then proceeded to contour an ITV on the 4D scan a PTV
was created from this volume and included the ITV + 7 mm margin. The target volume
encompassed all of the lower left lung lobe the treatment volume is illustrated in image 3 below,
this was a very large PTV to treat using vmat. The medical dosimetrist was then given a
prescription and specific objectives to begin treatment planning.
Beam Isocenter/Arrangement: The isocenter was placed in the center of the treatment volume.
There were two vmat partial arcs used to treat the PTV, the first beam traveled counter clockwise
from 178 to 302 with a collimator angle of 45, the second beam traveled clockwise from 302
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to 178 with a 315 collimator angle. This beam arrangement was chosen to limit dose to the
right lung and spinal cord. Another reason partial arcs were used is due to the lateral position of
the isocenter and possible gantry collision with the patient if a full arc were to be used. The
collimator is rotated off axis to eliminate leaf streaking throughout the treatment volume. Both
lung fields were planned using 6 megavoltage (MV) energy beams and treatment was planned
for the Elekta Synergy. The patient was treated on both the Elekta Synergy and Infinity, this was
possible due to having the Elekta Agility head on both machines.
Treatment Planning: The radiation oncologist put the prescription in Mosaiq along with
communicating planning objectives with the medical dosimetrist. The plan was to use two 6 MV
Vmat partial arcs to treat the PTV and limit dose to all surrounding structures including the heart,
right lung, spinal cord and esophagus. The prescription was prescribed to the Region of Interest
(ROI) Mean PTV Left Lung to a total dose of 30Gy in 2Gy fractions 96% isodose line. The TPS
used direct machine parameter optimization (DMPO) also referred to as auto planning for the
initial plan. Initial parameters that were entered included Combo Lung: mean dose of 18Gy and
Max dose of 20Gy (V20) under 30%; Heart: Mean dose of 13Gy, V20 under 30% and V15 under
50%; Esophagus: Mean dose of 27.5Gy, V32.5 under 33% and V29.8 under 66%; Spinal cord:
Max dose of 21Gy. Once the initial plan was done the medical dosimetrist altered the
prescription isodose line to get adequate coverage, along with drawing hotspot contours and
coverage contours. The plan was optimized again with these additional contours taken into
account. The final plan included two treatment partial arcs with 60 control points each to achieve
all objectives and give adequate tumor coverage. The prescription was 30Gy in 2G fractions to
an isodose line of 96%. The radiation oncologist reviewed the plan and dose volume histogram
(DVH) before giving his final approval to proceed with printing the plan and getting it ready for
quality assurance (QA) checks.
Quality Assurance/Physics Check: The dose for the treatment plan was double checked using
the Mobius program. Our departments tolerance is 90% of the measured points need pass the
gamma analysis of 3mm/5%. After printing the plan a second check was done on the treatment
machine also using the Mobius program. Again the tolerance for this check is also 90% of the
measured points need pass the gamma analysis of 3mm/5%. This check is then reviewed and
approved by physics staff before saving the document in the patients electronic medical record
(EMR).
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Conclusion: This case is very interesting to me as a new medical dosimetry student due to the
complexity of the case and the timeframe of getting the plan completed. I had not seen a case of
Sarcomatoid Lung Cancer or the extent of disease PLs case presented with. Through my
research I did learn about how rare Sarcomatoid Lung Cancer is and that unfortunately the
prognosis is not very good. Also the patient did return with a superficial lesion at the site of
where his chest tube had been. This lesion was from seeding of the tumor around the chest tube. I
also learned some Vmat planning techniques that will help speed up the planning process and
ensure a very good treatment plan. This included knowing your OR tolerance before you get
started and having clear communication with the physician about what he expects from the plan.
Even though this was a palliative case and IMRT is usually not used for palliation I know that
this plan gave the PL the best chance of increased survival with minimal complications.
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References
1. Stinson D, Lahaniatis J. Respiratory system tumors. In: Washington CM, Leaver D. eds.
Principles and Practice of Radiation Therapy. 4th ed. St. Louis, MO: Mosby-Elsevier;
2016:621-642
2. Franks TJ, Galvin JR. Sarcomatoid carcinoma of the lung: histologic criteria and
common lesions in the differential diagnosis. Arch Pathol Lab Med. 2010;134(1):49-54.
3. Ung M, Rouquette I, Filleron T, et al. Characteristics and clinical outcomes of
sarcomatoid carcinoma of the lung. Clin Lung Cancer. 2016;17(5):391-397.
http://dx.doi.org/10.1016/j.cllc.2016.03.001
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Image 1: Patient positioned on Civco wingboard with CT Spot markers placed over the position
of setup marks.

Image 2: Anterior and left lateral reference images and isocenter placement in comparison to
carina. These images were used on the first day of treatment for comparison with reference ports.
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Image 3: Anterior and Left lateral images with the treatment PTV in red.

Image 4: Isocenter placement in the axial view along with isodose coverage including a small
hotspot just posterior to the posterior portion of the heart.
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Image 5: Sagittal and Coronal view of isocenter placement along with isodose coverage
including a small hotspot medial and superior to the heart.

PTV

Spinal Cord

Left Lung
Esophagus

Combo Lung
Heart

Right Lung

Image 6: Dose Volume Histogram (DVH) demonstrates radiation dose to a tissue volume. The
OR that were evaluated for PLs case include the spinal cord, esophagus, right and left lung,
combo lung, and heart along with the PTV. This is a tool that quickly and easily shows the
amount of dose a certain volume of tissue receives.