Rare Malignancy of Neural Sheath Tumors in Spinal Canal: a case study.

I. Illness presentation and discovery

a. 71 y.o. male
b. Emergency room visit on 8/17/17 for severe low back/sacral pain
i. Imaging performed – CT pelvis bony anatomy
1. Avascular necrosis both femoral heads
ii. Pt admitted to hospital after ER visit on 8/18/18
c. MRI 8/18/17 Lumbar with and without contrast
i. Ordering dx spondylolisthesis & osteoarthritis
ii. Finding reviled severe canal narrowing and multiple tumors within spinal
canal
iii. Largest two at T12-L1 and L4-L5
iv. Head, c-spine, t-spine MRI imaging recommended
d. MRI 8/19/17 Head, C-spine, T-spine
i. Head – negative
ii. C-spine – no evidence of neoplasm
iii. T-spine – Several enhancing nodules
e. CT chest/abd/pelvis w contrast 8/19/17
i. Negative for primary malignancy
f. Neurology – Laminectomy performed 8/24/17
i. T12/L1 Laminectomies and Resections of lesions at L4
ii. Decompression of spinal cord – gross tumor remains
iii. Pathology sent out – Dx Malignant peripheral nerve sheath tumor
II. Past Medical History
a. Extensive problem list
i. Benign hypertensions with CKD stage III
ii. Kidney, aplastic
iii. Obesity
iv. Pulmonary nodule
v. Idiopathic parkinsonism
vi. DJD lumbar spine
 vii. GI bleed secondary to ischemic colitis
III. Social history
a. Alcohol use - rarely
b. Former smoker quit date 8/31/2014
i. 1 pack/day for 50 years
c. Father – Lung disease, smoker
i. Deceased age 91
d. Mother – Pancreatic cancer, solitary kidney from accident
i. Deceased age 55
e. Brother – No major problems
f. Married
i. 2 children
IV. Radiation oncology consultation 10/3/17
i. Palliative – local control, delay progression
ii. Start once patient healed from laminectomy surgery
iii. Discussion of treatment at lesion levels
1. Concern for good kidney – avoid area tx planning
iv. Discussion of possible side effects
v. Patient wants to proceed with radiation therapy
V. Radiation Therapy prescription
a. Treatment start 10/16/17 & end date 12/1/2017
b. T12- sacrum Total 5940 cGy in 33fx
i. Primary T12-Sacrum: 5040cGy in 28 fx
ii. Boost L2-Sacrum: 900cGy in 5 fx
c. VMAT IMRT
i. 6MV
VI. Patient Simulation
a. CT sim WO contrast 10/9/17
b. Positioning
i. Supine head first
ii. Arms above head
 1. Wing board
2. Triangular sponge under both arms
iii. Total Body Fix
1. Knee sponge under
c. Reference marks placed
i. Verifications sim date 10/13/17 (isoverify)
VII. Contouring
a. Scan sent to MIM
i. MRI fusion from 10/5/17 scan
b. MD contours in Eclipse
i. PTV Spinal cord (Top of field to mid L1)
1. spinal cord +5mm
ii. PTV Boost
iii. Cauda Equina (Mid L1-sacrum)
iv. CTV – entire spinal canal
c. Dosimetrist contours
i. Varian eclipse software
ii. Liver, stomach, spinal cord, bowel, Lt kidney
iii. Dose display on MD preference
VIII. Treatment planning
a. Varian Truebeam
i. IGRT - Exactrac
b. Isocenter
i. Mid total PTV (T12-Sacrum)
ii. In spinal cord
iii. L2-sacrum boost will have same iso
c. T12-Sacrum - VMAT
i. 6MV
ii. 4 arcs full arcs - Coplaner
iii. Collimator angles at 330°, 350°, 10°, 30°
iv. DVH objectives
 1. MD wishlist
2. Discuss with dosimetrist
d. L2-Sacrum Boost
i. 6MV
ii. 4 arcs full arcs - Coplanar
iii. Collimator angles at 330°, 30°, 15°, 345°
iv. DVH objectives
1. MD wishlist
2. Discuss with dosimetrist
e. Any difficulties in planning objectives
f. Evaluate composite DVH
IX. Quality Assurance/physics check
a. Radcalc for second check
i. Initial and boost
b. Sun Nuclear Arc Check phantom - Physics
i. Initial
1. 1386 diode measurements at 92.9% agreement within 3mm
ii. Boost
1. 1006 diode measurements made and 97.2% agreed within 3 mm
X. Three month follow up
a. MRI 3/1/18 Total spine
i. Multiple enhancement lesions T10-T11
ii. Progression superior to field
iii. Surgery not an option, Chemo not proven to be effective
iv. Planned additional radiation therapy treatment fields
1. Things to consider for next course
a. Treatment
b. Match line
c. OARs – spinal cord
XI. Conclusion
a. Primary malignant neuro sheath tumors rare
 i. Recap increased knowledge
b. VMAT
i. Better understanding of treatment concept
ii. Avoidance of case specific OARs
1. Pt only had one good kidney – left
c. Recurrence above site and will have future RT treatments
i. Made aware of things that would need to be considered for next plan
d. Struggled with
e. Overall effect on clinical internship experience