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Nick Piotrowski Clinical Practicum 1 February 24, 2013 Left Clavicle Metastasis History of Present Illness: CT is a 66 year old female that has recently been diagnosed with bone metastasis of her left clavicle. Earlier this month she reported to her primary care physician that she was having pain near her left shoulder. With a previous history of lung cancer and bone metastasis, she was instructed to receive more testing. A chest computed tomography (CT) scan revealed an irregular sclerotic lesion that had potential signs of expanding. While she has had previous radiation therapy, the treatment was not in this region, making her still a viable candidate for treatment. Past Medical History: CT has an extensive past medical history involving this disease as well as some unrelated diseases. She has a history of lung carcinoma, pericardial effusion, spleen enlargement, pleural effusion, hypertension, syncope, total abdominal hysterectomy bilateral salpingo-oophorectomy, gastric and sigmoid colon inflammation, as well as lumbar and small bowel abnormalities. CT has an allergy to Penicillin and mild allergy to Compazine. She has also had mental battles as she was diagnosed with schizophrenia 6 years ago, had visual hallucinations, and has been kicked out of her daughters home for allegedly beating her grandkids. Social History: CT has a family history of cancer from both her mother and father but cannot remember the diagnosis. She has been married twice and has one daughter who she has lived with in the past. She was a smoker for 20 years with a smoking husband and waitress for 25 years that may have attributed to second hand smoke. Medications: She is currently on 50 milligrams(mg) of Seroquel twice a day, and 10mg of Lexapro daily. She has also been on Nitrofurantoin, Lorazepam, Metoprolol succinate, Furosemide, Potassium Chloride, Butalb, Escitalopram oxalate, Prochlorperazine maleate, Ropinirole HCL, Morphine sulfate, and Fentanyl citrate. Diagnostic Imaging: Between August of 2005 and February 2013, the patient had numerous CT scans to the chest, abdomen, and pelvis. She has also had three full body bone scans, a brain

magnetic resonance imaging (MRI), and x-rays of each potential bone metastasis. These x-rays consist of the clavicle, lumbar, sacrum, and numerous rib lesions. Radiation Oncologist Recommendations: Due to numerous other complications, and her already being in and out of hospice care, CT was treated as a palliative case. There was no need for chemotherapy, but to relieve her pain she was a good candidate for external beam radiation therapy. It would be a short treatment of only 10 fractions in hopes to improve her quality of life. The Plan (prescription): For a palliative plan, CT was to receive 3000 centigray (cGy) at 300 cGy per fraction for 10 fractions. She was to be treated anterior/posterior (AP), posterior/anterior (PA), which was later changed to only an AP beam during the treatment planning process. To limit the amount of treatments there was no boost set in place for after the initial treatment. Patient Setup/Immobilization: The patient was simulated supine with her arms resting at her sides. To provide comfort a blue pad was placed under her back, a cushion under her knees, and a head rest at the appropriate height. She also had a Vac-Fix created to immobilize her upper body, similar to what is seen in Figure 1. Anatomical Contouring: I first set a user origin based on the BBs that were set on the day of the simulation. From there I contoured the left lung, spinal cord, mandible, and left and right humeral heads. Once finished, the physician set the field size that he wanted in order to cover the clavicular lesion. Beam Isocenter/Arrangement: Using a Varian iX linear accelerator, CT is receiving her treatment over a two week period of time. With the field set by the oncologist being on the distal portion of the clavicle, a 10.2 centimeter(cm) left shift from midline was required to reach the isocenter. It also required a 6.0cm superior shift, as well as a 0.9cm anterior shift as seen in Figure 2. The plan consisted of two 6 megavolts (MV) AP beams, both requiring collimator rotations, but with no need for multileaf collimators (MLC), or couch kicks. The first beam was an open field, requiring a 14.6 degree collimator rotation to line up the field border with the clavicle. The second AP beam needed to have the collimator rotated 90 degrees from the previous field to 104.6 degrees, in order to incorporate an enhanced dynamic wedge (EDW). Treatment Planning: Using Eclipse 8.6, the goal of CTs treatment was to reach a total dose of 3000cGy while sparing some surrounding structures. While the spinal cord, right lung, and right

humeral head were a great distance away, it was important that we still look at the dose they were receiving. Prior to the treatment, the physician set tolerances for the lung at 37 percent under 20 Gray (Gy), the spinal cord at a 45Gy maximum, and the humeral heads at a 50Gy maximum. With the prescribed dose being so low, there were no real threats to surpassing these tolerances, but we did still try and do our best to keep them as low as possible. With the left humeral head being the only structure remotely close, it was necessary to either use a block or rotate the collimator to keep it out of the field, in which I opted to do the later. As seen in Figure 3, this field orientation allowed me to keep my critical structures well below the tolerances that had been provided. With the beam orientation set, the next goal was finding a way to keep my hot spot down. With the body contour being irregular, it was a prime situation to use a small degree wedge. Unfortunately, the addition of the wedge pushed the hot spot underneath the toe and only slightly decreased the global maximum. To balance this out I created another AP field that I was able to weight the wedge lightly. Shown in Figure 4, with a 2:1 ratio, no wedge to wedge, the hot spot was decreased and my isodose coverage was more than acceptable. Quality Assurance / Physics Check: Before printing, the monitor units that were calculated by Eclipse were double checked using RadCalc. Once the numbers were found to be within tolerance, the plan was checked and signed off by both the medical physicist, as well as the attending physician. Conclusion: With it being my second month of treatment planning, I felt as though this was a good starting point for a competency. Even for a palliative treatment, this plan was very straightforward and I had no trouble in meeting any of my constraints. With that said, it did provide me with a chance to think outside of the box a little. Had I done a simple AP beam with or without a wedge, or an AP/PA treatment, the coverage would have been unacceptable and my hot spot too high. It also gave me another chance to adjust the weighting of beams, and the use of beam modifiers to see their effect on my plan. I also found this case to be intriguing due to the simulation experience I had with this patient. She was somewhat forgetful and unwilling to share information with us even though she has been treated in the past. Reviewing her chart gave me a greater insight into what she had to deal with outside of her current disease. Without the patient contact every day, it is easier for a dosimetrist to lose sight of what we are truly working for. Our immediate job is to create a treatment plan for cancer patients, but it is also our job to understand difficulties that the patients are going through, and find ways to make it better.

Figure 1: Vac-Fix immobilization device courtesy of Vac-Q-Fix Cushions.

Figure 2: Isocenter and reference point placement on clavicle

Figure 3: Dose Volume Histogram of plan

Figure 4: Plan dose distribution

References 1. D-Positioning Systems. Vacuum products. Positioning and Immobilization. 2013. Available at: http://www.rpdinc.com/html/d-vacuumproducts.html. Accessed January 23, 2013.