1

Eyob Mathias Clinical Practicum II June 26, 2013 Intensity Modulated Radiation Therapy for Adenocarcinoma of the Lung History of Present Illness: CG is a 67 year old female who presented with persistent cough in April of 2013. She had a chest X-ray done on the 5th of April that showed a 15 x 19 millimeter (mm) right upper lobe (RUL) mass. There was also hilar and paratracheal lymphadenopathy in addition to this mass. Findings were suspicious for malignancy and computer tomography (CT) scan was recommended. She underwent CT scan on the 10th of April. The result revealed a mass measuring 1.9 x 1.4 centimeter (cm) in the RUL as well as extensive peritracheal lymphadenopathy measuring 2.8 x 3.6 cm. There was also right hilar lymphadenopathy measuring 2.6 x 2.1 cm. She then underwent a positron emission tomography (PET) scan done on the 26th of April which confirmed fludeoxyglucose (FDG) uptake in the right upper lobe, right hilar and right paratracheal nodes. Staging was felt to be radiographically T1b N2 M0 disease. Magnetic Resonance Imaging (MRI) of the brain was recommended which was done on the 2nd of May. This showed no evidence of metastatic disease but some chronic small vessel ischemic changes. She had a CT scan guided biopsy on the 13th of May. This was positive for malignancy. Final pathology report showed stage III adenocarcinoma of the lung. Patients main complaint is a persistent cough since January of this year. She also has shortness of breath, more on exertion related to her chronic obstructive pulmonary disorder (COPD). Lung cancer and COPD share a common risk factor in cigarette smoking and a large portion of patients with lung cancer suffer from COPD synchronously.1 Some epidemiologic studies found that smokers with COPD are up to five-fold more susceptible to lung cancer than smokers with normal lung function.1 Patient Medical History: CG had a medical history of COPD, hypercholesterolemia and hypertension. She also had past surgical history of abdominal aortic aneurysm repair in 2009, vocal cord nodule removal, hysterectomy, colonoscopy in 2010 for polyps, left breast biopsy in July of 2012 and right breast biopsy in 2003. Diagnostic Imaging Studies: CG had a chest x-ray and a computed tomography (CT) scan that revealed RUL mass, hilar and paratracheal lymphadenopathy. She also had a PET scan done in April of 2013 which confirmed FDG uptake of the RUL region.

Family History: CGs husband passed away in January of 2013 due to lung cancer. CGs mother died of colon cancer and her father died of myocardial infraction (MI). Social History: CG has a smoking history of at least 50 packs per year since her teenage years. She recently cut down her smoking habit to about 4-5 cigarettes per day. She drinks alcohol socially. Medication: CG is currently taking Dexamethasone, Ondansetron, Endocet, Percocet, Benzonatate, Atenolol, Licinopril, Symbicort, Lovastatin, Cilostazol, Omeprazole and Albuterol sulfate. Recommendations: Its not sufficient to make therapeutic decision solely based on the stage of a cancer.2 Its important to assess individual features of the tumor before recommending treatment options.2 In the case of CG, the location and size of the lung lesion ruled out the possibility of surgery, so the physician recommended neoadjuvant chemo-radiation therapy. Patient may become a candidate for surgery after successfully completing the initial course of the radiation treatment. She came to our oncology department on May 23, 2013 to discuss with the physician about the radiation therapy treatment process and its possible side effects. After she verbalized her understanding of the treatment process, she agreed to proceed with the treatment and CT simulation date was scheduled. The Plan (Prescription): The radiation treatment plan was designed for the patient to receive a total of 5040 centigray (cGy) at 180cGy for 28 fractions using Intensity Modulated Radiation Therapy (IMRT). For patient receiving 50.4 Gray (Gy) to the total tumor and lymph node volume, conedown dose of up to 66Gy is permitted.3 In this case, the physician scheduled the patient to reevaluate the tumor after receiving 50.4 Gy. Depending on the tumor size reduction, tumor resection may become a possibility. Patient Setup/ Immobilization: SP was simulated in a supine position aligned to lay straight on a wing board (figure 1). Her hands were raised above her head holding the wing board bar. Wedge shaped sponges were placed under each elbow for support and kept her hands in position. A large wedged sponge was also placed under her knees. A large bore GE Light Speed CT scanner was used for the simulation process. The radiation therapists put BB markers on the patient using the sagittal and lateral laser beams (figure 1 & figure 2). The CT images were exported to the Digital Imaging and Communication in Medicine (DICOM) server.

Anatomic Contouring: The CT slice images were downloaded from the DICOM server to Pinnacle3 9.2 radiation treatment planning system (TPS) and to the Medical Image Merge (MIM) deformable fusion software. Using the MIM software the dosimetrist fused the planning CT image with PET/CT images to better visualize target volume delineation (figure 3). The radiation oncologist contoured the gross tumor volume (GTV) and provided 0.7mm margin for the planning target volume (PTV) (figure 4). Furthermore, the dosimetrist contoured the left lung, right lung, heart, esophagus, carina, spinal cord and three rings around the PTV (figure 5). The purpose of these contours was to monitor the dose to organs at risk (OR) while planning to deliver the desired dose to the PTV and the three rings around the PTV were used as objectives during plan optimization. Beam Isocenter/ Arrangement: A Varian trilogy linear accelerator (Linac) machine was used to treat the patient. During the simulation process, the radiation oncologist placed the isocenter at the mid-plane of the GTV. Gantry angles of 2250, 2600, 3000, 2400, 200, 600, 1400 and 1800 were used in combination with collimator angles of 00, 3440, 3390, 3100, 3440, 80, 490 and 00 respectively (figure 6 & figure 7). There was no couch angle associated with any of the beams. Each field consisted of 6 mega voltage (MV) photon energy beams. Treatment Planning: Field sizes were adjusted according to the PTV. The dosimetrist reviewed the digitally reconstructed radiograph (DRR) view of each field to make sure the collimator angle and the gantry angle were positioned properly before initiating the optimization process. The objective goals were entered in the inverse planning window according to each ORs tolerance dose limit. The computer calculated the beam weight, intensity modulation and proper dynamic multileaf collimator (MLC) motions according to the defined objectives dose limits. Each field had MLC blocking pattern defined by the computer optimization algorithm. After the plan was completed to the dosimetrists satisfaction, it was saved for the radiation oncologist to evaluate (figure 8 & figure 9). The radiation oncologist reviewed the dose volume histogram (DVH) and evaluated the dose coverage to the PTV as well as doses to the OR (figure 10). The physician approved the treatment plan and selected the 97% isodose line for treatment. Quality Assurance Checks: Monitor unit (MU) check was performed using a quality assurance (QA) software known as Radcalc. At our clinical site, a 3% deviation in MU is the tolerance for any IMRT plans. The plan was approved with -0.4 % for the 2250 beam, -0.0% for the 2600 beam, -2.4% for the 3000 beam, -1.8% for the 3400 beam, 0.3% for the 200 beam, -1.4% for the

600 beam, -0.9% for the 1400 beam and 1.8% for the 1800 beam (Figure 11). Finally, I performed an IMRT QA procedure on the LINAC using OmniPro QA software, IMRT MatriXX measurement devise and solid water phantom (figure 12). The treatment was then evaluated and approved by the medical physicist before the first treatment date was scheduled. Conclusions: This plan was slightly challenging for the dosimetrist because of the critical structures surrounding the target volume. It was difficult to reduce the dose to the spinal cord and the total lung below their limit while adequately covering the PTV. However, there is no boost prescription for this case and the maximum dose given will only be 50.4Gy. From this plan, I learned different gantry angles placements on IMRT plan and the use of collimator angle to block some critical structures in order to make the optimization process easier and maximize the use of MLC motion. I also learned about creating different objectives in order to control the dose distribution and achieve better dose coverage or reduce the dose to critical structures.

Figures

Figure 1. Patient Setup, Left lateral view

Figure 2. Patient setup, AP view

6 Planning CT Image

PET image

Deformed and fused PET/CT image.

Figure 3. Fused PET/CT image

Figure 4. GTV (red volume) + PTV (green volume)

Figure 5: Organs at risk and rings surrounding the PTV (Blue = ring 1, yellow-green= ring 2, maroon = ring 3)

Figure 6. Beam orientation

Figure 7. Treatment plan summary

10

Figure 8. Isodose distribution and 3-dimentional beam view

11

Figure 9. Isodose distribution (green = 20%, orange = 50%, yellow = 80%, blue = 90%, green 95%, pink = 97%)

12

PTV

Total lung Esophagus

GTV

Rt Lung

Lt Lung Heart

Cord

Figure 10: Dose Volume Histogram (DVH)

13

14

15

Figure 11: Radcalc MU check data

Figure 12: IMRT MatriXX QA Measurement device

16

Reference 1. Wang H, Yang L, Zou L et al. Association between Chronic Obstructive Pulmonary disease and Lung cancer: A Case-Control Study in Southern Chinese and a MetaAnalysis. PLoS ONE. 2012;7(9) 2. Quint L. Lung cancer: Assessing respectability. Intl Cancer Imag Soc. 2004; 4(1): 1518 3. Hansen E, Roach M. Handbook of Evidence Based Radiation Oncology. 2nd ed. New York: Springer Science + Business Media;2010: 647-645