Tsai Kevin Tsai June Case Study July 4, 2013 IMRT/SIB for Malignant Neoplasm of Nasopharynx

History of Present Illness: Patient CS was a 52-year-old male diagnosed with locally advanced nasopharyngeal carcinoma on his left neck. The patient noticed swelling in his neck 1 year before his diagnosis but did not see a doctor until he was incarcerated. Patient CS denied many symptoms except for some dysphagia and odynophagia for 6 months, unintentional weight loss of 15 pounds, shortness of breath, night sweats, and changes in his voice. Past Medical History: Patient CS had a past medical history of schizophrenia. Patient had his left kidney removed and liver resected due to gunshot wound to his abdomen in 1986 at the age of 27. He also had wrist surgery. CS has no known allergies. Social History: CS smoked one pack per day of cigarettes for the past 30 years and drank a pint of alcohol a week for the past 10 years. He also used cocaine and marijuana occasionally. His sister and mother both had thyroid problems. His father had an unknown cancer and his brother had an unknown type of head cancer. Patient is currently incarcerated. Medications: CS uses the following medications: Doculase, MiraLax, Acetaminophen, Amlodipine, Bacitracin/Neomycin/Polymyxin, Benztropine, Calamine topical lotion, DiphenhydrAMINE, Haloperidol, Magnesium hydroxide, Morphine, Prochlorperzaine, Senna, Surg-onc mouthwash, and Trazodone. Diagnostic Imaging: On 11/7/2011, patient CS underwent a laryngoscopy that showed a large mass posterior to the left tonsils. He then had a fine needle aspiration (FNA) which was positive for malignancy suggestive of Epstein-Barr Virus (EBV) associated carcinoma. On 11/11/11, CS had a computed tomography (CT) of the neck, which showed an enhancing mass in the left pharyngeal region as well as numerous enlarged ipsilateral lymph nodes; no enlarged contralateral nodes were seen. On 11/18/11, CS was taken to the operating room for nasal endoscopy and direct laryngoscopy. The biopsy taken confirmed the patient had nasopharyngeal carcinoma. A magnetic resonance imaging (MRI) was performed on 12/30/11, revealing a mass increased in size since the previous study including involvement of the left carotid artery. A positron emission tomography computed tomography (PET-CT) revealed a large mass of

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adenopathy in the left jugulodiagastric region with enlarged left level II and level III lymph nodes. Radiation Oncologist Recommendation: After reviewing the patients history and pathology, the radiation oncologist believed that concurrent Cisplatin and radiation was best for the patient because the tumor was growing significantly. The tumor was staged IV T4N2bM0. Due to the proximity of the tumor to critical structures, the radiation oncologist decided that intensity modulated radiation therapy (IMRT) should be used to decrease dose to critical structures and still cover the entire tumor. The goal for this patient was to achieve tumor control while minimizing dose to critical organs. The Plan (Prescription): The doctors prescription included 2 planning target volumes (PTV). The first PTV (PTV1) consisted of the gross tumor with margin. This region was treated to 6996 centigray (cGy) in 33 fractions at 212 cGy per fraction. The second PTV (PTV2) consisted of nodal volumes at risk. This region was treated to 5412 cGy in 33 fractions at 164 cGy per fraction. Both of the PTVs were treated concurrently using the simultaneous integrated boost (SIB) fractionation technique. Patient Setup / Immobilization: On 3/28/2011, CS underwent a CT simulation at our department for radiation therapy treatment. He was setup in the supine position with both arms to his side (Figure 1). An Alpha-Cradle was created under the patients shoulders and arms to limit any movement. A Lite-Cast mask was then formed around the patients chin and forehead to immobilize the patients head (Figure 1). A knee wedge was put under the patients knee for comfort and support. When the patient was immobilized, a CT scan was performed and the images were sent to dosimetry for contouring and treatment planning. Anatomical Contouring: Once the images were imported to our Eclipse 8.9 treatment planning system (TPS), the radiation oncologist began contouring the tumor (Figure 2), nodal volumes at risk (Figure 3), and the brachial plexus (Figure 4). An MRI was fused with the CT scan to help identify the target volume as well as certain critical structures. The medical dosimetrist contoured the rest of the organs at risk (OR), which included the brain stem, spinal cord, esophagus, larynx, eyes, lens, optic nerves, optic chiasm, parotids, mandible, and oral cavity (Figure 5-7). Treatment planning for the patient started after the doctor entered the target volumes and when the dosimetrist contoured all the ORs.

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Beam Isocenter / Arrangement: Placing the isocenter started at finding the 3 BBs placed on the patient during the CT simulation. The dosimetrist then combined PTV1 and PTV2, creating a PTV-ALL (Figure 8). The isocenter is then placed in the middle of PTV-ALL (Figure 9-11). A shift from the BBs to the isocenter was then calculated and given to the radiation therapist. Intensity modulated radiation therapy for head and neck (H&N) patients at our department and this patient utilizes 9 complex treatment beams. The 9 IMRT beam angles were 200o, 240o, 280o, 320o, 0o, 40o, 80o, 120o, and 160o (Figure 12). The intensity and multileaf-collimators (MLC) of each beam is created by the TPS. The optimization process adjusts the weights of each beam to produce a conformal dose distribution around the target volume while minimizing dose to certain ORs. The patient was treated with a 6 mega-voltage (MV) energy on a Varian 21EX linear accelerator. Daily kilo-voltage (kV) imaging was used for positioning before each treatment. Treatment Planning: For this patient, the radiation oncologist used the SIB technique, which is a common IMRT technique for nasopharyngeal carcinoma treatment. For regular sequential (SEQ) techniques, the low risk PTV (PTV-LR) is irradiated in the first plan and the dose is boosted to the high risk PTV (PTV-HR) in the second plan with the same dose per fraction for the whole treatment. For the SIB technique, The PTV-LR and PTV-HR are all treated simultaneously with different dose per fraction. The number of fractions of SIB is therefore less than SEQ. The SIB technique is more conformal than SEQ because it only needs a single optimization and do not require a plan summation. The suitable selected techniques between SEQ and SIB depend on tumor shape and target planning.1 The treatment planning process started by creating a 0.5 cm ring (GAP) around the PTV-ALL (Figure 13). Another 2 cm ring (SHELL) is created around the PTV-ALL. The GAP structure is then removed from the SHELL leaving a moat looking shape (Figure 14). This is created to eliminate splashes of dose into normal tissues. During the optimization process, an upper constraint of 95% of the prescription dose (6646 cGy) is set for the SHELL. We want the prescription dose to be tightly wrapped around the inner ring and for the dose to fall off quickly when it reaches the 2 cm outer ring. Next a normal tissue structure (SKIN-PTV) was created by subtracting the SHELL and GAP from the body contour (Figure 15). The normal tissue structure was used to reduce dose to normal tissue around the PTV. An upper constraint of 75% of the prescription dose (5247 cGy) was set during optimization to reduce dose to normal tissues structures. Intensity modulated radiation therapy for this patient was planned using inverse

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planning technique meaning the dosimetrist defined the target dose and programmed normal tissue tolerance doses to create a number of beam portals and beam-intensity patterns with each portal.2 Once optimization was completed, dose volume histograms (DVH) were generated and checked by the radiation oncologist. The treatment planning goals for the critical and normal tissues were: the parotid V30 should be less than 50%, spinal cord should not have a max dose over 50 Gray (Gy), and brainstem to have a max dose of less than 54 Gy. The radiation oncologist reviewed the plan and approved it for physics check and treatment. Quality Assurance / Physics Check: The monitor units (MU) from the plan were reviewed with another independent software named RadCalc. The Eclipse treatment plan was exported to RadCalc for comparisons and the difference was 1.6%, which was less than the 3% tolerance. The medical dosimetrist created a verification plan so that the physicist could run an IMRT quality assurance (QA) on the machine to test the fluences of the beam. The medical physicist reviewed the complete IMRT plan before the patient began his radiation treatment. Conclusion: This case study regarding IMRT/SIB technique to H&N patient was very educational and rewarding. This case allowed me to understand the benefits and risks between the SIB and SEQ technique. Although it took a lot more time creating a SIB plan, it seems much more beneficial for the patient because of the reduced overall total fractions. The patient history allowed me to get a better understanding of common symptoms that can usually occur in nasopharyngeal cases. Overall, I believe this case study has improved my understanding significantly in IMRT treatment planning and I look forward to planning more interesting cases in the future.

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Figure 1: Patient position at simulation

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Figure 2: PTV1

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Figure 3: PTV2

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Figure 4: Brachial Plexus

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Figure 5: Organs at Risk

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Figure 6: Organs at Risk

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Figure 7: Organs at Risk

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Figure 8: PTV ALL

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Figure 9: Isocenter on Sagittal view

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Figure 10: Isocenter on Frontal View

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Figure 11: Isocenter on Transverse View

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Figure 12: 9 IMRT beam angles (200o, 240o, 280o, 320o, 0o, 40o, 80o, 120o, and 160o)

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Figure 13: Gap (0.5 margin around PTV-ALL)

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Figure 14: Shell (2.0 margin around PTV-ALL)

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Figure 15: Skin-PTV (Gap and Shell subtracted from the skin contour)

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Figure 16: DVH

Tsai 21 References 1.) Khayaiwong P, Tungboonduangjit P, Suriyapee S, et al. Dosimetric Comparison between Simultaneous Integrated Boost and Sequential Intensity-Modulated Radiotherapy Techniques in Nasopharyngeal Carcinoma. http://www.tmps.or.th/meeting2012/FullPaper/paowarin.pdf. Accessed July 5, 2013. 2.) Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsvier; 2010:333.