1 Susan Hunt Monthly Case Study March 21, 2014 Whole Brain treatment plan for brain metastases

History of present illness: JR, a 72-year old male, was recently diagnosed with stage IV adenocarcinoma of the bronchus and upper lobe of the left lung with brain, adrenal and bone metastases. A chest x-ray in January 2014 showed a mass in the lung, so a Computed Tomography (CT) scan was done, which found a 19-mm mass in the left upper lobe. The CT also revealed enlarged lymph nodes throughout the mediastinum, measuring up to 1.1 X 1.7 cm in the pretrachial region and suspicious hilar lymph nodes. These results led to a PET (Positive Emission Tomography) CT scan, which showed increased uptake in pulmonary nodules as well as nodes in the lower cervical, left superclavicular, mediastinal and hilar areas. Also showing increased uptake were the left adrenal gland, right acetabulum and right sacrum. In February 2014, surgery removed 4 lymph nodes, all of which tested positive for poorly differentiated adenocarcimoma. Since cerebral metastases (mets) are extremely common,1 and the patient is an older male with extensive metastatic disease, an Magnetic Resonance Imaging (MRI) study of the brain was ordered. The MRI showed 11 cerebral mets up to 1 cm in diameter with no surrounding edema. The patient reported no headaches, blurred vision, balance problems, motor or sensory dysfunction, back or bone pain, shortness of breath, hemoptysis, dyspnea on exertion or weight loss. In fact, the patient stated that he felt very well. Past Medical History: In 1999, JR was diagnosed with stage T1N0 adenocarcinoma in the upper lobe of the right lung. At that time, the tumor was surgically removed along with 6 peribronchial lymph nodes, which all tested negative for malignancy. The patient has a long history of anxiety disorder and hypertension. He has undergone numerous surgeries to correct a chronic nonunion of the left proximal humerus. He has had an appendectomy and a laparoscopic cholecystectomy. Social History: The patient is a former smoker, smoking a half pack of cigarettes per day. He recently quit smoking. He is married and still works part time. Medications: JR takes 1 mg of folic acid daily, 12.5 mg of losartan potassium daily, alprazolam as needed for anxiety and oxycodone acetaminophen as needed for pain.

2 Diagnostic Imaging: After the initial imaging studies that identified the lung mass and the involved lymph nodes, the patient underwent an MRI of the brain, a common procedure after discovery of extensive disease. The brain MRI showed 11 cerebral mets up to 1 cm in diameter with no surrounding edema. Radiation Oncologist Recommendations: The radiation oncologist recommended JR undergo radiation therapy to the brain as a palliative measure to help control the brain mets. Since the tumors are numerous and scattered, there will be no Gross Tumor Volume (GTV) identified as a target. Rather, the entire brain will be irradiated. The Plan (Prescription): The patient was prescribed a radiation dose of 3000 cGy to be delivered to the brain in 10 daily fractions. Patient setup/Immobilization: The patient was positioned supine on a B carbon fiber headrest, with the arms resting on the chest. A sponge was placed under the knees for comfort and a specialized mask was made to immobilize the head. Anatomical Contouring: Since this is a whole brain treatment, no GTV was identified by the oncologist. The CT images were uploaded into the treatment planning computer and a checklist was used to contour the following: Left and right optic nerves, eyes, lenses and temporal lobes, the brainstem, optic chiasm, cribiform process and spinal cord. Beam Isocenter/Arrangement: The axial slice containing the 3 BBs placed on the mask during the simulation procedure were located and a point was placed at the intersection of the lines going through these BBs. This point was identified as the isocenter. Two lateral beams were created using the isocenter as the central axis. The angle of the gantry was adjusted for each beam so that the anterior edge of each beam lined up behind the patients eyes. The collimator jaws were set to create a rectangle 21 cm wide by 19.5 cm long, with the central axis centered on the isocenter. Using the contours, blocks were added to each beam to block the eyes while keeping the cribiform process and the temporal lobes in the field. Since the inferior margin is frequently set too far superiorly to include the entire brain,2 care was taken to make the fields large enough, then carefully blocking the eyes without blocking any of the brain tissue (in the cribiform process). The blocks were arranged so that the brainstem and spinal cord were included in the field and there was approximately 1.5 cm of flash beyond the skull in all directions. See Figure 1 to view the Digitally Reconstructed Radiographs (DRRs) showing the Beams Eye View (BEV) of each field.

3 Treatment Planning: The treatment planning system used was Pinnacle 3 by Phillips. The two beams were each assigned a photon energy of 6 Megavolts (MV) and 1 control point was assigned to each beam to help cool down the hot spots around the edges of the skull. The beams were weighted equally. Figures 2 -4 show the isodose distribution in the three planes at the isocenter, and Figure 5 shows a three dimensional (3D) skin rendering of the dose. A Dose Volume Histogram (DVH) was generated to graphically depict the dose to the contoured regions. The DVH can be seen in Figure 6. Quality Assurance/Physics Check: Radcalc is the name of the computer software used to verify the dosages for this plan. Figure 7 shows the Monitor Unit (MU) calculation sheet generated by the RadCalc program. The medical physicist reviewed and approved the plan. Conclusion: The patient is currently undergoing treatment. He continues to feel well. The reason I chose this particular case for the case review is because this patient was my first competency. It was the first treatment plan I created entirely by myself. I met the patient and helped in the simulation process as well as the first treatment. It is a relatively simple plan but I feel that I learned the method of angling the beams so that neither beam diverges into the eyes. This method protects the sensitive eye structures from the effects of radiation. Also, contouring the cribiform process helps to keep the margin tight behind the eyes so that none of the brain material is inadvertently omitted from the field.

4 References: 1. Bentel GC. Radiation Therapy Planning 2nd edition. New York, NY: McGraw-Hill; 1996. 2. Washington CM and Leaver D. Principles and Practice of Radiation Therapy 3rd edition. St. Louis, MO: Mosby Elseiver; 2010.

5 Figures

Figure 1. DRRs showing BEV with blocks for each beam

Figure 1. Dose distribution axial view

Figure 2. Isodose distribution sagittal

Figure 4. Isodose distribution coronal

Figure 5. 3D skin rendering

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Figure 6. DVH

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Figure 7. MU calculations from RadCalc program (Page 1 of 2)

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Figure 7. MU calculations from RadCalc program (Page 2 of 2)