1

Ali Fitzpatrick
March Case Study
March 28, 2014
Palliative Esophagus
History of Present Illness: Patient HS is a 79 year old male who presented with vomiting,
difficulty swallowing, and a 15 pound weight loss over the course of one month. He was
admitted to the hospital on January 22, 2014 and a CT scan showed distal esophageal wall
thickening with a slightly enlarged gastro hepatic ligament that was concerning for esophageal
cancer. An esophagogastroduodenoscopy (EDG) showed a hard, circumferential mass located in
the distal one third of the esophagus. Biopsy confirmed a diagnosis of poorly differentiated
squamous cell carcinoma esophageal cancer in the distal third of the esophagus. Malignant-
appearing lymph nodes were visualized in the gastrohepatic ligament and the celiac region. At
this time, HS was given a stage of at least 3B, T3N2Mx by endosonographic criteria. An
esophageal stent was placed on January 28, 2014 to help relieve symptoms for the patient, but
will likely occlude within 6 months.
Due to poor performance status, HS is not a candidate for surgery or chemotherapy. The patient
was referred to radiation oncology on January 30, 2014 for a palliative course of radiation
therapy. The radiation oncologist reviewed the patients history and performance status, and
ultimately recommended palliative radiation therapy to the gross tumor volume for long term
palliation and patency of the distal esophagus. The radiation oncologist reviewed the risks,
benefits and side effects of radiotherapy and consent to proceed with treatment was signed.
Past Medical History: HS has a past medical history of prostate cancer that was treated with a
prostatectomy. He suffered from an ischemic cerebrovascular accident (CVA) in 2004 and a
transient ischemic attack (TIA) in 2011. HS also suffers from depression, diabetes mellitus,
hypertension, bradycardia, back pain, Parkinson disease and an under socialized conduct disorder
of aggressive type.
Social History: HS is a retired airline ticket agent who lives in a nursing home. He is married
and has two grown children, one of whom helps in his care. HS is a former smoker who quit in
September of 1998. He denies any drug and alcohol use.
Medications: HS uses the following medications: carbidopa with levodopa, divalproex sodium,
heparin, levothyroxine, lidocaine, mirtazapine, pantoprazole and rotigotine.
2

Diagnostic Imaging: HS had a CT scan of his chest and pelvis on January 22, 2014. This
showed distal esophageal wall thickening with prominent enlargement of the
gastrohepaticligament lymph nodes consistent with suspicion for esophageal cancer. There was
also left pleural thickening with probable lower lobe atelectasis. On January 23, 2014, a distal
esophageal biopsy was performed which produced an official diagnosis of ulcerated and
infiltrating moderately to poorly differentiated squamous cell carcinoma. Following the biopsy,
HS had an endoscopic ultrasound and EDG to place an esophageal stent, which ruled out a
tracheoesophageal fistula.
Radiation Oncologist Recommendations: After the radiation oncologist reviewed the disease
and performance status of HS, it was recommended that a palliative course of treatment be
designed. Although HS had an esophageal stent placed, tumor growth through the stent can
happen frequently.
1
External beam radiation therapy is an effective, noninvasive and generally
well-tolerated technique to palliate dysphagia with incurable esophageal carcinoma.
2
The
radiation oncologist preferred a 3D plan with most of the dose coming from AP and PA fields,
with the possibility of a posterior oblique field to reduce dose to the spinal cord.
The Plan (prescription): The recommendation of the radiation oncologist was for a palliative
course to be delivered to the gross tumor volume (GTV). A margin of 0.7 cm was created
around the planning target volume (PTV), and a prescription for 267 cGy for 15 fractions was
written for a total of 4005 cGy.
Patient Setup/Immobilization: In February of 2014, HS had a CT scan performed for the
purpose of radiation therapy planning. The patient was laying on the table in the supine position
with his arms positioned above his head (Figure 1). An immobilization device was created for
the patient using Alpha Cradle. This mold shaped around the patients upper body to support his
arms in the raised position. The cradle extended inferiorly to the patients mid-thigh. A knee
cushion was provided for patient comfort. Three marks were made on the patients skin, one on
the anterior surface and two on the lateral surfaces for leveling (Figure 2). Wire was placed only
on the anterior mark.
Anatomical Contouring: After completion of the CT simulation scan, the CT data set was
transferred into the Varian Eclipse radiation treatment planning system (TPS). The radiation
oncologist contoured the GTV and PTV which included the distal 1/3 of the esophagus and
extended into the stomach to include the gastro-esophageal junction. The medical dosimetrist
3

contoured organs at risk (OR) which included the heart, spinal cord, lungs, stomach, liver,
kidneys and bowel. A structure for combined lungs minus the PTV was also established, along
with a combined kidney structure. The carina was also contoured for set-up purposes on the
treatment machine. The radiation oncologist reviewed the OR and verbally stated the
prescription and objectives to the medical dosimetrist.
Beam Isocenter/Arrangement: The medical dosimetrist placed the isocenter in the middle of
the GTV that the radiation oncologist contoured. This was about midplane anterior to posterior
and slightly to the left in the patients body (Figure 3). The anterior and posterior fields had a
gantry angle of 0 and 180 respectively. Treatment of many intrathoracic tumors require doses
higher than spinal cord tolerance, so in addition to anterior and posterior fields, some oblique or
lateral field arrangement is needed.
3
The medical dosimetrist decided to use two posterior
oblique fields to reduce dose to the spinal cord, with the gantry angle of the left posterior oblique
(LPO) being 130 and the right posterior oblique (RPO) being 250. The AP and PA beams
utilized an energy of 23 Megavoltage (MV) because of the patient separation in the area being
treated. The posterior obliques used energies of 6 MV. The obliques have a decreased energy
because they are traveling through a large amount of air in the lungs, so it is necessary to have a
decreased energy to reduce neutron contamination.
The field size for each beam was created using the PTV volume. A .07 cm margin was placed
around the volume and the multi leaf collimator (MLC) shape adjusted to this requirement. The
AP field includes a 20 enhanced dynamic wedge (EDW). This wedge was a tissue
compensating wedge due to the slope of the patients anatomy anteriorly. The heel of the wedge
was placed in the superior direction. The LPO and RPO fields also included 45 EDWs. These
wedges were inserted to bring down excess dose regions where all four fields were overlapping,
with the placement of the heels of the wedges in the anterior direction. The RPO required a
collimator rotation of 90 in order for the Varian EX linear accelerator to utilize a dynamic
wedge.
Treatment Planning: The radiation oncologist stated the dose prescription and objectives,
which were to cover 100% of the GTV with 100% of the dose and 95% of the PTV with 95% of
the dose. A dose of less than 3500 cGy would be accepted for the spinal cord. The combined
lung volume minus the PTV at 2000 cGy would be accepted at 20% or less. A calculation point
was placed within the GTV, but very close to the medial edge and slightly inferior within the
4

volume. The calculation point was placed in a different position from the isocenter because there
was some difficulty delivering dose to the inferior aspect of the PTV. Moving the reference
point inferior extended the dose lines inferiorly. The reference point was moved medially
because there was also trouble getting dose coverage in the area when air was surrounding the
PTV on three sides. Approximately half of the dose was delivered from the anterior direction
and the other half was delivered from the posterior direction. The AP beam delivered 53% of the
prescription, while the PA delivered 25%, the RPO delivered 12% and the LPO delivered 10%.
The patient would receive a total dose of 4005 cGy in 15 fractions. Once adequate coverage was
established for the GTV and PTV, the medical dosimetrist reviewed the dose volume histogram
(DVH), isodose lines and OR. The DVH (Figure 11) reflects that 99% of the GTV receives
100% of the dose, and 99% of the PTV receives 97% of the dose. The spinal cord receives a
maximum dose of 3318 cGy. Twenty percent of the total lung dose minus the PTV receives 16%
of the dose. The esophagus plan utilized four fields to provide adequate prescription coverage
and homogenous dose distribution throughout the GTV. The radiation oncologist reviewed the
plan and approved it for treatment on the machine.
Quality Assurance/Physics Check: The monitor units (MUs) for the plan were double checked
using the RadCalc program. The tolerance for the department between the TPS monitor units
(MUs) and the RadCalc MUs is 3% for each field, and this plan met these quality assurance
constraints. The plan created was considered a conventional treatment, and therefore, a quality
assurance (QA) test on the linear accelerator was not necessary.
Conclusion: Creating a plan that provided adequate dose coverage to a PTV that included air
proved be rather challenging for the medical dosimetrist. There was no build up region for the
LPO beam, so the GTV that abutted air was receiving less dose than the rest of the GTV. The
medical dosimetrist adjusted the weighting of the beams so there was a little dose as possible
coming from the posterior oblique beams, just enough to relieve some dose from the spinal cord.
The medical dosimetrist also moved the calculation point to the outer edge of the PTV to push
dose further towards the area with less dose.




5

References

1. Ahmad NR, Goosenberg EB, Frucht H, Coia LR. Palliative treatment of esophageal cancer.
Semin Radiat Oncol. 1994;4(3):202-214. doi: http://dx.doi.org/10.1016/S1053-
4296(05)80068-2
2. Murray L, Din O, Kumar V, Dixon L, Wadsley J. Palliative radiotherapy in patients with
esophageal carcinoma: A retrospective review. Pract Radiat Oncol. 2012;2(4):257-264. doi:
http://dx.doi.org/10.1016/j.prro.2011.12.002
3. Bentel C. Radiation Therapy Planning. 2
nd
ed. The McGraw-Hill Companies; 1996.






















6

Figures

Figure 1. Patient position in AlphaCradle immobilization device on CT simulation table.



Figure 2. Set-up marks places on patient on AP and RT lateral surfaces.
7


Figure 3. Isocenter placement from AP view.


Figure 4. Isocenter placement from RT lateral view.

8


Figure 5. Field shape on AP field.


Figure 6. Field shape on PA field.
9


Figure 7. Enlarged isodose line key for Figures 8-10.


Figure 8. Reference point placement and dose distribution on axial view.

10


Figure 9. Reference point placement and dose distribution on coronal view.


Figure 10. Reference point placement and dose distribution on sagittal view.


11


Figure 11. Dose Volume Histogram (DVH).



Total lung-PTV
Spinal Cord
Heart
PTV
GTV