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Jenny Kouri
Clinical Practicum I
February 10, 2015
Advanced Basal Cell Carcinoma of the Posterior Right Ear
History of Present Illness: This patient is an 85-year-old male with locally advanced basal cell
carcinoma (BCC) with the presence of squamous differentiation of the right posterior ear with a
4.2 cm ulcerative lesion eroding the ear cartilage. This ulcerative lesion presented with a pink
base and rolled borders and was associated with a blood-serum discharge that had been
unattended for several years. The patient had undergone Mohs micrographic surgery on 11/18/14
for a primary nodular basal cell carcinoma located in the tragus. A biopsy of the right posterior
helix was also completed and this revealed carcinoma with basaloid and squamous
differentiation. There is no palpable cervical or supraclavicular lymph node involvement
bilaterally. The patient was treated with Vismodegib for this lesion, which was not tolerated
well. He has ongoing pain in the right ear and right face area from this lesion. He has had poor
hearing for several years. This patient was deemed not a suitable candidate for surgical
resection. Radiotherapy was considered for management for the local advanced non-melanoma
skin cancer involving the right ear. The patient agreed to proceed with radiation therapy
treatments.
Past Medical History: The patient suffers from benign renovascular hypertension,
arteriosclerotic cardiovascular disease (ASCVD), hypercholesterolemia, hypertension, lowtension glaucoma, benign neoplasm of choroid, pseudophakia, abdominal aneurysm without
mention of rupture, chronic kidney disease, paint in the left upper limb, syncope, dizziness, and
impaired cognition. The patient is allergic to Lisinopril.
Diagnostic Imaging Studies: The patients last imaging study was PET/ CT on 4/1/14, which
showed focal hypermetabolism, an area of increased tracer of fluorodeoxyglucose (FDG)
activity, involving the right region of the right face, but no other pertinent findings.
Family History: This patient did not comment on his family history.
Social History: The patient lives with his son. He reports of no significant smoking or alcohol
use, historically.
Medications: The patient currently takes aspirin (BID), Meclizine (dizziness), Simvastatin
(cholesterol), and Vismodegib (BCC). The patient actively applies a 4 in x 4 in gauze pad and a
non-sterile gauze sponge for posterior ear wound care.

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Recommendations: For local control, the oncologist recommended radiotherapy of the right ear
with consideration of also treating the next eschelon of lymph nodes in the ipsilateral right upper
neck.
The Plan (Prescription): This treatment plan was designed for 3D conformal radiation therapy
(3D-CRT). The prescription was written for 275cGy per fraction to 90% of the point dose at
isocenter for 20 fractions. A total dose of 5500cGy was delivered.
Patient Setup/Immobilization: This patient was simulated on a Phillips Brilliance Big Bore CT.
The patient was positioned supine, head to gantry with a neutral neck and a closed mouth. His
dentures were removed prior to scanning. The patients head was turned slightly to his left with
his shoulders pushed inferiorly. His arms were placed at his sides. A large knee sponge was
utilized. To stress a reproducible set-up, a Variable Perf head and shoulder aquaplast mask
was molded. A 3-point set up was marked on the mask for laser positioning prior to daily
treatment. Four separate pieces of customized bolus material were constructed under the mask to
flatten out the irregular surface and to increase surface dose. To achieve a level plane, Super
Stuff (pink bolus) was used to fill the ear canal. In addition, Super Stuff was added behind the
ear. 0.5 cm of Super Stuff was then placed over the entire ear. A cutout of 1 cm of Superflab
was fashioned around the lateral ear. Figures 1-4 showcase the patients simulation setup and
bolus placement. Images were scanned from the most superior aspect of the head down to the
superior thoracic area. A total of 294 slices were taken at 1.5 mm per slice thickness. The
physician placed the simulation isocenter.
Anatomic Contouring: Prior to simulation, the therapist placed stickers on the outer lateral
cantus of each eye. After simulation, the physician delineated a gross tumor volume (GTV) and
a clinical tumor volume (CTV). The CTV was not drawn with a conventional expansion of the
GTV, but the volume was configured based on fluorodeoxyglucose (FDG) uptake of the PET/CT
scan.
Beam Isocenter/Arrangement: This patient was treated on a Varian Clinic IX linear
accelerator. In addition to the simulation isocenter, 2 other points were created during
planning. A point at central axis (CA) was set to 100 source-to-skin distance (SSD). A
prescription point was created on the same plane of the central axis point at a depth of 3
cm. This depth was found using a Percent Depth Dose Table for a 10 x 10 cone at 100 SSD.
This table is shown in Figure 5. Shifts from the simulation isocenter to the treatment isocenter
were adopted into the treatment planning system (TPS). A static right anterior oblique (RAO)

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beam was placed at the gantry angle of 285-degrees with energy of 16 MeV. The most probable
energy at the surface is given by the 90 percent depth dose. Any dose beyond the 90 percent
dose level, decreases abruptly.1 In addition to the depth of the target volume, energy is also
dictated by the required minimum dose to the target and the acceptable dose to critical organs.
With this criterion in mind, energy was chosen based off achieving full coverage of the CTV
within a depth of 4 cm. A distance of 3.7cm was found by measuring the distance from the skin
surface to the prescription point. Twelve MeV covered only a depth of 3.7, and to account for
electron discrepancies, 16 MeV was elected to cover a larger depth of 3.7 cm. It was noted that
skin surface dose would increase as a result of higher electron energy.
Treatment Planning: Pinnicle3 9.0 treatment planning software aided in the design of the
treatment plan. Field size is dictated by the isodose coverage to the target volume and the ability
to allow for an appropriate margin around the CTV.1 This plan involved a 10 cm x 10 cm cone.
The actual field size was 14 cm x 14 cm, which was dependent upon the selected Varian cone
applicator and beam energy. Figure 6 displays the chart used to select the appropriate field size.
Forty three percent of the field was blocked. A cerrobend cutout of the block can be seen in
Figure 7. This cutout was designed to shape the treatment area and protect normal tissues. A 1 in
block margin was set around the CTV. Initially, it was set at 2 in, but to assist in sparing of the
right mandible, the block margin was reduced an inch. A right lateral beams eye view DRR is
shown in Figure 8. One hundred percent of the dose was delivered by the RAO. Two hundred
and ninety-nine monitor units (MU) were delivered per fraction. Difficulties with this set-up
involved the irregular shape of the ear and the bolus-generated air gaps. The air gaps were
contoured and assigned a density correction equivalent of the bolus. This allowed for a more
even distribution of dose. Due to scatter, the isodose lines displayed a mushroom-like or
bulging curve at depth, which is typically expected from electrons. Electrons of high energies,
display a bulging for only low isodose levels.1 Figure 9 exhibits these lines as well at the full
coverage of the 90 percent isodose line (green). The dose volume histogram (DVH) shows the
max dose percent for the CTV is 93.32. Respectively, the mean and max dose of the mandible is
583.7cGy and 6694.5cGy.
Monitor Unit Check: With the aid of a pencil beam algorithm, Pinnacle3 calculated the initial
MUs. MuCheck preformed a second calculation check. The average difference between
MuCheck and Pinnacle3 for this plan was .10%. Acceptable limits are within 3%.

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Quality Assurance Check: On the first day of treatment, before delivery of radiation, a pre-port
film was taken. This is shown in Figure 11. The physician approved placement of the cutout
block. On the second day of treatment, a thermoluminescent dosimeter (TLD) was used to
measure the ionizing radiation exposure to the patient.
Conclusion: When planning a basal cell carcinoma of the ear, there are different options of
treatment planning that should be considered by the radiation oncology team. Due to anatomical
surface irregularities and the addition of bolus, planning must take into consideration the benefits
and drawbacks of establishing photon or electron energies. Throughout this specific case, I have
come to the realization that a plan is not going to be absolutely perfect. Complexity results from
non-flat surfaces and inhomogeneities. When using electrons, the isodose lines may look
undesirable due to unwelcomed air gaps. For electron energies, the skin sparing effect is
minimal. If the decision to elect anterioposterior (AP) parallel-opposed photon beams, then deep
healthy tissue risks exposure to radiation. Therefore, it is of utmost importance to work with the
physician and physicist to produce the best possible plan for the case at hand, regardless of its
imperfections. This can be achieved by establishing full coverage of the target volume and
minimizing dose to the surrounding structures at risk.

Figures

Figure 1: Placement of Super Stuff (pink bolus) was used to fill the ear canal and behind the ear.

Figure 2: 0.5 cm of Super Stuff was placed over the entire ear. A cutout of 1 cm of Superflab
was fashioned around the lateral ear

Figure 3: Aquaplast mask was used to immbolize the patient as well as the bolus.

Figure 4: This was the view of the patient set-up on the CT couch. The same positioning was
used for treatment.

Figure 5: A percent depth dose (PDD) table was used to find the prescription point depth.

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Applicator

18, 20, 22

4, 6, 9 MeV

12 MeV

15, 16 MeV

20 cm x 20

11 cm x 11

11 cm x 11

MeV
11 cm x 11

cm
10 cm x 6

cm
16 cm x 13

cm
16 cm x 11

cm
16 cm x 10

cm
16 cm x 10

cm
16 cm x 10

cm
10 cm x 10

cm
20 cm x 20

cm
14 cm x 14

cm
14 cm x 14

cm
14 cm x 14

cm
14 cm x 14

cm
15 cm x 15

cm
20 cm x 20

cm
17 cm x 17

cm
17 cm x 17

cm
17 cm x 17

cm
17 cm x 17

cm
20 cm x 20

cm
25 cm x 25

cm
25 cm x 25

cm
23 cm x 23

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22 cm x 22

cm
22 cm x 22

cm
25 cm x 25

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30 cm x 30

cm
30 cm x 30

cm
28cm x 28

cm
27 cm x 27

cm
27 cm x 27

Cone
6 cm x 6

cm
cm
cm
cm
cm
Figure 6: This chart used to find the appropriate effective field size.

No Mode
11 cm x 11

cm

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Figure 7: This showed the right lateral, beams eye view digitally reconstruction radiograph
(DRR). This was used to verify beam placement.

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Figure 9: This displayed the isodose lines of the treatment plan.

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Figure 10: DVH: The CTV is described by the teal line; mandible, blue; spinal cord, purple; and
brainstem, pink.

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Figure 11: The block cutout was used to block critical structures around the target volume.

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References
1. Khan F. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams and
Wilkins; 2010.