1 Spencer Arnould June Case Study June 2, 2013

Squamous Cell Carcinoma of the Skin History of Present Illness: Patient N is an 80-year-old man who has been recently diagnosed with stage III, Tumor 3 (T3), Node 1 (N), Metastasis 0 (M) squamous cell carcinoma of the skin. He has also been recently diagnosed with progression of the cancer into the epitrochlear lymph nodes. Patient Ns history dates back to July of 2012 where he noticed a small lesion on the dorsal side of his left forearm. The lesion started out small but began to grow rapidly to more than 3 times its original size to about 3 centimeters (cm). It also showed some signs of being raised, bumpy, and ulcerative. Patient N also had other spots around the primary lesion but nothing compared to the size of the original nodule. On October 24, 2012, after many different dermatology referrals, Patient N had a wide local excision of the squamous cell carcinoma with a graft from his left thigh placed on his forearm. A biopsy of this site was also taken which revealed a 3.2 cm poorly differentiated squamous cell carcinoma. Patient N was closely followed by both dermatology and plastic surgery until March 14, 2013, when he presented with a mass of about 5-6 cm in the same area. He had two more biopsies taken, one from the same forearm site, and one from the epitrochlear region. There was no residual disease in the forearm, but positive for a 4x6 cm mass with 3/3 positive lymph nodes and extranodal extension. The patient was referred to radiation oncology for treatment of his epitrochlear nodal region. Past Medical History: Patient N has a past medical history that includes squamous cell carcinoma, transient ischemic attack (TIA), seizure, coronary artery disease (CAD), peripheral vascular disease (PVD), hypertension, prostate cancer, pernicious anemia, and hyperlipidemia. Social History: Patient N is married and a retired electronics worker. He quit smoking recently and he denied any type of smokeless tobacco use. Medications: Patient N uses the following medications: Acyclovir (Zovirax), Amiodarone HCL, Amlodipine BesyLate (Amlodipine Oral), calcium (oral), Levothyroxine Sodium, Lovastatin (Mevacor), Trazodone HCL. Diagnostic Imaging: After the initial biopsy on the forearm site on October 24, 2012, and waiting for changes to occur on the cancer nodules, Patient N was sent for a PET (Positron

2 Emission Tomography) scan on March 28, 2013 which revealed a large intensity FDG (Fluerodeoxyglucose) -avid mass in the region of the left elbow, corresponding to the patients known site of squamous cell carcinoma skin lesions. Patient N was then sent for a standard CT (computed tomography) scan on April 11, 2013 which also agreed with the PET on the region of interest and corresponding site of recurrence. Radiation Oncologist Recommendation: After review of Patient Ns squamous cell carcinoma with positive lymph node and extranodal involvement in his epitrochlear region, the physician suggested that he continue with the current plan of receiving radiation therapy. The physician noted that since the disease was confined to the left arm and that there was no indication to distant metastasis, the radiation would help reduce his risk of local recurrence. Squamous cell carcinoma is one of the fastest growing skin cancers that arises from more mature keratinocytes of the upper dermis.1 It can arise anywhere on the body and is mostly found on the sun-exposed areas which can include the head, neck, hands, and in this specific case the arms.1 After a complete discussion about the risks and side effects associated with this type of treatment, the physician ultimately recommended that Patient N receive 7 weeks of daily radiation treatments, or 35 treatment sessions given 5 days a week, pending an assessment into a possible boost if necessary. The Plan (Prescription): The radiation oncologist treatment recommendation to Patient N was having his squamous cell carcinoma and lymph involvement treated to a total dose of 63 Gray (Gy) in 1.8 Gy fractions daily. Since the patient had already had an excision of the site earlier in the year, the physician recommended that he receive dose to both the previous disease site (squamous cell carcinoma), and the positive lymph node involvement. In many cases of skin cancers, radiotherapy is the best route for the elderly population because of the cosmetic outcome result and enhanced therapeutic effect.2 Patient Immobilization: On May 28, 2013, Patient N underwent a CT simulation scan for radiation therapy. He was placed into an Alpha Cradle, which had specialized liquid foam that took shape to his upper left side and left arm (Figure 1). This cradle immobilized his whole upper left side and arm so that the set-up could be consistent and reproducible daily for treatment (Figure 2). A knee cushion was also placed underneath his legs for additional support. After the scan was complete, the simulation therapists placed a reference tegaderm mark on the patient 2 cm right and 2 cm superior of the elbow joint, which was easily visible for lining the patient up

3 the first day. This reference mark is where the therapist will shift from on day one of the actual treatments (Figure 2). Anatomical Contour: After the scan was completed, the images were sent to the DICOM (Digital Imaging Communications of Medicine) staging server, which can import and export images into the necessary computers. The images were first pulled into Eclipse contouring for the residents and physicians to draw and mark volumes on the scan. They usually draw the gross tumor volume (GTV), and sometimes the clinical tumor volume (CTV), while also drawing specific structures that sometimes need to be avoided. After this has been completed, the dosimetrist will then start to contour organs at risk (OR). Since the treatment area was on the left elbow there was no actual OR to contour, only the GTV, CTV, and body external. Since the physician wanted the CTV to be expanded by 1cm in all directions, the voxel expander was used on the CTV structure and expanded to make a planning target volume (PTV). Beam Isocenter/Arrangement: After the contours had been drawn and the volumes expanded, it was up to the dosimetrist to come up with an adequate treatment beam arrangement that covered the target while eliminated entry or exit dose to the inner or medial portion of the body. In this specific case, since the left arm was in a better position away from the body, the dosimetrist used a parallel-opposed beam arrangement that included an anterior-posterior (AP) angle. This beginning beam arrangement is pretty standard when planning for any kind of AP/PA or 4-field box technique due to the ease of being able to see where dose is needed around the target, and inserting additional fields where necessary. Since the target volume was located on the medial aspect of the left arm, and slightly superior of the elbow, only two fields were needed to adequately cover the tumor volume (Figures 3 and 4). The medical dosimetrist also used specific gantry angles of 340 degrees and 170 degrees to achieve a better cosmetic outcome sparing a small strip of tissue for any future lymphatic drainage that may occur throughout treatment (Figure 5). Treatment Plan: The planning system used to calculate the treatment plan was UMPlan. When starting to plan an extremity case like this, the dosimetrist usually starts out with 6 megavoltage (MV) beams, and evaluates the necessity for anything higher. Since the tumor volume was relatively shallow in comparison to other parts of the body, there was no need for additional higher energy beams. As figures 3 and 4 indicate, both fields in this beam arrangement had a 0.7 cm-blocking margin around the PTV. The dosimetrist also weighted the fields according to the

4 superficial dose around the target. The right anterior oblique (RAO) field was weighted at 1 and the left posterior oblique (LPO) field was weighted at 1.25. The overall maximum dose to the PTV treatment volume was 67.5 Gy, with the humerus receiving a mean dose of 20.6 Gy and the elbow receiving a maximum dose of 62.7 Gy (Figure 6). Quality Assurance: The monitor unit calculation and monitor check were done in both the download (through UMPlan) as well as the second check through a medical physicist (usually hand checked). The monitor units on this 2-field left arm extremity technique were within tolerance and fell within the back-up time that is associated with our departments tolerance. Conclusion: Although there are many different methods to treating extremities, there are some special circumstances that may prove that it needs to be treated slightly different. Since this left arm was relatively narrow and needed to spare some normal tissue, the fields had to be adjusted and modified in order to achieve an adequate dose and treatment plan (Figure 7). We usually do not treat many cases like this within our department (photon treatment skin cancers including lymphatic involvement) so it was very interesting to be part of the treatment planning process. I feel that while I struggled somewhat with the beam arrangement and trying to find the right gantry and collimator angles, I came out with a very conformal left arm extremity plan. Although this case was fairly simple at a glance, it was a great learning opportunity for me to practice some advanced problem solving skills and come up with something that adheres and agrees with the planning directive targets. Overall, I feel that I did a great job with this plan and am looking forward to learning from future extremity cases.

5 Figures

Figure 1. Patient N is in an alpha cradle to immobilize his left arm and upper thorax.

Figure 2. This image shows Patient N in an alpha cradle with reference marks on his left arm. These marks are used to line up to and film daily.

Figure 3. This image shows the DRR (Digital Reconstructed Radiograph) of the RAO field.

Figure 4. This image shows the DRR of the LPO field.

Figure 5. This image shows both the RAO and LPO fields as they pass through the central axis of the left arm.

Figure 6. Dose Volume Histogram (DVH) showing the values of the PTV volume, humerus, and elbow.

Figure 7. This image shows a coronal view of the tumor volume on Patient Ns left arm. Note the narrow strip of tissue on the lateral border to account for any lymphatic drainage.

10 References 1. Washington CM, Blobe TA. Skin and Melanoma. In: Washington CM, Leaver D, eds. Principles and Practice of Radiation Therapy. 2nd ed. St Louis, MO: Mosby-Elsevier; 2004:893-918. 2. Carucci J, Rigel D, Friedman R. Basel Cell and Squamous Cell Skin Cancer. In: Hall L, Gryczan T, eds. Clinical Oncology. Atlanta, GA: The American Cancer Society; 2001:563575.