1 Katrina Lee February Case Study February 24, 2014 16 MeV Electron to the Nasal Bridge History of Present

Illness: Patient Q is a 69 year old male who is undergoing external beam radiation treatment to the nasal bridge. In January 2012, Mohs surgery was performed to remove squamous cell carcinoma located on the superior portion of the right nose. Mohs surgery is a surgical technique of progressively removing layers of cancerous skin cells.1 In late December 2013, a brain MRI revealed an invasion of underlying tissue near the left orbit. The patient received a biopsy evaluation which revealed likely non-Hodgkins lymphoma (NHL). By January 2014, the patient was officially diagnosed with follicular NHL of the left periorbital soft tissue and was referred to a radiation oncologist. The radiation oncologist suggested external beam radiation and discussed the risks, benefits, and potential side effects of treatment. The patient elected to receive radiation therapy treatment. Past Medical History: The patient has a vast medical history which includes asthma, astigmatism, cataracts, keratosis, colonic polyps, obesity, myopia, hearing loss, and diverticulitis. Social/Family History: Patient Q is a retired Naval veteran who was stationed in Vietnam for over a year. Throughout his stint in Vietnam, he was exposed to Agent Orange. Agent Orange is a pesticide that was used to eliminate vegetation in the Vietnam War. Exposure has been linked to various diseases, including several types of cancer.2 After retiring from the military, the patient worked as a maintenance mechanic. He currently lives at his home with his wife and son. He denies having a history of smoking, but admits that he received daily exposure to second hand smoke. The patient's family history includes a mother who died from uterine cancer, a father with skin cancer who died from alcohol cirrhosis, two brothers in excellent health, and a sister currently undergoing treatment for leukemia.

2 Medications: Q uses the following medications: Albuterol, Budesonide, Naphazolin, and 1000 mg fish oil. Diagnostic Imaging: The patient received an MRI study in December 2013. It revealed tissue invasion of the underlying structures near the left orbit. Radiation Oncologist Recommendations: The radiation oncologist recommended that the patient undergo external beam radiation therapy treatment to the nasal bridge. The Plan (prescription): The radiation oncologist prescribed 3000 cGy at 200 cGy per day over the course of 15 fractions. Patient Setup/Immobilization: The patient was positioned supine on the CT simulation couch with the head placed on a head rest. A 0.5 cm custom bolus was used to cover his nasal bridge and orbits. An aquaplast mold was used to immobilize the patient and set the bolus tightly to the face. A lead eye shield was placed over the aquaplast mask to protect the right eye. Anatomical Contouring: The CT data set was transferred and uploaded to the Philips Pinnacle 9.0 radiation treatment planning system (TPS). The medical dosimetrist contoured organs at risk (OR). The OR included the brain and brainstem and the right and left globes and lenses of the patient's eyes. The radiation oncologist contoured the optic nerves, lacrimal glands, GTV, CTV, and PTV. Figure 1 shows the OR that were contoured. Beam Isocenter/Arrangement: The physician set the isocenter on the left superior and lateral surface of the nasium following the CT simulation. Both the physician and the resident physician collaborated on where to contour the PTV. The medical dosimetrist set an electron beam on the anterior portion of the PTV. Several plans were evaluated using different electron energies, and a 16 MeV electron beam gave the best PTV coverage. A prescription point was placed 2.7 cm posterior to the surface of the skin. Treatment Planning: The radiation oncologist outlined goals for the medical dosimetrist to achieve for the plan. The physician wanted to get full coverage of the PTV. The goal to protect the right globe and lacrimal gland was important to the physician. However, exposure to the left globe and lacrimal gland was unavoidable. Steps were taken to ensure that the doses to those areas were minimized as much as possible. The optimal treatment resulted in a 16 MeV beam

3 arrangement covering the PTV with 90% of the prescribed dose (Figures 2 and 3). The physician approved the plan after viewing the dose volume histogram (DVH), shown in Figure 4. Quality Assurance/Physics Check: The treatment plan monitor units (MUs) were double checked using the program, MU Check. The acceptable tolerance at the hospital between the TPS and MU check is within 3% for each field for a plan. Figure 5 shows the MU Check for the electron plan. Thermoluminescent dosimeters, or TLDs, are used to measure the dose at the surface of the patient's skin. TLDs were used to measure the amount of radiation penetrating through the patient's custom bolus. Three TLDs were placed directly onto the patient's facial surface under the bolus and aquaplast mask. The TLDs were placed at the nasal bridge, the medial aspect of the left eye, and above the right globe. The recorded dose that the TLDs received were 203.2, 218.0, and 15.2 cGy, respectively. The results revealed and confirmed that the surface tissue received the expected doses. Conclusion: Acquiring an optimal treatment plan for this case was challenging. There were many consultations with the physician and various plans were evaluated. Various energies were considered for treatment, but 16 MeV was determined to give the PTV the best coverage. Ultimately, the physician prescribed to the 90% isodose line to account for electron scatter. It was not anticipated that scattering electron interactions with the lead eye shield would cause higher radiation to the patient's nasal bridge area. Additional bolus was added to further protect the patient. The challenges and unique aspect of electron treatments and interactions made this case study interesting and provides a learning experience for future treatment planning.

4 References 1. Mayo Clinic staff. Mayo Clinic. Tests and procedures: Mohs surgery. http://www.mayoclinic.org/tests-procedures/mohs-surgery/basics/definition/prc20014261. Updated: August 25, 2012. Accessed: February 19, 2014. 2. U.S. Department of Veterans Affairs. Public Health. Veterans' diseases associated with agent orange. http://www.publichealth.va.gov/exposures/agentorange/conditions/index.asp. Updated: December 30, 2013. Accessed: February 21, 2014.

5 Figures

Figure 1. An axial slice of the PTV, shaded in green. The 90% isodose line is the thick blue line that covers most of the PTV.

6 Figure 2. Sagittal view of the PTV coverage by the 90% isodose line.

Figure 3. Dose volume histogram showing the organs at risk.

Figure 4. MU Check for the plan