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Megan Whitley April Case Study April 28, 2013 Clinical Practicum I Medical Dosimetry Whole Brain with

h Field in Field: The patient WG is a 49 year old female with a diagnosis of metastatic recurrent breast cancer with brain metastasis associated with cytology-positive leptomeningeal dissemination. To break that down, dissemination means scattered throughout a considerable region, the leptomeninges refers to involvement of the pia mater and arachnoid membranes of the brain.1 The carcinoma within the spaces between the brain and the skull metastasized from previously diagnosed breast cancer. In 2002 WG was diagnosed with early stage breast cancer, and was treated with chemotherapy and endocrine therapy post left mastectomy, and had no radiation at that time. Although she has continued endocrine therapy since the time of her previous diagnosis, new symptoms of mild headache, accompanied by dizziness with nausea and vomiting caused doctors to request a Magnetic Resonance Imaging (MRI) scan. The MRI demonstrated a large cystic metastasis in the right frontal lobe as well as a large adjacent dural metastases. The findings were compatible with a diagnosis of leptomeningeal involvement. She underwent a right frontal craniotomy to resect the metastatic tumor. Tissue taken from the dura and craniospinal fluid (CSF) taken from the lateral ventricle during surgery demonstrated a pathology of adenocarcinoma consistent with the patients primary breast carcinoma. Past Medical History: WG has suffered with anemia and environmental allergies. Past Surgical History: WG had a total abdominal hysterectomy and bilateral salpingooophorectomy in 2009. She had a left sided mastectomy January 3, 2003, port placement in 2003, 2005, and 2007, bone biopsy on March 21, 2012 and June 20, 2012, and right frontal craniotomy April 8, 2013. Social History: WG has never been a smoker and consumes 1 glass of wine per week. Medications: WG takes Norco as needed, Keppra 500 milligrams (mg) twice a day, Dexamethasone 2 mg every 8 hours on ongoing taper, Famotidine 20 mg daily, Colace as needed, multivitamin, and calcium.

Family History: The patient has a history of a brain tumor in her mother diagnosed at age 62, and her father was diagnosed at age 72 with pancreatic cancer. Radiation Oncologists Recommendations: After meeting with WG and her husband, Dr. G, her radiation oncologist, recommended she undergo whole brain radiotherapy. He has prescribed a dose of 30 Gray (Gy) to be administered in 10 fractions at 300 centigray (cGy) per day. Therefore the patient will undergo radiation for 2 weeks. Patient Setup and Immobilization: For the simulation process, the therapist escorted WG to the computed tomography (CT) scanner, a GE LightSpeed. Before the complex simulation, the procedure was explained extensively to WG and the consent form was signed. A timeout was taken prior to the beginning of the simulation to verify the patients name, that she knew why she was having a scan, and to verify what was to be treated. Photos were also taken to be uploaded into the patients electronic chart. The patient was placed on the CT table with knee wedge beneath her knees, holding a foam ring in her hands, on a B headrest for neutral chin immobilization, on the head and neck board covered with a foam pad (see Figure 1). WG was also wearing an Aquaplast face mask molded to maintain cranial stability in both simulation and daily treatment (see Figure 2). Dr. G came into the simulation area after the scan was complete to set the isocenter, and the patients CT simulation was exported to Eclipse. Patient Contouring: After the patient was pulled into Eclipse for planning, contouring was done of both left and right eyes and lenses, brain, brainstem, spinal cord, and body. Treatment Planning: Metastatic disease is the diagnosis most commonly treated with whole brain irradiation, and this is due to the fact that its typically multifocal.2 When beginning to plan a whole brain, after the contouring has been done, one initial beam is placed, either a left or a right lateral. In the case of WG since the isocenter was set at the time of simulation, planning could commence and the left lateral beam was generated. Typically the field size is determined by allowing 2 centimeters (cm) of fall off on 3 sides of the field: the anterior, superior, and posterior. A multileaf collimator (MLC) is used to define the inferior border. To determine this field edge, the brain contour is turned on and by using a margin of 1.5 cm the MLCs are defined around the brain. This margin continues along the edge of the brain and brainstem, and the spinal cord as well, all the while using a margin of 1.5 cm to define the MLCs. Bentel2 tells us that in whole brain

treatments, if the entire cranial contents are to be treated, then divergence of the beam into the opposite eye can be a problem. As mentioned in the introduction, WGs diagnosis includes leptomeningeal dissemination. From this diagnosis we can discern that all of the areas surrounding the brain require adequate dosage. Thus, blocked margins may be less tight than traditionally seen. I planned this patient, and Dr. G asked me why, other than salvaging the eyes, do we worry so much with the MLCs in that area. The reason is due to the brain matter that abuts the ethmoid sinuses, found in the cribriform plate. This area of the brain must receive dose as well. The tricky areas of any whole brain cases are the eyes. The MLCs in this area are very important because they must allow adequate dose as well as provide protection for all ocular structures. If proper head positioning was obtained at the time of simulation, once the lenses are turned on, they should superimpose one another when viewed from the lateral aspect, as represented in Figure 3. In the case of WG, when the right lateral beam was created, it was clear that her head was not properly aligned, therefore compensation had to be made (see Figure 4). One method is to angle the gantry, but Dr. G did not want to do this. Thus, he drew different MLC blocks for each lateral field. Drawing the blocks differently around the globe and lens allowed the dose to be influenced in the same way as adding a gantry angle. After the 2 primary fields were set, the planning could begin, and Dr. G stated that he wanted the field in field technique used to decrease the hotspot and maintain conformal dose distribution. Field in field technique is often chosen over the traditional method of using wedge filters. In a study published in Australasian Physical and Engineering Sciences and Medicine, a comparison between the use of field and field technique versus wedge filters was done and it was found that in terms of homogeneity, field in field has better dose distribution. 3 It was also found that field in field could feasibly replace wedges.3 Demonstrated in Figure 5, the MLCs are used to decrease the hotspot and create a more conformal dose distribution. By copying the previously generated field, altering the MLCs to block regions of high dose, and giving a very light weighting, 1-4% in my clinic, the results of the field in field technique can be much the same as a wedge. By eliminating wedges, the therapists have to go into the room less, decreasing potential injury to them and decreasing the potential for human error during treatment.

The hotspot achieved for this plan was 107.1%. But, due to the leptomeningeal involvement Dr. G wanted the overall dose slightly hotter, so he prescribed to the 98% line. This change and the view of the plan at the end of planning can be seen in Figure 6, with the hotspot at 3279cGy, 109.3%, after the prescription was increased to the 98% line. The doses to all structures are registered on a dose volume histogram (DVH) and reported to the physician (Figure 7). The impact of the improper head placement on the lenses can be seen on the DVH, with the maximum dose to the left lens (1753.7cGy) being significantly higher than the right (946cGy) due to the divergence previously mentioned. Although the eye doses were slightly higher than optimal, Dr. G was very pleased with the outcome of WGs plan, thus he approved the plan. Then the approved plan was exported to Mosaiq and the beam data was provided by dosimetry for comparison by the therapist at the treatment console. Finally a backup calculation was performed in RadCalc. Physics: Once the plan was approved, and the secondary calculation verified, the plan was ready for treatment. Field in field treatments often require quality assurance (QA) verification, but only if the field in fields have been merged. In our clinic, a merge only occurs when the beams have been duplicated many times, causing an excess of fields. In this case, because the dose was accurately manipulated with only 2 extra fields, no merge was required, therefore no QA was required either. The last step for physics was to check the chart, make the information available in Mosaiq for the therapists, and sign off on the plan verifying that the treatment planning process was a success. First Day of Treatment: Before the first day of treatment, a beam verification simulation (BVS) is performed to verify patient positioning, beam arrangement, beam modification, and accuracy. The on-site physician authorizes the beginning of treatment after approving the port films. The port films are taken with an on board imager (OBI) in real-time, so that changes can be made and recorded for the treatment regimen to begin. This process prepares both the patient and the therapists to begin treatment. Conclusion/Impact: WG is a 49 year old female that presented with breast cancer in 2002 and has encountered battle after battle since that day. I met her when she had received further bad news. Not only had her cancer metastasized to the areas associated with her frontal craniotomy, but that the cancer was in the areas surrounding her brain.

Shockingly she was still in good spirits. Her symptoms of nausea, vomiting, and dizziness had subsided since her surgery, and she seemed to be looking up. Its remarkable to watch the human spirit shine through in the face of such information and after such a long fight. In that moment people often see someones faith, someones grace, and commonly someones fear. The human condition is amazing, and if we get to take nothing from our careers, it should be the appreciation of the resilience and the strength with which people are born. WG was one of these patients, and yet another person who teaches me more about who we have the ability to be.

Figures

Figure 1. This depicts the setup devices used for daily immobilization.

Figure 2. This is the patients face mask after it has been molded into shape for daily immobilization. The cross hairs delineate the isocenter.

Figure 3. This is the left lateral beams eye view that demonstrates proper alignment of the lenses.

Figure 4. This is the right lateral beams eye view that depicts the misalignment of the lenses.

Figure 5. This figure illustrates the ability of the field in field technique to manipulate the dose, virtually chasing it throughout the region of treatment.

Figure 6. This represents the dose distribution, the beam setup, the dose in the region of the eyes, and it shows the right lateral field in field.

Figure 7. This is the dose volume histogram that represents the doses received by the target and the surrounding critical structures.

References 1. Davis FA. Tabers Cyclopedic Medical Dictionary.19th ed. Philadelphia: F.A. Davis Company; 2001: 1166 2. Bentel GC. Radiation therapy planning. 2nd ed. Colombia: Macmillan Publishing Company; 1992:336. 3. Prabhakar R, Julka PK, Rath GK. Can field-in-field technique replace wedge filter in radiotherapy treatment planning: a comparative analysis in various treatment sites. Australas Phys Eng Sci Med.2008 Dec;31(4):317-24. PMID: 19239058. Accessed April 29, 2013.

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