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Lee Culp
April Case Study
April18, 2014
Intensity Modulated Radiation Therapy (IMRT)/Anterior-Posterior/Posterior-Anterior
(AP/PA) treatment of Malignant Neoplasm of Larynx
History of Present Illness: Patient KCis a 71 year old Caucasian malewho has a history
of left maxillary sinus carcinoma which was treated in 2009 with concurrent chemoradiation
therapy. Concurrent chemotherapy with radiation for the head and neck region allows for
simultaneous tumor control and normal tissue sparing.
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He had complete response and has
remained without evidence of disease since completion of treatment. In December 2011, he
developed hoarseness with a biopsy being performed, which returned positive for squamous cell
carcinoma of the glottic larynx. He was treated with concurrent chemoradiation therapy which
he completed in February 2012. He then developed locally recurrent disease requiring total
laryngectomy and neck dissections in June 2012. Final pathology noted 5 out of 25 lymph nodes
on the right side of the cervical and jugular chains were positive for metastatic disease. He then
developed recurrence of the tracheal stoma site in December 2012 for which he was treated with
Erbitux and had a complete response. He completed Erbitux treatment in June 2013. In
November 2013, he had esophageal dilation with tracheoesophageal groove puncture for a
speech prosthetic. Recently, the patient had been seen by the speech language pathologist for a
problem with his tracheoesophageal puncture valve not fitting properly. On exam, speech
pathologist had noted a recurrent soft tissue mass in the laryngeal stoma. The patient underwent
an operative biopsy of his trachea stoma as well as esophagogastroduodenoscopy and possible
dilation. His official diagnosis from the surgical pathology report is moderately differentiated
squamous cell carcinoma involving levels 3 and 4 and involving the subcutaneous tissue on the
attached ellipse of skin. He denies any bleeding from the lesion or discomfort caused by it. He
continues to have some mild dysphagia.
In April 2014, patient complained of significant neck swelling. His wife phoned the office, and at
that time, the patient was placed on a Medrol Dosepak. The patient also has complaints of
leakage from his tracheoesophageal puncture stating attempts to drink liquids causes leakage
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surrounding his tracheoesophageal puncture prosthesis. He does not feel that the neck swelling
has improved with the Medrol Dosepak. He denied any fever or chills. In March 2014, the
patients tracheoesophageal puncture prosthesis was removed by speech pathologist. The patient
had a temporary bleeding around the tracheoesophageal puncture site, with close monitoring and
light pressure, homeostasis was maintained. KC has been instructed from here on out, that if he
experiences difficulty breathing to immediately seek the services of an emergency service.
Past Medical History: KC has a past medical history of themaxillary sinus, and
laryngeal cancer, chronic obstructive pulmonary disease, hyperlipidemia, anxiety,
gastroesophageal reflux disease, and depression. In addition, KC reported an allergy to
adhesives.
Social History: KCis married, with two children. He lives in Jamestown, New York and
is retired from WalMart. He quit smoking in 1997, prior to that 1 to 1-1/2 packs per day for 30
years. He also was previously an alcoholic, but quit in 2003. He denies any intravenous (IV)
drug use. The patient also was adopted, and therefore does not have any direct information
regarding his family history.
Medications: KCuses the following medications: Singular, Simvastatin, Terazosin,
hydrocodone, as well as 6 cans per day via his percutaneous endoscopic gastrostomy (PEG) tube
of calcium and protein; and Erbitux once a week for chemotherapy.The cytotoxic effects of
radiation therapy in squamous cell carcinoma could be enhanced by Erbitux.
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Diagnostic Imaging:KChad a computed tomography (CT) scan of the soft tissues of the
neck with and without contrast in February 2014. The reason for this examination was to stage
and confirm KC's laryngeal carcinoma. Thin-sliced axial imaging of the neck was obtained after
administration of 75cc of Visipaque 320 intravenous contrast. Ten minute delayed imaging was
also performed. Findings were that just above and to the level of the tracheostomy, there is a 1.8
x 2.1 cm lesion which appears to represent a pseudoaneurysm. Posterior and inferior to the
pseudoaneurysm, there is a 3.5 x 4.2 x 5.1cm second homogeneous mass. This most likely
represents hematoma or other fluid collection although it could not be excluded the possibility
that this was a developing mass. This lesion somewhat displaces the trachea and tracheostomy to
the right. No other masses or lymphadenopathy were identified, nor were there lytic or sclerotic
bony lesions. Post-surgical changes of the sinus cavity were also present with mucosal
thickening in the left maxillary sinus and mild mucosal thickening in the right maxillary sinus.
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Axial images of the chest were obtained using the same technique as previously mentioned. The
heart is normal in size, there were no pulmonary masses or nodules. No consolidation, pleural
effusion, pneumothorax, nor acute bony abnormalities were present. This gave the impression
that no pathology was identified in the chest.
Radiation Oncologist Recommendations: Afterreview of KCs medical history and CT
reports, the radiation oncologist (RO) recommended KC to undergo IMRT irradiation of the
superior mediastinum. The basis for IMRT relies on an inverse-planning system, which
optimizes the delivery of nonuniform beam fluencies from multiple directions to allow the
intended dose to reach the target with maximal sparing of the dose to the normal
tissues.
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However, after time spent planning IMRT, a new report came to the attention of the
radiation oncologist that the patient may have had prior irradiation of part of the cervical spinal
cord that would be included in this IMRT field. There was no concrete evidence whether this
was absolutely true, so the radiation oncologist decided to err in caution and change the plan to
AP/PA. It was not known for certain the exact match lines of the prior radiation treatments.
Therefore, numerous dosimetrists and physicists worked together to develop the best AP/PA plan
from the information they had. The treatment fields are set up so that the center of the tumor
mass is the isocenter for the fields in the superior mediastinum. There was great concern given to
the amount of dose that the apex of the lung would receive during this treatment. At one point
there was fear this patient would either die from the cancer, or die from toxicity to the lung.
Also, the radiation oncologist was fearful that an overlap of fields from the prior radiation
treatment would occur at the level of the cervical spine. This caused worry that the spinal dose
may exceed its tolerance dose and injure the patient as well. Again, to err on the side of caution,
the radiation oncologist reduced the level of the match line as an extra safe margin.
The Plan (prescription): The radiation oncologists treatment recommendation to KC
was Anterior-Posterior/Posterior-Anterior (AP/PA) palliative irradiation to the superior
mediastinum, with a boost/second site not yet determined. The plan utilized2static 16 Mega
Voltage (MV) photon beams targeting the mediastinum, due to the location of the disease present
and possibility of prior radiation. The prescription dose for the superior mediastinum was 1000
cGy at 200cGy per fraction for 5 fractions. The radiation oncologist wants to start treatment on
KC as some time has passed, and will alter the prescription to the boost/site 2 as time goes on.
The boost/site 2 is not based on tumor response, but more on the comfortableness of the radiation
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oncologist. He was not entirely pleased that this patient was to be treated with AP/PA, and would
still prefer to treat him with IMRT.
Patient Setup/Immobilization: In April 2014 KC underwent a CT simulation scan for
radiation therapy treatment planning. Prior to the simulation, a confirmed consent was signed by
the patient and radiation oncologist. Then, the patient was placed in the supine position on the
CT simulation couch with his arms by his sides, tucking his thumbs under his buttocks. The
patients upper body was supported with a Civcotilt board because it was difficult for the patient
to lay flat. Atop of the tilt board a VacLock was then created to hold KC's upper body in a
permanent position to ensure reproducibility. The tilt board was set at 10
o
indexed, H-3 headrest,
and a butt-stop at B-5.(Figure 1).The use of the tilt board presented no difficulty in planning, as
the dosimetrists are used to this technique. The radiation oncologist marked the Central Axis
(CA)of the tumor by placing a BB crosshair on KC's skin and utilizing the leveling lasers on the
CT scanner.These points were triangulated to form the treatment planning isocenter. A planning
CT scan was obtained using 3 mm slices for a total of 96 slices. The CT images were transferred
to the Varian Eclipse planning system. The CT dataset will be used to establish portals, borders,
and contour structures by the physician and dosimetrist.
Anatomical Contouring: After completion of the CT simulation scan, the CT data set
was transferred into the Varian Eclipse 11.0.30 radiation treatment planning system (TPS). The
medical dosimetrist contoured organs at risk (OR) which included the heart, left and right lung,
total lung, port, and spinal canal.The carina is contoured in addition to help localization and aid
in the patient positioning for the radiation therapists when treating. This clinic, Cancer Care of
Western New York (CCWNY) has constraints for each the heart and total lung. For the heart, a
constraint called V30 is utilized regulating that 30 percent of the heart volume cannot receive
more than 3000 cGy. For the total lung the V20 constraint is adhered to; restricting the dose to
20 percent of the total lung cannot receivemore than 2000 cGy. This information can be obtained
easily with the utilization of the Dose Volume Histogram (Figure 2). The Multi Leaf Collimator
(MLC)was used to allow for full coverage of the tumor but following constraints given to the
dosimetrist to protect the heart, lungs, and as well as keeping hot spots under 10%.The radiation
oncologist reviewed the OR as well as the plan, and made final adjustments to the MLC leaves in
order to begin radiation treatment planning. The medical dosimetrist was given a prescription
objective sheet to begin treatment planning.
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Beam Isocenter/Arrangement: The medical dosimetrist placed an isocenter
corresponding to reference marks placed on KC's skin using the leveling lasers on the CT
scanner during his simulation. BBs were placed over these marks, and these points were
triangulated to form the treatment planning isocenter (Figures 3-5). 2 fields were used in the
planning of this AP/PA treatment for KC utilizing different gantry angles for the AP versus the
PA, although the collimator angles were consistent. For the AP field, the gantry was set at 0
o
, as
well as the collimator at 0
o
. For the PA treatment field, the gantry was set at 180
o
, with the
collimator remaining at 0
o
. Each beam utilized 16MV energy due to the depth of the tumor, and
skin sparring qualities of the 16MV beam. The weight on the AP beam was 0.614, and the PA
beam had a weight of 0.386 keeping the dose to the cord minimal. Each field aperture had a
MLC blocking pattern constructed by the dosimetrist and modified more specifically to cut cord
dose by the radiation oncologist (Figure 6). The dosimetrist determined field sizes of each beam
in relation to the treatment objectives to meet the goals of the desired dose distribution
throughout the tumor mass, as well as to keep dose low to the OR.
Treatment Planning:The radiation oncologist outlined the desired dose prescription and
objectives for the AP/PA superior mediastinum tumor treatment plan. The intention was to
irradiate the superior chest mass with an appropriate energy without destroying normal
underlying structures, and leaving the skin intact. The prescription dose was prescribed to a point
at isocenter of the AP beam, which was constructed from the images and data received from the
simulation CT scan. One half of the prescription dose was delivered to the AP beam, and the
other half of the daily prescription dose was delivered to the PA beam. The patient is to receive
100cGy to both the AP/PA beams; a daily total of 200 cGy. However, because of the heavier
weighting of the AP beam 124 monitor units (MU) is to be delivered to the AP, while the PA
beam is to receive98 MU.
Quality Assurance/Physics Check: The MUwere reviewed and a second check was
completed with a Quality Assurance (QA) computer program RadCalc. The MU for this
portion of the plan were within tolerance; less than 2% for each field.Specifically, monitor unit
validations are expected to have a total dose discrepancy of 3% overall, and 5% per beam,
independent of disease site.
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The planned MU for the APbeam were at 124, while the actual
delivered MU were 122; for the PA beam the planned MU were 98 actual delivered MU were 97.
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The AP/PA superior mediastinum treatment plan for KCwas reviewed by a junior medical
physicist for a final check before treatment began (Figure 7).
Conclusion: Overall, this was a rather difficult case for the dosimetrist to plan. Initially,
the radiation oncologist requested an IMRT plan to be constructed for KC, in a short time frame.
This put a lot of pressure on the dosimetrists. There was quite a bit of communication, daily,
between the dosimetrists and radiation oncologist - even the senior dosimetrist got involved with
the planning. It was difficult to make a plan that covered the entire tumor but did not damage the
lung permanently. At one point, there was fear that KC was either going to die from the tumor
because of the lack of adequate tumor coverage, or die from lung damage. According to the
Emami
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Tolerance of Normal Tissue to Therapeutic Radiation tables, the mean dose to the V20
of the lung is 1300 cGy. Anything surpassing that dose can cause pneumonitis, or death. Once a
good IMRT plan was made, it was discovered that KC had prior radiation at a different location
with incomplete data, which threw the IMRT plan out the window. The information about the
prior radiation was obtained from the patient and his wife. However, incomplete data was
received from the other clinic. The radiation oncologist was weary that because of the location of
KCs prior radiation that possibly he had received a dose to his spinal cord which would overlap
in the planned IMRT design. No one was sure the dose that the area in question had received, nor
were they positive the area in question was of real concern. The radiation oncologist decided to
approach this plan then conservatively and proceed with the notion the patient had been prior
treated in this area, and therefore it was not safe to allow the IMRT plan to go ahead. A new plan
was then designed; the AP/PA to the superior mediastinum. The AP/PA plan reduced the risk of
overdosing the prior area more so than the IMRT plan. If the chosen match line was not correct,
and IMRT was used, the patient would have received a toxic dose to the spinal cord which could
have been fatal. At this point, the radiation oncologist is planning on altering his prescription
after 1000cGy has been delivered, however it has not been completed as of yet. KC was
supposed to start treatment in the first week of April - but because of the complexity of the
previously stated information, he has yet to begin.



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References
1. Cante D, Franco P, Sciacero P, et al. Combined chemoradiation for head and neck region
myxofibrosarcoma of the maxillary sinus. Tumori. 2013;99(2):e80-3.
http://dw.doi.org10.1700/1283.14214.
2. Koukourakis G, Kouloulias V, Koukourakis M, et al. The efficacy of combined treatment
with cetuximab (erbitux) and radiation therapy in patients with head and neck cancer.J
BUON. 2009;14(1):19-25. www.ncbi.min.nig.gov/PubMed/19373942. Accessed March 22,
2014.
3. Livi L, Buonamici FB, Simontacchi G, et al. Accelerated partial breast irradiation with
IMRT: new technical approach and interim analysis of acute toxicity in a phase III
randomized clinical trial. Int J Radiat Oncol Biol Phys. 2010;77(2):509-515.
http://dw.doi.org 10.1016/j.ijrobp.2009.04.070.
4. Emami B. Tolerance of normal tissue to therapeutic radiation. Reports of Radiotherapy and
Oncology. 2013;1(1):35-48. http:// http://journals.sbmu.ac.ir/rro/article/view/4316/3851.
Accessed March 22, 2014.














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Figures


Figure 1.Civco, Inc. Tilt board at CT simulation.

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Figure 2.Dose Volume Histogram (DVH).

Figure 3.Isocenter placement in the sagittal view. (Lung calc = isocenter)
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Figure 4.Isocenter placement in the frontal view. (Lung calc = isocenter)
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Figure 5.Isodose placement in the transverse view. (Lung calc = isocenter)

Figure 6.DRR of treatment field, showing isocenter, size and location of tumor.
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Figure 7.Physics MU RadCalc check.