Ashley Smelko

Case Study 2017

April 9, 2017
Intensity modulate radiation therapy (IMRT) Lung Treatment Planning with
Implementation of Lung Ventilation Protocol.
History of Present Illness: In early August of 2016, patient PM visited the Emergency Center
at the hospital when she developed progressive tightness in her chest accompanied by difficulty
breathing. A chest x-ray was performed at that time which revealed a patchy opacification on her
right upper lobe. A follow-up CT on August 16, 2016 revealed a lobulated mass in the right
upper lobe with multiple tiny nodules surrounding. The mass measures 2.8 x 2.6cm. A PET scan
was performed weeks later on October 21, 2016. The scan showed uptake in the lymph nodes in
the paratracheal region and in the right suprahilar mass. There is no uptake below the diaphragm
and upon review of the bone window imaging, there are no bone metastases present. Following
this scan, patient PM underwent a bronchial biopsy, on November 8, 2016, which confirmed the
diagnosis of moderately differentiated squamous cell carcinoma. A month later, she had a
paratrachial and subcarina lymphnode biopsy which also revealed moderately differentiated
squamous cell carcinoma. Patient PM is diagnosed with Stage IIIB (T4, N2, M0) right lung
cancer. There was progression of the tumor on a CT scan obtain on December 13, 2016. The
tumor has increased size and now measures 4.9x3.8x6.7cm. There is also sclerotic osseous
lesions in the thoracic spine which is suspicious for osseous metastases.
On December 20, 2016 patient PM meets with her medical oncologist to discuss treatment
options. She was referred to radiation oncology. Due to the tumors close proximity to the
bronchus and large size she was not a candidate for surgery. It has been recommended by the
medical oncologist for her to receive a course of definitive radiation with concurrent
chemotherapy. Standard, daily fractionated and twice daily hyperfractionated treatment options
were discussed. The side effects of both options were explained to patient PM. Side effects
include fatigue, erythema, desquamation of the skin of the chest wall, rib fracture, odynophagia,
dysphagia, dyspnea, and possible radiation-induced pneumonitis. She will undergo a treatment
planning simulation and an immobilization device will be created. A 4-D CT scan and her PET
imaging will be fused to ensure an accurate administration of radiation. She will have daily
image guidance for exact localization before irradiation. Patient PM was sent for an MRI on
1/19/17 and these results will be reviewed with neuroradiology to investigate possible
intracranial metastases.
Past Medical History: This patient has a past medical history of hypertension, arthritis, asthma,
dyspnea, and cancer. Her past surgical history includes the following procedures: C-section,
tonsillectomy, arthroscopy knee, rotator cuff repair x 2, cataract extraction, bronchoscopy w/
mediastinoscopy, and colonoscopy. She has a food allergy to almonds which causes swelling of
the lips, tongue, and throat.
Social History: PM was employed for 46 years as a registered nurse. She retired at 66. She is
married with two children. She had a 140-pack-year smoking history and quit 20 years ago. She
occasionally drinks socially and denies any illicit drug use. Her familial history is significant for
caner. Both parents are deceased. Her mother had stomach cancer and her father had lung
cancer.
Medications: PM is currently taking the following medications: Norco, Furosemide, Mucinex,
Zyrtec, Calcium Citrate-Vitamin D, and Aspirin.
Diagnostic imaging: In early August 2016, PM was experiencing difficulty breathing which
resulted in a visit to the Emergency Center where a chest x-ray was obtained. This revealed a
mass in the right upper lung. On August 16, 2016 she had a follow up CT which revealed the
right upper lung mass and its close proximity to the right bronchus. A PET CT was scheduled on
10/21/16 which revealed uptake in the lesion as well as in the paratracheal and subcarinal lymph
nodes. A biopsy of the bronchus was performed on 11/8 followed by a mediastinoscopy and
bronchoscopy to obtain a biopsy of the lymph nodes on 12/7/16. The biopsies diagnosed her
with Stage III right lung cancer with moderately differentiated squamous cell carcinoma.
Another chest CT was obtained on 12/13/16 which shows the tumor dimensions of 3.4 x 2.6cm.
After completing a consultation with the medical oncologist and radiation oncologist, patient PM
underwent a final diagnostic CT before treatment planning. The tumor now measures
4.9x3.8x6.7cm when compared with previous studies. After the treatment planning simulations
she was sent for an MRI, on January 19, 2017, to check for intracranial metastasis.
Radiation Oncologist Recommendations: PMs work up showed a large mass in the right
upper lung. Due to the tumors close proximity to the bronchus and heart she was not a
candidate for surgery. The radiation oncologist stated that she could be a candidate for the
University of Colorado early phase clinical trial which incorporates lung functioning imaging
into radiation treatment planning to spare healthy functioning lung volumes. PM underwent a 4-
D CT simulation to represent breathing motion during the study. A ventilation imaging set was
fused with the 4-D CT simulation set. In the ventilation imaging set, the volumes of functioning
lung are colored and contoured by physics. These functional areas were then contoured by
medical dosimetrists and set as avoidance structures during the planning process. A 9-field
intensity modulated radiation therapy (IMRT) technique will be used while sparing and avoiding
the left lung and heart. Dose constraints will include the esophagus, trachea, spinal cord, and the
healthy functioning lung volumes as defined by physics. A benefit of this study is the ability to
modify the treatment plan as lung function improves. If lung function improves the patient will
undergo an additional ventilation imaging scan and new volumes will be created and avoided.
The Prescription: The treatment plan recommended by the radiation oncologist contained a 9-
field IMRT beam arrangement while sparing most of the left lung (Figure 1). The prescription
dose for the entire treatment is 200cGy daily for 30 fractions. The planning tumor volume (PTV)
is prescribed to 60Gy while the gross tumor volume (GTV) is prescribed to 70Gy. During the
course of treatment PM will be seen weekly and re-evaluated. If breathing functioning improves
she will be sent for additional studies to spare healthier functioning lung volume. A standard
plan will be created and will be used as a baseline comparison for the functional plan with
functional lung avoidance structures.1
Patient Setup/Immobilization: PM completed her radiation treatment planning simulation on
January 13, 2017. She completed a 4-D CT scan to accurately represent tumor and organ motion
during respiration. She was placed supine with her arms above her head. An alpha cradle was
created to immobilize and to accurately reproduce her positioning daily for treatment. A knee
sponge was used for comfort and her feet were bound for extra immobilization. The radiation
therapist placed marks on her chest and sides to help with tumor localization (Figure 2). A
radiopaque marker was placed on the marks as a reference point during planning. Measurements
were recorded from anatomical land marks to ensure proper placement if patient PM removes the
temporary marks. The anterior mark was placed 11cm inferior of the xiphoid process.
Anatomical Contouring: The data image sets were imported into Pinnacle3 version 14.0
treatment planning system (TPS). There are 9 phases of the CT simulation which gives a
representation of active breathing. The ventilation imaging study (Figure 3) and the PET scan
are also fused to these data sets. The ventilation imaging creates a functioning lung volume that
will be transformed into a critical structure. The critical structures for this patient include the
heart, esophagus, trachea, primary bronchial tree, cord, lungs, and aorta. Critical structures are
contoured on each phase, through a process called propagation, and then an average of the
volumes is created. Before averaging the volumes, the medical dosimetrist reviews each scan,
slice by slice, to ensure the contoured volumes are reasonably similar to the GTV and other
structures originally drawn by the radiation oncologist. Once this average volume is created it is
transposed to the average CT scan which is the data set used for treatment planning. The
radiation oncologist or resident contours the clinical target volume (CTV) and planning target
volume (PTV) once the scans have been propagated. The main volumes used for dosing include
the GTV, CTV, PTV, PTV plus 5mm of margin around the volume (PTV+5mm), and internal
target volume (ITV) for tumor movement.
Beam/Isocenter Arrangement: This plan was created to be implemented on the Elekta SL3
linear accelerator. A large portion of beam delivery will be passing through the lung. Due to the
lower density of the lung, 6MV was selected as the beam energy. The isocenter was placed in
the right lung at mid-depth within the patient. The PTV was used by the TPS to place the
isocenter in the center of the volume (Figure 4). The beams were placed at the following
angles: 200, 225, 250, 275, 300, 325, 350, 15, and 175. There is an avoidance between angle 15
and angle 175 to avoid the left lung and heart. Due to the close proximity to the heart,
esophagus, and trachea, IMRT was the selected modality. The field size was also determined by
the size of the PTV. The length of the field size remains constant while the width varies to try
and keep the dose as conformal as possible. The length of the field remains constant to prevent
dosing superiorly and inferiorly. The width changes to allow for the dose to be manipulated
around the PTV. The TPS automatically adjusts the width based on the parameters set by the
dosimetrist. The field size does not always encompass the PTV at certain angles due to the
location of different organs or dose constraints.
Treatment planning: The radiation oncologist weighed the benefits of conventional
fractionation and twice daily (BID) treatments. The doses were 200cGy daily versus 150cGy
BID. The patient preferred to be treated once daily which resulted in the oncologist prescribing
60Gy to be delivered in 30 fractions or 200cGy per fraction. Prolonging radiation therapy
treatments does not impact late reactions but it does decrease the severity of early effects.2 The
main goal of this treatment plan is to increase and preserve lung function while reducing tumor
volume. The radiation oncologist defines constraints by the use of a strict documentation which
contains a detailed list of constraints with corresponding doses (Figure 5). The radiation
oncologist list the constraint dose limits which gives the dosimetrist objectives to meet. At the
end of the planning process the medical dosimetrist documents the doses that each constraint
volume receives to explain to the radiation oncologist what was met or unachievable when the
plan is reviewed prior to approval. Pinnacle3, version 14.0 was the TPS used to create this plan.
Objectives are added into the IMRT planning pane. The medical dosimetrist assigns values to
these objectives. The dose documentation requests defines dose to the GTV and PTV as 70Gy
and 60Gy respectively. In the TPS the dosimetrist is able to define a minimum dose, maximum
dose, uniform dose, maximum dose volume histogram (DVH) or minimum DVH. The medical
dosimetrist may assign a number of constraints to the same volume. A value is also assigned to
that constraint to weight its importance among the other volumes or regions of interest (ROI).
The spinal cord dose was to be less than 46Gy, the volume of the esophagus receiving 50Gy
(V50) was to be less than 30%, and the heart V45 < 35% and V30 < 50% (See Figure 6). The
IMRT parameters used 40 iterations with a maximum of 65 segments to complete the
optimization. The beam type was set to step and shoot multi-leaf collimator (MLC) and the
optimization type was set to Direct Machine Parameter Optimization (DMPO) (Figure 7). After
each completed optimization the dosimetrist is able to change constraints to achieve the
prescribed dose and constraints set by the oncologist. The final plan covered 94.7% of the GTV
volume with 70Gy, the CTV received 100% of 60Gy, and 96.6% of the PTV received 60Gy. All
constraints were met on the boarding pass except the V60 of the esophagus. The objective was
17% but 18.5% of the volume was receiving 60Gy. The close proximity of the esophagus to the
treatment volume caused the dose to exceed the planned objective. The physician approved the
plan with the GTV receiving 97% of the dose and the global max dose was 80.308 which is 33%
higher than the prescribed dose (see Figure 8 and Figure 9).
Quality Assurance/Physics Check: The treatment delivery system was verified through the use
of an ArcCheck. A copy of the treatment plan is generated and the imposed onto the ArcCheck
cylinder (Figure 10). The linear accelerator delivers the treatment plan to the ArcCheck cylinder
phantom and the 1386 diode detectors generate a three-dimensional (3D) beams eye view
(BEV) dose distribution.3 The 3D dose distribution should be within 2% of the TPS generated
dose distribution. The physicist reviews the results and approves their portion of the treatment
plan. The plan is now ready to be implemented for radiation therapy treatments.
Conclusion: The IMRT lung treatment planning with implementation of lung ventilation
protocol allows a healthy lung volume to be defined and to be avoided by high treatment doses.
The healthy lung volume can be challenging to plan around but it can offer better breathing
results to the patient. An excellent plan is initially generated and then the ventilation scan is
fused to the treatment planning CT. The healthy ventilation volumes are added as objectives to
the optimizing tool. The biggest challenge is trying to force dose away from these volumes
while still delivering adequate dose to the GTV and PTV. There are times when the TPS is
unable to spare dose to the healthy volumes. At this point a decision has to be made whether to
sacrifice coverage to the treatment volume or to deliver dose to and through healthy tissues. A
second ventilation scan may be ordered to demonstrate improved lung functionality which
indicates the need to re-evaluate, re-simulate, and re-plan. Another challenge the radiation
oncology team faces is reproducibility. Upon simulating for a second plan the patient did not set
up well and the original plan was used for the remainder of the treatment. It is always a goal to
improve the treatment plan but alternative planning options may not always have better results.
Although there are various challenges associated with various cases, the IMRT lung treatment
planning with implementation of lung ventilation protocol is an excellent guide for sparing
healthy functioning lung tissue and improving respiration while achieving excellent dose
coverage to the treatment volume.
 References
1. Grills I, Vinogradskiy Y, Zhang M. Feasibility Study Incorporating Lung Function
Imaging Into Radiation Therapy for Lung Cancer Patients. University of Colorado,
Denver. National Cancer Institute (NCI).
https://clinicaltrials.gov/ct2/show/NCT02528942 Published 2015. Accessed March 23,
2017.
2. Hendee WR, Ibbot GS, Hendee EG. Radiation Therapy physics. 3rd ed. Hoboken, NJ:
Wiley-Liss; 2005: 417.
3. ArcCheck and 3DVH [computer program]. Melbourne, FL: SunNuclear Corporation.
2016.
 Figures

Figure 1. Three dimensional reconstruction of patient demonstrating 9-field beam distribution to

treatment volume.
Figure 2. Computed Tomography simulation showing treatment position and immobilization
device.
Figure 3. Ventilation imaging showing rainbow color wash. The areas of red and yellow show
higher functionality. These colors are turned into a structure and are avoided in the ventilation
plan.
Figure 4. Three dimensional (3D) skin rendering displaying isocenter. Skin rendering image is
generated from the CT scan by the treatment planning system.
Figure 5. Boarding pass which reflects the objectives requested by the physician and the doses
the medical dosimetrist was able to achieve.
GTV
PTV
Cord
Esophagus
Trachea

Heart

Figure 6. Treatment
evaluation Dose Volume
Histogram (DVH).
Figure 7. Intensity modulated radiation therapy (IMRT) segment shapes generated by the Direct
Machine Parameter Optimization (DMPO) tool.
Figure 8. Four pane view showing isocenter inside of volume on axial (top left, sagittal (top
right) and coronal (bottom left) views. The bottom right pane shows the maximum hot spot of
8030cGy.
Figure 9. Slice series showing isodose distribution through the treatment volume.
Figure 10. (Top) Three dimensional (3D) DVH showing delivered dose distribution when
compared to the treatment planning system. (Bottom) ArcCHECK cylinder.