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Nathaniel Miles
Clinical Oncology Assignment

The patient was positioned for simulation and subsequent treatments head first supine.
One of the immobilization devices used has the patient laying on a wingboard, which supports
his arms as he holds handles above his head. This setup keeps his arms out of the way of the field
as well as stabilizes his body in the same position. His arms and head are also being supported
and immobilized with a vacuum bag that keeps his head and arms in the same position daily for
treatment.

The dose schedule for the patient is 200 cGy per day once daily for 30 days totaling
6000cGy. This fractionation schedule is considered standard fractionation for radiation therapy.
There has been conflicting studies about the benefit of using hyper-fractionation, changing the
fractionation to 200cGy twice daily, but there has been no consensus yet as to whether
accelerated fractionation is beneficial enough to warrant the added burden of having the patient
come in for treatment twice daily.1,2 The studies indicate that the same benefits from accelerated
fractionation, such as twice daily, can be gained through concurrent chemotherapy, which this
patient is undergoing. Studies have found the benefit of prescribing 6000cGy to the tumor and
that increasing the dose beyond this amount has no benefit and increases acute toxicity to the
esophagus.3

Organs at risk (OAR) for this volume include heart, spinal cord, lung, Esophagus,
Stomach, and Liver. The lung meets the constraint of V20<30%, if you look at the organ without
the PTV, as indicated by the lung-ptv constraint. Figure 1 below shows a coronal image of the
patient with organs at risk contoured and labeled. Figure 2 is a list of organs and their constraints
as listed in QUANTEC.4
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Figure 1. Contoured Target and Organs at Risk

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Figure 2. Table of Planning Objectives for Organs at Risk and Toxicity Endpoints
Organ at Risk (OAR) Desired Planning Objective Toxicity Endpoint
Heart Mean <26 Gy Pericarditis
V30<46% Pericarditis
V25<10% Long term cardiac mortality
Spinal Canal 50 Gy<0.2% Myelopathy
60 Gy<6% Myelopathy
69 Gy<50% Myelopathy
Lung V20≤30% of volume V20=34% (Not Met, Symptomatic
Mean 7 Gy Pneumonitis)
Mean 13Gy Mean 1975 cGy (10% of
Mean 20Gy population will have symptomatic
Mean 24Gy pneumonitis)
Mean 27Gy
Lung-PTV V20=29.5% (Met)
Esophagus Mean <34 Gy Mean 2610 cGy
V35<50% V35=40%
V50<40% V50=14.5%
V70<20% V70=0%
Max 6550cGy
Stomach D100<45 Gy D100=21cGy
Liver Mean <30-32 Gy Mean 102 cGy
Mean <42 Gy
Mean <28 Gy
Mean <36 Gy
All constraints are from Quantitative Analyses of Normal Tissue Effects in the Clinic
(QUANTEC)4

The lymph nodes that were treated along with the tumor include the Cervical Nodes,
Hilar Nodes, and Paratracheal nerve groups. These nerves were treated because of the positive
nodal involvement noted in the biopsy report as well as the enlarged nodal regions seen on the
CT scan. Figure 3 is a coronal image of the patient with nodal regions labeled.
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Figure 3. Nodal Regions in the Treatment Field

The superior boundary of the target volume lies between C4 and C5 vertebrae. The
inferior border of the target volume is between the T6 and T7 vertebrae. Laterally the target
volume is 15.5cm across. Spanning from the right lateral border of the right humoral head to the
left lateral border 3.75cm past the T1 Vertebra. At the volume’s most posterior it is
approximately at the level of the intervertebral foramen of the T6/T7 Vertebrae. The volume is
most anterior along the superior border of the Cervical Nodal PTV where it is approximately at
the level of the Larynx. Figures 4-8 show the boundaries of the target volume with anatomical
references labeled.
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Figure 4. Superior Border of Target Volume

Figure 5. Inferior Border of Target Volume

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Figure 6. Lateral Borders of Target Volume

Figure 7. Anterior Border of Target Volume

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Figure 8. Posterior Border of Target Volume

For the treatment plan VMAT technique was used with 3 partial arcs going from 180.1
degrees to 45 degrees, just past the mediastinum. The plan used partial arcs in order to minimize
dose to the contralateral lung. The reasoning behind the use of a third field was the large field
size and the fact that the leaves are unable to travel past 15cm in the x direction. Therefore, in
order to get full PTV coverage a third arc needed to be added. The arcs start with a clockwise
rotation, followed by a counterclockwise arc, and ending with a clockwise rotation ending at 45
degrees. The arcs are collimated at different angles so the leaf leakage is not leaking into the
same tissue as the gantry travels arcs across the patient. The collimator angles are 30 degrees for
the first arc, 330 degrees for the second arc, and 90 degrees for the final arc. The couch is not
moved during the treatment, shortening the treatment time, and minimizing error in setup. The
main goal during optimization was to get full coverage of the PTV while keeping the dose to the
rest of the lung, heart, spinal canal, and esophagus minimal. The treatment fields are depicted in
figure 9 below. A dose volume histogram with organs of risk is depicted in figure 10 with
another list of constraints from QUANTEC and whether they were met in figure 11.4
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Figure 9. Treatment Plan Fields

Figure 10. Dose Volume Histogram

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Figure 11. Planning Objective Constraint Outcomes

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome
Heart Mean <26 Gy Mean 1238 cGy (met)
V30<46% V30=12% (met)
V25<10% V25=16% (Not Met, Possibility of
longterm cardiac mortality)
Spinal Canal 50 Gy<0.2% Max 3616 cGy (met all objectives)
60 Gy<6%
69 Gy<50%
Lung V20≤30% of volume V20=34% (Not Met, Symptomatic
Mean 7 Gy Pneumonitis)
Mean 13Gy Mean 1975 cGy (10% of population
Mean 20Gy will have symptomatic pneumonitis)
Mean 24Gy
Mean 27Gy
Lung-PTV V20=29.5% (Met)
Esophagus Mean <34 Gy Mean 2610 cGy
V35<50% V35=40%
V50<40% V50=14.5%
V70<20% V70=0%
Max 6550cGy
Stomach D100<45 Gy D100=21cGy
Liver Mean <30-32 Gy Mean 102 cGy
Mean <42 Gy
Mean <28 Gy
Mean <36 Gy

All constraints are from Quantitative Analyses of Normal Tissue Effects in the Clinic
(QUANTEC)4
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References

1. Dağoğlu N, Karaman S, Arifoğlu A, Küçücük S, Oral EN. Definitive radiotherapy in locally

advanced non-small cell lung cancer: dose and fractionation. Balkan Med J. 2014;31(4):278-285.
2. Tomita N, Kodaira T, Hida T, et al. The impact of radiation dose and fractionation on outcomes
for limited-stage small-cell lung cancer. Int J Radiat Oncol Biol Phys. 2010;76(4):1121-1126.
http://doi.org/ 10.1016/j.ijrobp.2009.03.069.
3. Bernard M, Holt D, Heron DE, et al. Clinical outcomes and dosimetric parameters for stage IIIB
non-small cell lung cancer. Int J Radiat Oncol Biol Phys. 2015; 93(3):E428-E429.
http://doi.org/10.1016/j.ijrobp.2015.07.1640.
4. Marks LB, Yorke ED, Jackson A, et al. Use of normal tissue complication probability models in the
clinic. Radiat Oncol.2010;76(3):S10-S19.