Jacquelyn Palermino

Case Study Outline

March 8, 2018

Intensity Modulated Radiation Therapy (IMRT) planning using 4DCT-ventilation imaging

for thoracic functional avoidance in lung cancer

I. History of Present Illness

a. 84-year-old male
b. 12/8/2015 – CT of Chest w/o IV contrast
i. Presentation
1. Right lower lobe bandlike density consistent with scarring
a. Measuring 0.8 x 0.8 cm
c. 2/22/16 – CT of Abdomen/Pelvis with IV and Oral Contrast
i. Showed basilar scarring with nodular density in right lower lobe of lung
1. Measured 0.8 x 1.0 cm
d. 6/20/16 – CT of Chest w/o contrast
i. Stable 1.0 cm nodular density right lower lobe with mild increase in
adjacent atelectasis
e. 9/17/2016 - CT of Chest w/IV contrast; PE protocol
i. Evaluation of pulmonary embolism
1. No disease found
a. Nodule under surveillance- increased in size
f. 12/28/2016 - PET/CT
i. Nodule
1. Showed low-level FDG avidity
ii. Radiotracer uptake of hilum
iii. Low malignancy potential – recommended for follow up
g. 2/2/17 Pulmonary Function Test
h. 7/14/17 – CT of Chest w/IV contrast; PE protocol
i. No evidence of pulmonary embolism
ii. Emphysema and thick-walled bronchiectasis in right lower lobe
i. 9/7/2017 – CT of Chest with IV contrast
i. Right lower lobe abnormality
ii. Increase in size (2 nodules)
1. Right lower lobe mass measures 3.2 x 2.2 cm
2. New nodule just superior to mass measures 1.6 x 1.5 cm
iii. Enlarged mediastinal lymph nodes
1. 13mm in short axis in right lower paratracheal region
2. 16mm in subcarinal region
3. 11mm in upper paraesophageal region
j. 10/13/2107 - PET/CT
i. Showed increase FDG activity in both nodules and multiple lymph nodes
 k. 12/1/17 - Endobronchial Ultrasound & Fine Needle Aspiration biopsy
i. Cytopathology report for subcarinal and right paratracheal regions
1. Positive for metastatic non-small cell carcinoma consistent with
adenocarcinoma of lung primary
2. Clinically staged – IIIA (cT3, cN2, cM0) adenocarcinoma of right
lower lobe
l. 12/7/17 - Saw Medical Oncologist
i. Recommended concurrent chemoradiation
m. 12/14/17 - Consultation for Radiation
n. 12/18/17 – Simulation for Radiation Therapy
i. Patient eligible for functional planning based on image heterogeneity
ii. Patient has a 15% reduction in regional lung function
o. 12/21/17 – Aerosol Ventilation/Pulmonary Perfusion Study with SPECT CT
i. Colorado clinical trial protocol
p. 12/26/17 – Mediport placement
q. 1/6/18 – MRI Brain
i. No evidence of intracranial metastasis
II. Past Medical History
a. Hypertension
b. Prostate Cancer
i. Stage II T1c N0 M0, Gleason 6 adenocarcinoma of prostate
ii. Definitive RT to total dose of 7560 cGy, delivered by ART/IMRT
iii. Completed treatment 7/24/2008
c. COPD – 5/2015
d. Basal cell carcinoma
e. Leukemia – 2/17/16
i. CLL by flow cytometry
f. Osteoarthritis of Right and Left Hip
i. Left total hip replacement – 7/25/16
ii. Right total hip replacement – 6/23/17
III. Social History
a. Marital Status
i. Married
b. Occupation
i. Served abroad in Germany after World War II in 1957-1958
ii. Newspaper editor for Detroit news
1. Retired in 1998
c. Tobacco/Alcohol/Drug Use
i. Current Smoker
1. Smokes approximately 5 cigars a day
a. Started smoking cigars in 1970s
i. Prior to 1970s-smoked a pipe
ii. Alcohol use
 1. Consumes alcohol on a nearly daily basis
iii. Drug use
1. Denies use of illicit/recreational drugs
d. Family History
i. Negative for family history of malignancy
IV. Medications
a. Albuterol
b. Aspirin
c. Cardizem CD
d. Advair Inhaler
e. Pravachol
f. Flomax
g. Umeclidinium Bromide Inhaler
h. Vitamin D
i. Multivitamin
V. Diagnostic Imaging
a. 9/7/2017 – CT of Chest with IV contrast
i. Right lower lobe abnormality
ii. Increase in size (2 nodules)
1. Right lower lobe mass measures 3.2 x 2.2 cm
2. New nodule just superior to mass measures 1.6 x 1.5 cm
iii. Enlarged mediastinal lymph nodes
1. 13mm in short axis in right lower paratracheal region
2. 16mm in subcarinal region
3. 11mm in upper paraesophageal region
b. 10/13/2107 - PET/CT
i. Showed increase FDG activity in both nodules and multiple lymph nodes
c. 12/1/17 - Endobronchial Ultrasound & Fine Needle Aspiration biopsy
i. Cytopathology report for Subcarinal and Right paratracheal regions
1. Positive for metastatic non-small cell carcinoma consistent with
adenocarcinoma of lung primary
2. Clinically staged – IIIA (cT3, cN2, cM0) adenocarcinoma of right
lower lobe
d. 12/21/17 – Aerosol Ventilation/Pulmonary Perfusion Study with SPECT CT
i. Colorado clinical trial protocol
e. 1/6/18 – MRI Brain
i. No evidence of intracranial metastasis
VI. Radiation Oncologist Recommendations
a. Case to be discussed at Thoracic Multidisciplinary Tumor Board
b. Concurrent chemotherapy radiation
c. Suggest MRI of Brain for complete staging and work-up
d. Offered clinical trial NCT02528942 (Colorado Lung Study)
 i. “Early phase clinical trial incorporating lung function imaging into
radiation therapy for lung cancer patients”
1. Consent to treatment
a. Signed consent to participate in IRB 2016-037 protocol,
University of Colorado Lung Function Study on 12/18/17
2. Protocol Requirements
a. Pathology
b. Clinical and Imaging criteria
VII. Treatment Outline
a. Prescription (Right Lower Lobe & Mediastinum)
i. 60 Gy in 2 Gy for 30 fractions
ii. IMRT
1. 9 fields
2. Gantry positioned 25 degrees apart from one another
b. Virtual Simulation – 12/18/17
i. 2 CT scans- Gated (breathing motion) and Non-gated (free breathing)
c. Verify Simulation – 12/27/17
i. Isocenter location placed on skin for alignment purposes
ii. Imaging completed to verify patient setup
1. CBCT and ortho pair
d. First Treatment – 12/28/17
e. Treatment Course completed – 2/8/18
VIII. Patient Setup/Immobilization
a. Supine
b. Alpha cradle
i. Arms above head
ii. Chin raised
c. Knee Fix
d. Rubber band
e. Leveling marks
i. Placed on cradle for alignment
ii. Leveling tattoos given on abdomen for alignment
f. Isocenter tattooed on patient’s chest
i. Placed during verification simulation
g. 4D treatment planning CT completed with Esophageal contrast
i. Used to assess tumor motion with breathing
IX. Anatomical Contouring
a. Philips Pinnacle3 treatment planning system
b. Scans
i. 4D CT scan used for planning from simulation
c. Contours
i. Physician
 1. GTV, GTV-ITV, PTV, aorta, carina, pulmonary trunk, esophagus,
heart, proximal bronchial tree, trachea
ii. Dosimetrist
1. Spinal cord, lungs, skin, treatment couch, ventilation lung contour
showing portions of lung used for breathing
X. Beam Isocenter/Arrangement
a. Isocenter placed in center of PTV contour
b. Elekta linear accelerator (Synergy)
i. 6 MV
c. Beam placement
i. IMRT
1. 9 field (Step and Shoot)
2. Gantry Angles
a. 220, 225, 250, 275, 300, 325, 350, 15, 175
3. Beams directed to deliver dose only through right lung
4. Avoidance of critical structures
5. Reduce dose to functional lung per protocol
6. Dose limitations based on tolerances specified in boarding pass
and protocol
a. Concerns with lung and esophagus dose
7. Very conformal plan with use of IMRT
ii. Daily CBCT guidance for imaging
XI. Treatment Planning
a. Philips Pinnacle3 version 14.0
b. Radiation Oncologist specifies prescription and objectives per protocol
i. Daily dose, fractionation, total prescribed dose
c. IMRT Planning vs. Ventilation Planning
i. Protocol guidelines
ii. IMRT Standard Plan
1. Constraints and Tolerance Limits
a. Deliver adequate dose to target volume and limit dose to
critical structures
iii. Ventilation Plan
1. Additional contouring used for ventilation imaging
2. Priority for optimization per protocol
a. Deliver prescribed dose to PTV
b. Meet dose limits of OARs
c. Reduce dose to functional lung
iv. DVH Comparison
1. Evaluate dose to all structures and volume
2. Make sure within tolerances
v. Articles supporting use for ventilation study
1. Increase in local control
 2. Lower risk to normal tissue
3. Benefits
XII. Quality Assurance/Physics Check
a. MapCHECK for IMRT plan on linear accelerator
i. Array of diode and beam influence checks
ii. Physics calculation check –MapCHECK reviewed by another physicist
XIII. Patient Follow-up
a. Side effects during treatment
i. Week 1 - Occasional nonproductive cough
ii. Week 2 - Shortness of breath when walking long distances
iii. Week 4 - Slight pain on swallowing, long standing dry cough
b. Follow-up CT of chest after completion of RT
i. Scheduled for 3/6/18
XIV. Conclusion
a. IMRT with Ventilation lung protocol
i. Benefits for patient
ii. Limitations on dose constraints
b. Interesting case
i. Use of protocol helps to avoid functional portions of lung and decreases
the rate of side effects that may occur from radiation treatment to healthy
lung tissue
c. Things I learned