Jenny Huang

VMAT for Secondary Neoplasm of the Brain

I. History of Present Illness
a. 40 y.o male
b. June 2016, experienced pain on lower left extremity (LLE) and shortness of
breath (SOB).
i. Patient was worked up for LLE DVT and bilateral pulmonary edema
(PE) and a left lung mass was found
ii. MRI brain was negative
c. December 2016
i. Patient was s/p 6 cycles of Carbo/ Alimta
d. February 2017 bone scan at Seton Williamson
i. Osseous mets in the cervicothoracic junction of the spine, T3, left SI,
left posterior 6th rib, right frontoparietal bone, right supraorbital rim
and left ischial bone.
ii. Patient started on Opdivo
iii. Patient reported worsen mid to low back pain so patient was referred
to Austin Cancer Center (Dr. Rivera) for palliative radiation.
e. March 2017 palliative radiation
i. OTV 12/30 Gy T1-T4 BV
ii. Diagnosis: Stage IV (t4 N3 M 1b) LUL NSCLC
iii. Systemic treatment: Opdivo
iv. CC: pain improving. No new complaints
A/P: continue XRT as planned
f. May 11, 2017 5 weeks post radiation to T1-T4 VB 30 Gy
i. Patient had PET/ CT
ii. Report
iii. Patient had severe pain to his right hip even with maximum amount of
pain medication.
g. May 25, 2017
i. OTV 3/30 Gy Sacrum
ii. CC: Lower back pain and sacral pain worse since follow-up.
iii. MRI C-spine due to PET findings. Report showed C3 met without
compression fracture or extraosseous extension and T3 lesion that had
some retropulsion that is worse compared to before tx on 3/8/2017.
iv. A/P: continue XRT as planned
h. August 2, 2017
i. 4 months status post radiation to T1-T4 VB 30 Gy and he completed
radiation to the sacrum 30 Gy on 6/8/2017 and to the right hip 30 Gy
on 6/29/2017
i. October 30, 2017
i. OTV 0/24 Gy Right cerebellar lesion – SRS x1
ii. A/P: SRS fraction today
j. January 10, 2018
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i. 9 months post radiation to T1-T4 VB 30 Gy, sacrum 30 Gy and right

hip 30 Gy.
ii. Patient had increasing memory loss and confusion.
iii. CT head and MRI brain on 12/29/2017 showed a large temporal lobe
mass with surrounding edema and midline shift.
iv. Patient is s/p left temporoparietal craniotomy on 12/30/2017
v. Pathology: metastatic adenocarcinoma
vi. CT C/A/P on 12/30/2017 showed progression of metastatic disease in
the bones and lungs.
vii. Patient was referred back to Austin Cancer Center for WBI (whole
brain irradiation) and palliative radiation.
viii. After radiation, patient may start 3rd line therapy with taxotere,
cyramza and zometa.
II. Past Medical History
a. Left lower extremity pain
b. Shortness of breath
c. Bilateral pulmonary edema
d. Left lung mass
III. Social History
a. Married
i. No children
b. Warehouse driver
c. Non-smoker
d. Mother
i. No history of cancer
e. Father
i. No history of cancer
IV. Medications
a. Dexamethasone
b. Xanax
c. Olanzapine
d. Ambien
e. Compazine
f. Prochlorperazine maleate
g. Hydrocodone-acetaminophen
h. Oxycontin
i. Zofran\Percocet
j. Percodan
k. OPDIVO
V. Diagnostic Imaging
a. MRI brain 6/16/2016
b. Bone scan 2/16/2017
c. PET CT 5/3/2017
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d. MRI brain 8/17/2017

e. CT head and MRI brain 12/29/2017
f. CT C/A/P 12/30/2017
VI. Radiation Oncologist Recommendations
a. Recommended: XRT Brain 2500 cGY
b. Final Rx: XRT Brain 1000 cGy and 1800 cGy
VII. The Plan (Prescription)
a. 1000 cGy in 2 fractions
b. 1800 cGy in 3 fractions
c. Simulated 1/11/2018
d. Started course 2/1/2018 and ended 2/13/2018
VIII. Patient Setup/ Immobilization
a. 4D treatment planning CT
b. Supine on full pad
c. Face mask, S-frame, B timo, holding a ring, bolster
d. 3-point setup
IX. Anatomical Contouring
a. Pinnacle treatment planning system
b. Dr. Structures
i. CTV = resected left temporal brain lesion cavity, delineated from
pre and postop MRI fused to RTP
ii. PTV = CTV + 5 mm
c. Dosimetrists Contours
i. Treatment couch, brain, brainstem, lens, orbit, optic chiasm
X. Beam Isocenter/ Arrangement
a. Varian 21iX
b. Isocenter placed close to the center of PTV
c. VMAT plan
XI. Treatment Planning
a. Pinnacle 3
b. Radiation oncologist entered prescription and planning objectives based off
protocol
c. VMAT was proposed at the time of sim
d. Evaluate DVH
XII. Quality Assurance/ Physics Check
a. Plan is exported to RadCald
b. VMAT is schedule on linac for portal dosimetry
i. Use diode array and EPID to measure beam fluence
c. MU second checks and VMAT QA approved by physicist
XIII. Conclusion
a. Treatment planning outcome
b. Struggled with
c. Things I have learned