Christina Ong

Hybrid Planning for Treatment of Upper GI

I. History of Present Illness
a. 48 y.o. male
b. 7/15/2017, presented to ED at New York Presbyterian – Brooklyn Methodist
Hospital complaining of two weeks of worsening jaundice, pruritus, and
abdominal pain
c. 7/16/2017, admitted
i. No significant past medical history
ii. Intermittent chronic migraines
iii. Worsening pruritus since 2 months
iv. Abdominal bloating and jaundice since 2 weeks with darkening of urine,
indigestion, nausea, occasional vomiting, and decreased bowel
movements.
d. On admission, US Abdomen
i. Multiple non-shadowing echogenic foci in the gallbladder
ii. Mild hepatosplenomegaly
iii. Cyst in the right lobe of the liver
1. 1.5 cm thickness
2. Over 5 cm in length
e. 7/17/2017 MRCP
i. A dilated gallbladder lumen with no filling defects
ii. Findings of a cyst of the liver and left renal cysts
f. 7/19/2017 ERCP
i. A biliary stricture 2cm in length, begins distal to cystic duct insertion and
extends proximally to the confluence, CHD, and left haptic duct
ii. Consistent with klatskin tumor Bismuth-Corlette Type IIIB
iii. Pending brushings/FISH/molecular analysis
iv. Stenting of right intrahepatic duct; left intrahepatic ducts were occluded
g. 7/20/2017 CT Liver Protocol
i. CT Abdomen/Pelvis with Contrast showed encasement of the portal vein
but no noted evidence for vessel invasion (which is not a contraindication
to transplantation)
ii. CT Chest showed no other evidence of metastasis disease
h. 7/21/2017
i. Discussed with patient about possibility of cancer of the bile ducts or
cholangiocarcinoma
ii. Likely requirement of PTC decision made to transfer patient to New York
Presbyterian – Weill Cornell Medical College, accepting attending
physician Dr. Benjamin Samstein, Chief of Liver Transplantation and
Heptaobiliary Surgery  post stenting of right biliary stent, the TB has
not improved
iii. A liver transplant evaluation will be performed at New York Presbyterian
– Weill Cornell Medical College
 Christina Ong

i. 7/21/2017 met with Radiation Oncology

i. Recommendation: once PTC is placed, proceed with neoadjuvant radiation
therapy with HDR brachytherapy to the intrahepatic ductal tumor,
followed by concurrent external chemoradation therapy
j. 8/18/2017 New York Presbyterian – Weill Cornell Medical College
i. Patient underwent a right trisegmentectomy with PV reconstruction and a
roux-en-y hepaticojujunostomy
ii. There was an intraoperative portal vein thrombosis treated with heparin
drip (now Lovenox)
k. 8/25/2017 New York Presbyterian – Weill Cornell Medical College
i. Patient was brought back to OR for x-lap, revision of hapticojujunostomy,
and placement of J-tube
ii. Pathology
1. A low grade, 4.2 x 3.0 cm, pT3, N1 (2 of 3 nodes +) perihilar
adenocarcinoma
2. Lymphovascular as well as perinueral invasion present and
extension to the margin of the resection (R1)
l. 10/13/2017 started cycle 1 of gemicitabine/capecitabine as per SWOG s0809
i. Complicated by grade 3 neutropenia which delayed the administration of
his day 8 gemcitabine by one week
ii. Shortly after his 1st dose of gemcitabine, patient developed significant
abdominal ascites as well as a right flank fluctuating cystic nodule
m. 10/17/2017 PET
i. Mild hypermetabolic activity )SUV 3.6) along the resected edge of the left
hepatic lobe which may be postoperative vs residual tumor
ii. No evidence of carcinomatosis
n. 11/10/2017 proceed with cycle 2 of gemicitabine/capecitabine
i. His ascites has improved and he tolerated the 2nd dose of hemcitabine
without issue
ii. Gemcitabine dosage reduced for grade 3 neutropenia during cycle 1
o. 1/6/2018 – 1/11/2018, presented to ED and admitted to New York Presbyterian –
Brooklyn Methodist Hospital complaining of diarrhea x 1 week
i. No sick contact, recent travel, fever, chills, or dysuria
ii. Found to have C. Diff, thought to be secondary to chemotherapy
iii. Met with Medical Oncology and Radiation Oncology
1. Remains a good candidate for adjuvant chemoradiothearpy  hold
off until patient filly recovers from C. Diff
p. 1/6/2018 CT Abdomen/Pelvis
i. Moderate amount of abdominal ascites, diffuse bowel wall thickening
suggesting diffuse colitis
q. 2/1/2018 Radiation Oncology outpatient follow up
i. A repeat PET/CT to assess disease status
 Christina Ong

ii. IMRT is being considered to maintain local control. However, a fine line
needs to be respected between achieving local control and possibly
endangering the remaining left lobe functions
r. 2/13/2018 PET prior to initiating chemoradiation with xeloda
i. Hypertrophy of the lateral segment of the liver
ii. Decrease in activity (SUV 1.7 previous 2.7) along the stent
iii. Decrease in activity (SUV 2.0 previous 3.6) along the resected edge of the
left hepatic lobe
iv. New suspicious hypermetabolism SUV 1.7 and a soft tissue density in the
right lateral chest wall musculature overlying the 8t and 9th ribs suspicious
for tumor implantation along the site of the surgical drain
v. Concern for peritoneal implant in the LUQ extending interior to the spleen
and into the pericolic gutter
1. The reading radiologist felt the findings were suspicious for
recurrence and recommended a CT with IV contrast to further
characterize followed by likely IR guided biopsy
s. 2/282018 Radiation Oncology outpatient follow up
i. s/p adjuvant gemcitabine/xeloda x 4 cycles
ii. Planned now for chemoradiation—capecitabine + EBRT
II. Past Medical History
a. Kidney stone: resolved
b. Migraines, neuralgic: resolved
III. Social History
a. Works as a carpenter
b. Lives with his girlfriend/partner
c. Alcoholic, 1-2 whiskey drinks daily for 7 years
d. Ex-smoker for 15 years
i. Quit about 7 years ago
e. No intravenous drug abuse or any illicit drug use
f. No tattoo or skin piercing
g. Mother
i. Ovarian cancer
IV. Medications
a. Ascorbic acid
b. Colace
c. Lasix
d. Ondansetron
e. Oxycodone
f. Saccharomyces boulardii with mannan-oligosaccharides
g. Senna
h. Simethicone
i. Spironolactone
j. Vancomycin
 Christina Ong

V. Diagnostic Imaging
a. 7/16/2017 US Abdomen
i. Multiple non-shadowing echogenic foci in the gallbladder
ii. Mild hepatosplenomegaly
iii. Cyst in the right lobe of the liver
1. 1.5 cm thickness
2. Over 5 cm in length
b. 7/17/2017 MRCP
i. A dilated gallbladder lumen with no filling defects
ii. Findings of a cyst of the liver and left renal cysts
c. 7/19/2017 ERCP
i. A biliary stricture 2cm in length, begins distal to cystic duct insertion and
extends proximally to the confluence, CHD, and left haptic duct
ii. Consistent with klatskin tumor Bismuth-Corlette Type IIIB
iii. Pending brushings/FISH/molecular analysis
iv. Stenting of right intrahepatic duct; left intrahepatic ducts were occluded
d. 7/20/2017 CT Liver Protocol
i. CT Abdomen/Pelvis with Contrast showed encasement of the portal vein
but no noted evidence for vessel invasion (which is not a contraindication
to transplantation)
ii. CT Chest showed no other evidence of metastasis disease
e. 10/17/2017 PET
i. Mild hypermetabolic activity )SUV 3.6) along the resected edge of the left
hepatic lobe which may be postoperative vs residual tumor
ii. No evidence of carcinomatosis
f. 1/6/2018 CT Abdomen/Pelvis
i. Moderate amount of abdominal ascites, diffuse bowel wall thickening
suggesting diffuse colitis
g. 2/13/2018 PET prior to initiating chemoradiation with xeloda
i. Hypertrophy of the lateral segment of the liver
ii. Decrease in activity (SUV 1.7 previous 2.7) along the stent
iii. Decrease in activity (SUV 2.0 previous 3.6) along the resected edge of the
left hepatic lobe
iv. New suspicious hypermetabolism SUV 1.7 and a soft tissue density in the
right lateral chest wall musculature overlying the 8t and 9th ribs suspicious
for tumor implantation along the site of the surgical drain
v. Concern for peritoneal implant in the LUQ extending interior to the spleen
and into the pericolic
VI. Radiation Oncologist Recommendations
a. Recommended chemoradiation—capecitabine + EBRT
VII. The Plan (prescription)
a. 60Gy to gross disease; 54Gy to anastomosis site; 48.6Gy to regional nodes in 27
fractions  changed to 60Gy to gross disease in 30 fractions and 54Gy to
 Christina Ong

anastomosis site; 48.6Gy to regional nodes in 27 fractions as the positions of the

liver and bowel bag are switched from their normal anatomical positions after
surgery. The bowel bag is right between PTV60Gy and PTV54Gy. In order to
limit dose to the bowel bag PTV60Gy is delivered between more fractions so the
dose to the bowel bag is constrained
b. SIBT
c. Simulated 2/20/2018
d. Started course 2/28/2018 and ended ---
VIII. Patient Setup/Immobilization
a. 4D-CT with Varian RPM with oral contrast 1 hour prior to simulation
i. Used to assess tumor position with patient respiratory cycle
b. Supine w/ arms up on Alpha cradle
c. Wedge behind knees with legs straight
d. Anterior and lateral tattoos
IX. Anatomical Contouring
a. Eclipse treatment planning system
b. Radiation Oncologist/Resident Contours
i. Used 4D scan to assess motion along with PET/CT
ii. Esophagus, Lungs, Heart, Stomach, Kidneys, Bowel Bag, Spinal Cord
iii. GTV and iGTV (60Gy), iCTVp (60Gy), iCTVn (48.6Gy), iCTV (54Gy)
and PTV expansions
c. Medical Dosimetrist Structures
i. Treatment couch
ii. Contrast dye override
iii. “Opti” and ring structures for VMAT
X. Beam Isocenter/Arrangement
a. Varian TrueBeam1032 TDS
i. 6MV RAO/RPO 3D-CRT
ii. 10MV VMAT
b. Two isocenters created
i. One for 3D-CRT on the right abdominal wall
ii. One for VMAT in the center between PTV 48.6Gy and PTV 54Gu
c. 3D-CRT
i. Designed to keep dose off bowel bag and deliver 60Gy to gross disease
ii. Used 6 MV energy
1. Superficial tumor volume
iii. Parallel opposed beams at 346° and 163°
1. Limit dose to surrounding OARs
iv. 45° dynamic wedges on both beams
1. Collimator rotation 90°
2. Reduce hot spots
d. VMAT
i. 10 MV energy
 Christina Ong

1. Treating abdomen and liver lymph nodes

ii. 3 full arcs; coplanar
a. Avoidance sectors placed to avoid going through the
section overlapping with the bowel bag in 3D-CRT
XI. Treatment Planning
a. Varian Eclipse IEC
b. Radiation Oncologist submitted planning directive
c. VMAT was proposed at the time of simulation
d. Hybrid Planning was chosen
i. Medical Dosimetrist designed 3D-CRT for superficial abdominal wall and
VMAT for abdomen and liver lymph nodes
e. Plan sum created with both plans
f. Evaluation of DVH
i. Constraints that are met
ii. Constraints that are not met
1. Treatment plan approval note from Radiation Oncologist
g. Compare to VMAT plan
h. ? research article on hybrid planning and its advantages and disadvantages
XII. Quality Assurance/Physics Check
a. Both plans exported to RadCalc
i. MU second check
b. VMAT is scheduled on TrueBeam prior to treatment for QA
i. Discuss QA technique and results
c. MU second checks and VMAT QA approved by physicist
XIII. Conclusion
a. Hybrid technique blends together the benefits of both 3D-CRT and VMAT
treatment planning
i. Patient presented with superficial and centrally-located PTVs with
abnormal anatomical positioning of bowel bag and liver post-op
ii. VMAT  too much bowel bag dose
iii. 3D-CRT  designed to treat superficial tumor volume to 60Gy
b. Things I struggled with
c. Things I learned