1

Amanuel Negussie Clinical Practicum I January 25, 2012

Papillary Thyroid Carcinoma History of Present Illness: DS is a 64 year old male with a left neck mass of thyroid cancer. In October 2012, the patient noticed a left neck mass that was approximately the size of half a baseball. A neck computed tomography (CT) study was performed and demonstrated a mass displacing the trachea and multiple abdominal lymph nodes. A chest CT also showed a mass extending to the mediastinum and multiple lung nodules, four of them with a size over 1 centimeter (cm). The patient also underwent a fine needle biopsy that showed a follicular neoplasm. In December 2012, DS underwent a total thyroidectomy. Operative reports mentioned extensive invasion and necrosis, including four major soft tissue masses in the region of the left thyroidectomy bed, the largest measuring 6.5x3.8x3 cm. The masses demonstrated moderate internal vascularity. No abnormality was seen with the right thyroid. The patient was released with a T3 staging. In January 2013, the patient took a thyroid replacement hormone and radioiodine ablation of 150 millicurie (mCi) of Iodine (I) -131. Past Medical History: DS has a past medical history of hypertension and dyslipidemia. He also had a total thyroidectomy, hormone replacement therapy, and radioiodine ablation. He has no known allergies. Family History: DS has an aunt who was previously diagnosed with Hodgkins lymphoma. Social History: DS is a self-employed individual. He is married and has no children. The patient denies the use of any drug, alcohol, and tobacco. Medication: DS is currently taking Aquaphone Healing Ointment, Decusate, Liothyronine, Sennosides, and Levothyroxine. He also takes Aspirin, Ibuprofen, Oxycodone, and Acetaminophen as needed for his pain. Diagnostic Imaging Studies: In early November, DS underwent a CT and ultrasound procedure that showed a large left thyroid mass extending into left lateral neck and mediastinal lymph nodes. Recommendations: Although the patient had a total thyroidectomy, hormone replacement therapy, and radioiodine ablation, he has a new mass growing in his left neck. For a recurrent

follicular cancer and for thyroid cancer that does not respond to I-131 treatment, external beam radiation treatment may be effective.2 As a result, external beam radiation therapy (EBRT) was recommended to control the new growing tumor. The Plan (Prescription): The radiation oncologists treatment recommendation to DS was three-dimentional (3D) conformal radiation therapy to the left neck mass. The radiation treatment plan was prescribed to 3000 centigray (cGy) at 300 cGy per fraction to the 98% isodose line for 10 fractions. Patient Setup/Immobilization: Patient was simulated supine with his neck extended using an aquaplast mask to immobilize head and shoulders (Figure 1). In addition, he was holding a shoulder strap to push the shoulder out of the treatment field. A Philips large bore 16 slice CT machine was used for the simulation. Head and neck images were taken at 0.3 cm slices. Anatomic Contouring: During simulation, the radiation oncologist put a wire marker on the scar across the neck where the surgery was performed. After the completion of CT scan, the CT slice images were imported to the Pinnacle3 9.0 radiation treatment planning system (TPS). The radiation oncologist then contoured the gross tumor volume (GTV) and planning target volume (PTV) on the TPS. Afterward, the certified medical dosimetrist (CMD) contoured the wire marker along with the body, left mastoid, spinal cord, mediastinum, trachea, vocal cords, and lips. Beam Isocenter/Arrangement: A Varian 21 IX 3994 linear accelerator (Linac) machine was used to treat the patient. The CMD placed a new calculation point within the GTV, because the isocenter placed by the radiation oncologist was close to the right field border. A two fields, anterior/posterior (AP) and posterior/anterior (PA), field arrangement was used. Gantry rotation was set at 0o for the AP and 180o for the PA, and the collimator was set at 0o for both fields. The AP field consisted of 6 megavolt (MV) and the PA consisted 18 MV beam energy. Treatment Planning: Each field has a multileaf collimator (MLC) blocking pattern which was constructed by the physician to define the treatment field. An enhanced dynamic wedge (EDW) of 15o was used on both treatment fields to account for the curvature of the neck, and reduce dose to the thinner part of the neck. Both the AP and PA fields were weighed proportional, 50% each. The plan was completed with a total monitor unit (MU) of 445, maximum dose of 3144.9 and a hot spot of 4% located within the GTV. Monitor Unit Check: The MU check was performed on MUcheck8.2.0 software. At our clinical site, a 3% deviation in MU is the tolerance for any 3DCRT plans. Anything outside this range

needs to be recalculated and fixed by the dosimetrists or physicists prior to treatment. The plan was approved with a 0.5% difference on the AP and -0.3% difference on the PA. Quality Assurance Checks: The treatment plan was later checked and approved by the radiation oncologist and medical physicist before the patient started his treatment. Conclusion: The challenge I faced when observing this treatment plan was understanding why the prescription was not calculated at the simulation isocenter (sim iso). However, after reviewing the International Committee on Radiation Units and Measurement (ICRU) 50 report, it was clear to me that a calculation point can be placed within the field if the sim iso is blocked or close to the field borders. According to the ICRU 50 report,1 a reference point should be clinically relevant and easy to define. It also suggests that the point should be selected where it should be accurately determined and cannot be affected by a steep dose gradient.1

Figures

Figure 1: Aquaplast immobilization mask

Figure 2: 3D AP and PA beam arrangement

Figure 3: Beams eye view (BEV) of the AP field

Figure 4: Beam and wedge arrangements

Figure 5: transverse, coronal, and sagittal view of dose distribution

Figure 6: Dose Volume Histogram (DVH)

10

References 1. ICRU Report 50. Prescribing, Recording, and Reporting, Photon Beam Therapy. Bethesda, MD.1993: 29-30. 2. Perez CA, Halperin EC, Brady LW. Principle & Practice of Radiation Oncology. 4th ed. U.S.A. Lippincott Williams &Wilkins; 2004: 1189-1190.