Tsai Kevin Tsai May Case Study June 13, 2013 IMRT/SIB for Nasopharyngeal Mass

History of Present Illness: Patient HH is a 56 year-old male presented with a right neck mass. The patient initially saw hematology/oncology on 2/19/2013 for epistaxis (nose bleed). The patient stated that he had been experiencing epistaxis on his right side for 2-3 months. He complained of coughing up coffee colored sputum for the past 4 months. Patient also complained of pain in his nose, right face, and right neck for the past 3-4 months. Tumor growth into the posterior nasal fossa can produce nasal stuffiness, discharge, or epistaxis.1 Patient HH described numbness to his upper lip and also experienced right-sided hearing loss. The orifice of the eustachian tube can be obstructed by a small tumor; ear pain or a unilateral decrease in hearing may occur.1 Past Medical History: Patient HH has a past medical history of Hepatitis C and osteoarthritis. The patient reported no past surgical history as well as no known allergies. Social History: HH worked as a cook but is currently unemployed. He has an elementary level education. He is married and lives with his wife in Chicago. The patient states that he smoked tobacco for more than 20 years but quit about 20 years ago. He denies any alcohol and drug use. HH has no neurological deficit and wears glasses for reading. The patient shared that his father died from liver cancer and his paternal uncle had leukemia. Medications: HH uses the following medications: Ketoprofen gel, ibuprofen, and Tenofovir. Diagnostic Imaging: On 2/26/2013, HH underwent a flexible fiberoptic laryngoscopy. No mass or lesions were found in bilateral nasal cavities. There was a mass found on the right nasopharynx adjacent to the eustachian tube orifice. It was ulcerative but not actively bleeding. No mass was found in the left nasopharynx, oropharynx, hypopharynx, supraglottis, or glottis. A fine needle aspiration was ordered and collected later that day and pathology results suggested nasopharyngeal carcinoma. On 2/28/2013, HH underwent a computed tomography (CT) of the neck with contrast for evaluation. The images showed an expansible mass centered at the superior nasopharynx, destroying the inferior wall of the sphenoid sinus and extending into the sphenoid sinuses. There was also invasion into the right cavernous sinus and orbital apex, with thickening of the right inferior and lateral rectus muscles. Posteriorly there was partial erosion of

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the clivus, and the mass extended to the right posteriorly and abuts the superior portion of the right internal carotid artery. There were also bulky level II and level III lymph nodes bilaterally measuring up to 4.0 x 1.9 centimeters (cm) on the right. This was why patient HH had so many symptoms and complications. Besides assessing neck node metastases, a search for distant metastases was also needed. The most common site of distant metastasis for nasopharyngeal carcinoma is bone, followed closely by lung and liver.1 On 3/20/2013, HH underwent a magnetic resonance imaging (MRI) scan with and without contrast of the abdomen to check for distant metastasis. The liver and pancreas were both normal with no mass. Radiation Oncologist Recommendation: After the radiation oncologist reviewed the patients history and pathology, he recommended HH to receive adjuvant-radiation therapy to the nasopharynx and lymph nodes. Because the nasopharynx is immediately adjacent to the base of the skull, surgical resection with an acceptable margin is impossible therefore making radiation therapy the main treatment for carcinoma of the nasopharynx.1 Due to the proximity of the planning target volume (PTV) to normal and critical structures and to the geometry of the PTV, intensity modulated radiation therapy (IMRT) is used in order to decrease the dose to certain dose-limiting structures while maintaining adequate dose and coverage to the PTV. The goal for this patient was to achieve tumor control while minimizing the risk of both acute and late grade 2+ toxicity. The Plan (Prescription): The initial clinical target volume (CTV) consisted of the tumor and involved nodes with a margin. The PTV included the CTV and a 5-millimeter (mm) margin. The entire PTV was treated to a dose of 6996 centigray (cGy) in 33 fractions at 212 cGy per fraction. The intermediate and low risk nodal volumes were treated to 5940 cGy at 180 cGy per fraction and 5412 cGy at 164 cGy per fraction for 33 fractions each, respectively. The entire plan was also treated with a simultaneous integrated boost (SIB) fractionation technique. Patient Setup / Immobilization: On 5/20/2013, HH underwent a CT simulation scan for this radiation therapy treatment. He was scanned in a supine position on the simulation couch with both arms to his side (Figure 1-3). An Alpha-Cradle was made around his shoulders to prevent any movement. A lite cast (Figure 2) was then created around his chin and forehead to immobilize the patient so he could not move during his treatments. A knee wedge was also inserted under the patients knees for comfort and support (Figure 1-3). Once the patients setup and immobilization had been completed, the radiation therapist put markers and BBs on the

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patient so they could be identified on the scan during treatment planning. The images were sent to the treatment planning system and treatment volumes and normal structures are defined. Anatomical Contouring: After the CT scan was completed, the images were imported into the Eclipse treatment planning system (TPS) for contouring and treatment planning. The radiation oncologist contoured the PTV as well as the intermediate and low risk nodal volumes. Magnetic resonance images were fused with the CT to help identify the tumor and lymph nodes. The medical dosimetrist contoured all the organs at risk (OR), which included the brachial plexus, brain stem, spinal cord, esophagus, cochlea, larynx, eyes, lens, parotid, optic nerves, mandible, oral cavity, and temporal lobe. Once the ORs had been contoured, the medical dosimetrist began the treatment planning process according to the doctors prescription. Beam Isocenter / Arrangement: The isocenter was placed in the center of the entire PTV by the medical dosimetrist. It sat directly in front of the fourth vertebral body and in the middle of the neck (Figure 4-6). The reason the isocenter should be as near to the middle of the PTV as possible is because the multi-leaf collimators (MLCs) are smaller when they are closer to the isocenter. Smaller leaves produce a more smooth and conformal coverage of the PTV. The IMRT plan created for HH utilized 9 complex treatment beams. The 9 IMRT beam angles are 200o, 240o, 280o, 320o, 0o, 40o, 80o, 120o, and 160o (Figure 7-15). The intensity and MLC of each beam angle are all created by the TPS to deliver the desired dose distribution to the target and reduce dose to the critical structures. Treatment Planning: Intensity modulated radiation therapy for this patient was planned using inverse planning technique. The patient was treated on the Varian 21EX linear accelerator equipped with MLC. The prescription for this patient was to deliver 6996 cGy to PTV 1 (Figure 16), 5940 cGy to PTV 2 (Figure 17), and 5412 cGy to PTV 3 (Figure 18). All of the PTVs were combined into one large PTV (Figure 19) and treated simultaneously using 6 megavoltage (MV) energy with daily kilo voltage imaging (kV) for positioning. Dose volume histograms (DVH) were generated and checked by the radiation oncologist (Figure 20). The treatment planning goals for the critical and normal tissues were: the parotid V30 should be less than 50%, spinal cord should have a max dose less than 50 Gray (Gy), and brainstem to have a max dose of less than 54 Gy. The radiation oncologist reviewed the plan and set the plan normalization value to 95.59%.

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Quality Assurance / Physics Check: The monitor units (MU) from the plan were reviewed with another independent software named RadCalc. The Eclipse treatment plan was exported to RadCalc for comparisons and the results came out less than 3%, which was within tolerance. The medical dosimetrist created a verification plan so that the physicist could run an IMRT quality assurance (QA) on the machine to test the fluences of the beam. The medical physicist also reviewed the complete IMRT plan before the patient began his radiation treatment. Conclusion: There were many challenges for the medical dosimetrist when planning IMRT for head and neck tumors. One of the challenges is to cover the entire target with the prescription dose without sacrificing critical structures. The dosimetrist must be familiar with the TD 5/5 of all the OR so that complications can be minimized. In this case, there were 3 PTVs that the radiation oncologist wanted treated and all to a different dose (Figure 21-23). The dosimetrist created 9 treatment beams that were all non-opposing and utilized the optimization feature in the TPS. All of the PTVs in this case were optimized in a single plan instead of two separate plans. The benefit of irradiation with IMRT using SIB approach is that the numbers of fractions are significantly shortened.

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Figures

Figure 1: Patient position at simulation

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Figure 2: Patient position in simulation

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Figure 3: Patient position in simulation

Figure 4: Isocenter placement in the axial view

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Figure 5: Isocenter placement in the frontal view

Figure 6: Isocenter placed in the sagittal view.

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Figure 7: IMRT field sizes automatically determined by Eclipse TPS (Angle 0 degrees)

Figure 8: IMRT field sizes automatically determined by Eclipse TPS (Angle 40 degrees)

Figure 9: IMRT field sizes automatically determined by Eclipse TPS (Angle 80 degrees)

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Figure 10: IMRT field sizes automatically determined by Eclipse TPS (Angle 120 degrees)

Figure 11: IMRT field sizes automatically determined by Eclipse TPS (Angle 160 degrees)

Figure 12: IMRT field sizes automatically determined by Eclipse TPS (Angle 200 degrees)

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Figure 13: IMRT field sizes automatically determined by Eclipse TPS (Angle 240 degrees)

Figure 14: IMRT field sizes automatically determined by Eclipse TPS (Angle 280 degrees)

Figure 15: IMRT field sizes automatically determined by Eclipse TPS (Angle 320 degrees)

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Figure 16: PTV 1

Figure 17: PTV 2

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Figure 18: PTV 3

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Figure 19: PTV ALL

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Figure 20: Dose Volume Histogram (DVH)

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Figure 21: Dose distribution to PTV 1

Figure 22: Dose distribution to PTV 2

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Figure 23: Dose distribution to PTV 3

Tsai 18 References 1.) Chao C, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd ed. PA: Lippincott Williams and Wilkins; 2011:211-225.