Phillip Ihaza

Clinical Radiotherapy
6/15/14

Case Study

1. General patient information and brief medical history (gender, age, medical/social history
relevant to diagnosis)
The patient is a 64 year old Caucasian female born on 12/25/1949. The patient is 5 4 94 lbs. The
patient has previous breast cancer and previous cancer of the left forehead/ left eyebrow. The patient
has not had any previous radiation therapy or chemotherapy. Neither has the patient had any hormonal
therapy. The patient has had a bilateral mastectomy on November of 2008 or 2009. The patient is single
living in her own home with a good support network by her account. She has a 20 year history of 1 pack
per day cigarette use but quit both tobacco and alcohol in 1982. She has no illicit drug history.

2. Presenting signs/symptoms of patient

There is a dense paralysis of the right cranial nerve facial nerve with the complete soothing of the brow,
inability to completely close the right eye, flattening of the nasolabial fold, and immobile and drooping
right side mouth. The patient has an inability to perform an upward gaze and an upward inward gaze.

3. Diagnostic/clinical detection and work up:

(imaging procedures, lab biopsy, surgery)
The patient has not had radiologic studies since 2/19/2014 at which time she had a MRI scan as well as a
CT scan of the orbits which show the mass in the left orbit in the region of the medial canthus with
adjacent bone and encasement of the superior oblique muscle. An MRI scan of the neck was done in
10/2013 as part of her facial nerve workup was unremarkable. Temporal bone CT was also negative at
that time.
4. Diagnosis: (Histopathology, staging, grading)
Squamous cell carcinoma of the left orbit/left ethmoid sinus status post gross total resection with bone
invasion and positive margins, pathologic stage pT4NxM0.
5. Adjuvant Therapies: (surgery, Chemotherapy, Immunotherapy)
The patient had a dermatologic Mohs surgery of the left forehead/ left brow region. The patient also
had a complex procedure including a parotidectomy and a facial nerve dissection and exploration with

mastoidectomy and infratemporal facial nerve decompression at the infralabyrinthine segment and
stylomastoid foramen for a right facial nerve palsy.
The patient is also having chemotherapy concurrently.
6. Dose, fractionation scheme, treatment modality, beam arrangement, reduced/cone down
fields, etc.
The dose is 5040 cGy with a conventional fractionation scheme of 28 fractions with a daily dose of 150
cGy. The is followed by boost of 1620 cGy with 9 fractions with a daily dose of 180 cGy.
7. Planning simulation/localization procedures: (immobilization devices, beam alignment,
anatomical borders, patient positioning, field sizes, target volumes, contrast media, skin
markers/tattoo.)
The simulation set up is a C headrest with a customized aquaplast mask made during simulation. Also a
knee sponge and T straps to bring the shoulders down. The patient is supine with their arms by their
side with the help of the T straps. No contrast due to the patient being highly allergic to iodine. And no
skin markers or tattoos, all markers are put on the mask.
8. Description of field borders in relation to bony anatomy, lymphatics (routes of spread), and
critical organs in treatment fields).
The superior border of the field is the supraorbital margin. The inferior border is the middle of the
maxillary sinus. The field border extends from the middle of the right ethmoid sinus to the middle of the
left eye, and posteriorly through the middle of the sphenoid sinus.
The critical organs in the treatment field is the left eye, the retina of the left eye, the left optic nerve,
and the brain.
9. Treatment Unit Information: ( the patient will be treated using treatment type, stationary,
fixed field, arc, IMRT, SRS, number of ports, beam energy, beam alignment, treatment/gantry
angles, modifying devices, couch angle, etc.
The patient is prescribed for an initial course of 28 fractions, each of 180 cGy, to 5040 cGy using IMRT.
An IMRT plan was then generated and approved using RapidArc with normalization to affect 95%
coverage with 100% dose.
There are 9 ports, RPO 225, RAO 330, RASO 330.6, RAPO 340, AP 0, LAIO 19.5, LAO 75 (couch angle , Lt.
LAT 90, LPO 135 (couch angle 30). The beam energy is 6x.
10. Explanation of treatment rationale for planning and field verification techniques:
The treatment plan prescribed is IMRT. IMRT allows the for a more dose to a more defined tumor
volume. Because the area of treatment is the orbit this is preferred because the there are critical organs
in the field such as the brain which can only take a certain dose. Also when dealing with that area you
have to worry about effect nerve cells like the optic nerve. And nerves dont not regenerate so once a
nerve is damaged it is damaged for good. So it is very important to avoid these OARs.
11. Organs at risk (OARs) and Tolerance Doses:

Brain 5000 cGy

Optic nerve 5000 cGy
Optic chiasm 5000 cGy
Lens of the eye 500 cGy
Retina of the eye 6000 CgY

12. Acute and chronic possible radiation side effects/ complications and patient education
strategies for prevention, healing and comfort:
The main concern with radiation therapy is damage to parts of the eye, leading to problems such as
cataracts, retinal detachment, glaucoma, or bleeding into the eye. These can result in partial or
complete loss of vision or other problems, which may not happen right away.
A few other side effects include dry eye
Loss of eye movements
13. Critical Thinking: Reflection of your interactions with the patient/family, clinical instructor(s),
issues and concerns:
The patient is very conservative and reserve. But at the same time she is very polite. She comes in and
greets everyone with a good morning and thats as far as the conversation goes. I believe that the
patient lacks confidence due to the various facial surgeries that she has had. Therefore she is very quiet
and soft spoken.
14. Proper citation of references using APA format.

1) Georgetown University Hospital Medical chart, retrieved on June 19, 2014

2) Eye cancer. (n.d.). Retrieved from

http://www.cancer.org/cancer/eyecancer/detailedguide/eyecancer-what-is-eye-cancer