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Adriana Dalea
Clinical Practicum I
March 23, 2014
Palliative Treatment for Metastatic Endometrial Cancer Case Study
History of Present Illness: NS is a 74 year old female who was initially diagnosed with
endometrial cancer in 2004. At diagnosis, she already had metastatic disease. She was treated
first with neoadjuvant hormonal therapy, external beam and brachytherapy radiation, followed
by a hysterectomy. She later developed metastases and was treated with systemic chemotherapy,
most recently in January 2014. Her current diagnoses are secondary malignant neoplasms of the
brain and spinal cord and secondary malignant neoplasms of the bone and bone marrow.
Previously, the patient received 4500 cGy external beam radiation therapy to the pelvis, followed
by a tandem and ovoid boost. The upper border of her pelvic field was the L4/L5 interspace. Her
disease was very slowly progressive. The patient was admitted in the hospital on March 5
th
, after
initially presenting to the emergency room with progressive back pain, radiating down to both of
her legs. In addition, the patient complained of tenderness in the lower cervical spine. Her pain
was severe, mostly when moving or trying to get up and walk. She reported difficulties getting to
the bathroom on time to urinate and had a Foley catheter in place. NS had an MRI imaging study
of her spine, and that revealed a lesion to her T12 vertebral body. The patient was seen by the
neurosurgery department and they made a decision not to proceed with surgical excision of her
spine tumor.
Past Medical History: The patient has a history of endometrial cancer as described above,
hypertension and two C sections.
Family History: The patients sister has leukemia. Her mother had cancer and a tumor removed
from her cecum.
Social History: NS is married. She quit smoking cigarettes in 2004. She denies any alcohol use,
or any other illicit drugs.

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Diagnostic Imaging Studies: An MRI exam was performed in March 2014, and it demonstrated
a tumor of the T12 vertebra.
Radiation Oncologist Recommendations: Considering that the neurosurgery department
decided not to proceed with surgical removal of the spine lesion, and based on the overall patient
condition and metastatic disease, the radiation oncologist recommended palliative radiation
targeted to the T12 vertebra, in order to decrease the local symptoms and reduce the pain.
The Plan (Prescription): The radiation oncologist prescribed 3,000 cGy with 10 fractions of
300 cGy each, for an anterior-posterior (AP)/posterior-anterior (PA) plan, 18 MV beam energy,
total of 2 parallel-opposed fields, no blocks to be utilized. The plan was prescribed with
palliative intent.
Patient Setup/Immobilization: For the simulation, the patient was positioned supine on a full
blue pad, arms by the side, a yellow headrest under the head, central axis was 15.5 cm superior
of umbilicus and 1 cm right medial. Computerized tomography (CT) with a large bore CT
simulator was done and the study was sent to the Eclipse Treatment Planning System for
planning. The study included both the thoracic and lumbar spine. No additional custom
immobilization devices were utilized.
Anatomical Contouring: The medical dosimetrist delineated only the external body for this
plan.
Beam Isocenter/Arrangement: Isocenter and markings were placed during the simulation.
Isocenter was placed anterior to the T12 vertebral body. The plan was to treat the patient with 18
MV beam energies, two opposed fields.
Treatment Planning: The planning system used was Varian Eclipse. Two opposed fields were
created, 8 x 10.71 cm size, normalized to deliver 100% of the dose to the isocenter. Both beams
had 18 MV energies and were equally weighted. There were no blocks or MLC used. The
radiation oncologist requested a mid-plane calculation of the dose for this plan. Per the literature,
this is one of the most common approaches in the palliative AP/PA radiation therapy treatment
planning.
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The calculation algorithm was Analytical Anisotropic Algorithm (AAA) with no
heterogeneity correction applied. This approach is demonstrated to give a homogeneous

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distribution of the dose and good coverage of the target.
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Prior to the beginning of the treatment,
this plan was presented, discussed and approved by the radiation oncologist.
Quality Assurance/Physics Check: The Monitor Unit (MU) calculation was checked with
RadCalc and for each field the differences were within the 3% limit for both fields. For the AP
field the percent difference was 0.1%, whereas for the PA field was 0.3%. (Figure 9)
Conclusion: This case study was informative and useful; from a medical dosimetry student point
of view it represents a good learning experience; not using the heterogeneity correction ensured
the homogenous dose distribution to the middle of the treated plane field. Considering the extent
of this patients metastatic disease, the pain and discomfort, the prescribed plan was the best
approach and purpose of palliation was accomplished. The mid-plane dose calculation of two
opposed AP/PA fields delivered a homogeneous dose distribution and this can be observed in
Figures 5, 6 and 7.













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References
1. Barton R, Robinson G, Gutierrez E, Kirkbride P, McLean M. Palliative radiation for
vertebral metastases: the effect of variation in prescription parameters on the dose
received at depth. International Journal of Radiation Oncology*Biology*Physics.
2002;52(4): 1083-1091. http://libweb.uwlax.edu:2092/10.1016/S0360-3016(01)02738-9
Published March 15, 2002. Accessed March 23, 2014.
2. Andic F, Baz Cifci S, Ors Y, et al. A dosimetric comparison of different treatment plans
of palliative spinal bone irradiation: analysis of dose coverage with respect to ICRU 50
report. Journal of Experimental & Clinical Cancer Research. 2009; 28: 2.
http://www.jeccr.com/content/28/1/2 Published January 7, 2009. Accessed March 23,
2014.













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Figures


Figure 1. Isocenter placement in the beam eye view, AP set up DRR with graticule.


Figure 2. Isocenter placement in the beam eye view, PA set up DRR with graticule.

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Figure 3. Isocenter placement in the beam eye view, lateral set up DRR with graticule.


Figure 4. 3D view with beams alignment.


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Figure 5. Isodose lines distribution axial view.


Figure 6. Isodose lines distribution coronal view.

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Figure 7. Isodose lines distribution sagital view.


Figure 8. Dose volume histogram (DVH).

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Figure 9. MU verification with Rad Calc.