Jackie Palermino

Dos 531 Clinical Oncology

February 25, 2018

Clinical Oncology Assignment

Directions: Divide the following anatomical areas amongst your group members and
complete the following assignment. For groups with 4 members you may choose 2 primary
tumors in the same area (head and neck, chest, or pelvis) but they should not be the same
tumor site.

 Primary Head and Neck with lymph nodes

 Primary Lung/Mediastinum or Breast/chest wall with lymph nodes

 Primary Pelvis (any tumor found below L4-L5) with lymph nodes

Find a case in your clinic that you have worked on, or are working on, to research and answer
the corresponding questions (Note: this can be a case that your clinical instructor is planning
or planned but you observed/participated). Please include any references and helpful
screenshots to describe your rationale and to explain the treatment plan design and process.

For this assignment, I chose to review a Primary Lung/Mediastinum case with lymph nodal
involvement of the Right Lung/Mediastinum. The patient was diagnosed with Stage IIIA (T3 N2
M0) adenocarcinoma of the right lower lobe. Lymph nodal involvement of the subcarinal and
right paratracheal regions were positive for adenocarcinoma of the lung primary. The staging
for this patient is classified as T3, N2, M0 because of the size, location, and extent of the
disease. In the case of this patient, there were 2 separate tumor nodules (3.2 x 2.2 cm and 1.6 x
1.5 cm) found in the same lobe of the lung which classifies it as T3. The cancer spread to lymph
nodes around the carina and right paratracheal regions located on the same side as the primary
lung tumor classifying it as N2. At the time of diagnosis, there was no appearance of distant
metastasis (M0).1

Questions:
1. How was this patient positioned for simulation? What positioning devices/accessories
were used, how and why? (5 points)
For this case, the patient is laying in the supine position (on patients back), with his arms
over his head in an alpha cradle, a knee fix under his knees, and his feet rubber banded. An
 alpha cradle is an immobilization device that is made of liquid styrofoam. In making this
device, chemicals are mixed together to form a chemical reaction that allows for the
expansion of the material. Once the reaction is completed the chemicals harden to conform
around the patient's anatomy. The alpha cradle is used to support the patient's arms and
make sure the patient's arms are in the same position every day for treatment. Another
reason for the use of an alpha cradle is to make sure the arms are out of treatment field
area because we do not want to treat or give any dose to the patient's arms. A knee fix was
placed under the patient's knees to help with comfort and to relieve pressure off the
patients back. The rubber band around his feet helped to remind the patient to hold still
during the treatment. It is also used to keep the patient's feet in a neutral position so the
patient does not cross their feet causing them to roll or twist in any direction.

2. Discuss the target dose as defined by your physician and the rationale behind the total
dose and fractionation regimen. Include any references or current research to help
answer the question. (5 points)
The patient is receiving radiation treatments to his mediastinum and the lower lobe of his
right lung. The physician prescribed to a volume using 6MV energy and a 9-field IMRT
(intensity-modulated radiation therapy) technique with a simultaneous integrated boost
(SIB). The physician prescribed to two dose levels using a SIB to deliver a higher dose to the
primary disease or gross tumor volume (GTV_ITV) and a lower dose to the planning target
volume (PTV) or subclinical disease and the surrounding region of interest.2 The
recommended radiation dose for a patient with inoperable locally advanced NSCLC (Stage
IIIa or IIIB) is 60-70 Gy to the planning target volume (PTV) in 2 Gy/fraction/day, or 60-63 Gy
 to the PTV in 1.8-2 Gy/fraction/day plus an SIB to the GTV_ITV of 70 Gy in 2-2.2
Gy/fraction/day with concurrent chemotherapy.3 This type of technique helps to maintain a
tolerable dose to surrounding critical structures, while still delivering a high dose to the
gross tumor volume. The PTV volume for this patient's plan is prescribed to receive a total
dose of 60 Gy, while the GTV_ITV will receive a higher prescribed dose of 70 Gy. The
physician used conventional fractionation with a daily dose of 2 Gy to the PTV and 2.33 Gy
to the GTV_ITV for 30 fractions.

3. What specific avoidance structures were contoured? Include a screen shot of your
contoured target and organs at risk. Create and embed a table of OAR tolerance doses
based on your physician prescription and include any associated QUANTEC values. List
the contraindications if tolerance doses were to be exceeded. (20 points)
The critical structures within the area of treatment for this case that were contoured
include the spinal cord, aorta, and esophagus. The heart, trachea, proximal broncial tree,
and the total lung volume for both lungs minus the ITV volume were also contoured. In the
image below, the PTV is colorwashed in blue and the GTV_ITV is colorwashed in red.

Organs at Risk (OAR) Desired Planning Objective Planning Objective Contradictions

Outcome
Spinal Cord Max 50 Gy (QUANTEC) Max Dose 35.8 Gy Myelopathy
Aorta Max Dose ≤ 90 Gy (Clinical Site) Max Dose 71.9 Gy *Only listed for
SBRT/SRS
Fractionation*
Esophagus V50 <40% (QUANTEC) 39.30% Grade 2+
esophagitis
Heart Mean Dose <26 Gy (QUANTEC) Mean Dose 16.5 Gy Pericarditis
Trachea Max Dose ≤ 90 Gy (Clinical Site) Max Dose 73.8 Gy *Only listed for
SBRT/SRS
Fractionation*

Proximal Bronchial Max 80 Gy (QUANTEC) Max Dose 77.4 Gy *Only listed for
Tree SBRT/SRS
Fractionation*

Lungs-ITV V20 < 30-35% (QUANTEC) 36.20% Pneumonitis

4. Identify any involved lymph nodes in your treatment region. Embed a screen shot of the
nodal regions with corresponding labels. (15 points)
The lymph nodal regions that are involved in the treatment region include the right
paratracheal nodes and the subcarinal nodes. Below is a diagram4 of the regional lymph
nodes of the lung as well as a screenshot from multiple slices of the patient's plan showing
the nodal region included in the GTV.
 Figure 1. Regional Lymph Nodes of the Lung4

5. Use your IMAIOS Subscription: http://www.imaios.com/en and other anatomy references

to describe the anatomical “boundaries” (physical limits) of the area treated. Embed a
diagram and/or screen shot of your CT data to point out the boundaries. (20 points)
Due to this patient’s history and staging, the patient is not a good surgical candidate. The
patient is receiving concurrent chemotherapy and radiation therapy. For treatment
planning, physicians and dosimetrists use specific target volumes and margins to create the
best treatment. These target volumes consist of GTV, ITV, CTV, and PTV. Initially, the
physician contours the gross tumor volume (GTV) which includes the tumor volume that
was seen on the PET/CT imaging. The ITV volume provides a margin around the GTV with
the additional margin taking into account respiratory motion. With improved technology,
physicians are able to use the respiratory phases from 4-dimensional CT scans to monitor
tumor motion and make adjustments to the planning volumes. According to Vaporciyan et
al,5 the use of 3D measurements for lung tumor motion demonstrates that every tumor
moves at least 5 mm with respiration, but the motion from any angle will be less than 5 mm
for about one-third of lung cancer patients. The clinical target volume (CTV) is then created
to encompass any possible microscopic disease as well as lymph node involvement. An
expansion of 6 mm-8 mm from the GTV to the CTV is commonly used to ensure adequate
coverage.5 The PTV volume is the planning target volume which is an expansion of the CTV.
This volume considers all possible motion, whether it may be caused from respiratory
motion or through setup uncertainty, of the tumor volume and any possible microscopic
disease or lymph node involvement.
For this patient, the treatment is delivered to the primary tumor located in the right lower
lobe and the right paratracheal and subcarinal lymph nodes. The treatment fields extend
superiorly from approximately the T1-T2 vertebral bodies and inferiorly to approximately
the T12 vertebral body, just superior to the diaphragm.
In the images below, the GTV is bright green, ITV is red, CTV is yellow-green, and PTV is
blue. The tumor volume determined from this patients PET scan is contoured as the GTV.
The ITV volume is an additional margin around the GTV that accounts for respiratory
motion. The CTV volume includes an additional margin around the ITV for any microscopic
disease and to make sure all lymph nodes in the immediate area are included for treatment.
The PTV is planning target volume that has an additional margin on the CTV. This planning
target volume accounts for setup error or patient movement.
The outline of the PTV is contoured in blue and the yellow contour outline shows the location
of the carina.

6. Describe, in detail, the radiation treatment technique used to treat this anatomical
region. (20 points)

 Examples: Technique type (VMAT, IMRT, Conformal), VMAT-Number of arcs,

their direction, collimator rotations, number of degrees. Beam angles, couch
rotations, field design, wedges, use of split fields, etc. Include all specific setup
information to describe your process. Include any screen shots to help
describe your plan design.
This patient's treatment consisted of using an IMRT technique which consisted of 9
beams. The gantry angles for beam placement were spaced out 25 degrees from one
another. The gantry angles were 175°, 15°, 350°, 325°, 300°, 275°, 250°, 225°, and 200°.
There was no use of any collimator or pedestal angles. This beam arrangement allowed
for the radiation to be directed only towards the affected right side of the patient while
sparing as much dose as possible to the left lung. The use of MLCs (multi-leaf
collimators) were used for blocking and to form the shapes of the treatment fields. This
helped to deliver the radiation to the areas of interest and limit the dose to any organs
at risk.
Beam orientation-(25 degrees apart from one another)

Example of MLCs used for the RPO_200 (gantry angle). The MLCs are filled in to show
the blocking and field shape throughout each segment of this beam.
7. Include a final DVH of your treatment plan with appropriate labels and discuss your
ability to meet the target and OAR tolerance guidelines. (15 Points)
The final plan consisted of 95.2% of the PTV volume receiving 100% of the prescribed dose (60
Gy) and 97.7% of the GTV_ITV volume receiving 100% of the prescribed dose (70 Gy). We used
objective constraints to limit the amount of dose to certain structures. By assigning each ROI
(structure) a specific objective type (i.e. Min Dose, Max Dose, Max DVH), dose limit in cGy, and
weighting factor, we were able to achieve our tolerance limits through optimizing the plan. We
achieved the minimal dose requirement for both target volumes while keeping our critical
structures (OARs) under the maximum dose tolerance limits. The OARs were all within
tolerance limits except the Lungs-ITV. It was slightly over its limit of 35%, with a total of 36.2%
for a volume receiving 20 Gy. The physician reviewed this case and accepted the plan as it was
planned because when we tried to raise the constraint on the Lungs-ITV, the coverage of the
PTV and GTV_ITV decreased. The physician felt it would better for the patient to have better
coverage of the tumor then to minimize dose to the Lungs-ITV.
Some examples of the objective constraints that were used to help optimize our plan are shown
below.
References
1. Non-Small Cell Lung Cancer stages. American Cancer Society Web site.
https://www.cancer.org/cancer/non-small-cell-lung-cancer/detection-diagnosis-
staging/staging.html. Accessed February 19, 2018.
2. Ji K, Zhao LJ, Liu WS, et al. Simultaneous integrated boost intensity-modulated
radiotherapy for treatment of locally advanced non-small cell lung cancer: a
retrospective clinical study. The British Journal of Radiology. 2014;87(1035):20130562.
doi: 10.1256/bjr.20130562.
3. Selek U, Bölükbaşı Y, Welsh JW, Topkan E. Intensity-modulated radiotherapy versus 3-
dimensional conformal radiotherapy strategies for locally advanced non-small cell lung
cancer. Balkan Medical Journal. 2014;31(4):286-294.
doi:10.5152/balkanmedj.2014.14529.
4. Rusch VW, Asamura H, Watanabe H, et al. The IASLC lung cancer staging project: A
proposal for a new international lymph node map in the forthcoming seventh edition of
the TNM classification for lung cancer. Journal of Thoracic Oncology. 2009;4(5):568-577.
doi:10.1097/JTO.0b013e3181a0d82e
5. Vaporciyan AA, Kies MS, Stevens CQ, et al. Therapy for NSCLC. In: Kufe DW, Pollock RE,
Weichselbaum RR, et al., eds. Holland-Frei Cancer Medicine. 6th ed. Hamilton, ON: BC
Decker;2003. Available from: https://www.ncbi.nlm.nih.gov/books/NBK13752/