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Teri Burrier
April Case Study
April 4, 2018
SBRT Planning for Treatment of the Right Lung
History of Present Illness: The patient, RC, is an 82 year-old male who, in May 2017, began
coughing up small amounts of blood in the morning. In addition, he was experiencing an
increased shortness of breath upon exertion, which caused him to have difficulty walking long
distances. A PET/CT was performed on June 28, 2017 that showed a 2-cm hypermetabolic right
middle lobe lesion. Due to the findings, a biopsy was recommended to determine pathology; and
this was delayed until October per the patient’s request. On October 24, 2017, a bronchoscopy
with biopsy was performed. The majority of the cells obtained from this biopsy were benign
respiratory epithelial cells, with no malignant cells identified. No diagnosis could be made from
the biopsy obtained, so further testing was done on November 11, 2017, via a CT-guided core
needle biopsy. The pathology from this sampling was positive for adenocarcinoma and a second
PET/CT was ordered for restaging. The second PET/CT was performed on December 8, 2017,
and showed no evidence of metastatic disease, so the patient was referred to a thoracic surgeon
for a surgical consultation.
The patient met with a thoracic surgeon on December 12, 2017. After a review of the
patient’s physical condition, it was determined that RC would be a very high-risk surgical
candidate due to his multiple medical comorbidities, including COPD and a severe aortic
stenosis. Since the patient was not a surgical candidate, the surgeon recommended the patient
consider radiation therapy as an alternate treatment option, which the patient was agreeable to.
On December 21, 2017, RC met with a radiation oncologist to discuss his treatment options.
Both conventional and stereotactic body radiation therapy (SBRT) were explained to the patient,
with the radiation oncologist recommending SBRT to a total dose of 50Gy delivered in 5
fractions for a greater chance of local control.
Past Medical History: The patient presented with a significant past medical history, including
that of esophageal cancer from an unknown date 20 years ago. The cancer was removed
surgically via laparotomy, and no radiation was given to the thorax at that time. A history of
aortic stenosis was also noted, which the patient was being evaluated for prior to the lung cancer
diagnosis. He is a candidate for a transcatheter aortic valve replacement (TAVR) procedure;
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however, it was recommended that he seek treatment for his known lung mass prior to having
this done. The patient’s history also includes hypertension, reflux, and COPD. Of these, the
patient noted that the COPD causes him the most distress and requires the use of multiple
inhalers.
Social History: RC is retired from the army where he worked as a helicopter pilot. He is
married with one son, who also has a history of lung cancer. The patient is a cigarette smoker
and has smoked a pack a day for the last 65 years. According to the Centers for Disease Control
and Prevention,1 smoking is the number 1 risk factor for lung cancer and is linked to 80% to 90%
of all lung cancer cases. RC also reported that he was previously a heavy drinker; however, he
quit 20 years ago after his esophageal cancer diagnosis. The patient noted having siblings with
cancer, including a brother with lung cancer of unknown histology and a sister with brain cancer.
Medications: The patient reported using the following medications at the time of his consult:
Albuterol, Aspirin, Lipitor, Lisinopril, Lopressor, Omeprazole, Singulair, and Spiriva.
Diagnostic Imaging: The patient’s initial PET/CT scan on June 28, 2017, showed a 2-cm right
middle lobe lesion that was highly suspicious for malignancy. A CT angio of the abdomen and
pelvis was done on September 25, 2017, for evaluation of the pelvic vessels for the purpose of
TAVR planning. The radiologist noted the mass seen in the right middle lobe in the report and
commented that no metastatic disease could be seen in the abdomen or pelvis.
A bronchoscopy was performed under fluoroscopic guidance on October 24, 2017;
however, the results were inconclusive, and a CT-guided biopsy, which was positive for
adenocarcinoma, was obtained under local anesthetic on November 17, 2017. A chest x-ray was
obtained following both the bronchoscopy and CT-guided needle biopsy to ensure the patient
had not developed a pneumothorax post procedure. Both CTs were negative for pneumothorax.
A final PET/CT scan was ordered for restaging and was performed on December 8, 2017.
This scan revealed the right middle lobe mass had grown more than 3 cm from the prior PET/CT
done in June and now measured 5.2 cm. No metastatic disease was noted, classifying the disease
as T2 N0 M0.
Radiation Oncologist Recommendations: Statistically, surgery is the treatment of choice for
non-small cell lung cancer with a lobectomy or pneumonectomy of centrally located (T1 or T2)
stage 1lesions, resulting in a 60-70% 5-year survival rate.2 Unfortunately, RC was not a surgical
candidate due to his medical comorbidities and was referred for radiation therapy as an alternate
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treatment option. Conventional therapy for non-small cell lung cancer is typically delivered to a
dose of 50-66Gy in 1.8-2.5Gy a fraction over a course of 6-7 weeks.2 According to Bezjak and
Bradley et al,2 conventional therapy has inferior results when compared to surgical interventions,
with 5-year survival rates ranging from 10-30%. The recommendation for the patient to receive a
dose of 50Gy in 5 fractions utilizing SBRT was based on the improved chance of local control
that is achieved when delivering the prescribed dose over a shorter period. According to a study
by Onishi and Shirato et al,3 SBRT can have similar results to surgery with 5-year local control
rates for T1 tumors at 92% and T2 tumors at 73%.
The Plan (prescription): The patient was prescribed a total of 50Gy in 5 fractions using
intensity modulated radiation therapy (IMRT). A cone beam CT (CBCT) was requested prior to
each treatment in order to ensure accurate alignment of the target volume. Before planning of a
patient can begin, all necessary immobilization devices must be created and a special treatment
planning CT must be done. The CT simulation appointment for RC was scheduled for December
22, 2017, with an anticipated start date of January 3, 2018, and a completion date of January 12,
2018.
Patient Setup/Immobilization: For immobilization a Civco Body Pro-Lok device was used,
which consists of a long carbon-fiber board with multiple attachment points. A wing board was
placed on the superior portion of the board with a headrest. A large vaclok, which would be
molded around the patient to help maintain a consistent position for daily treatment, was placed
over the headrest and down the length of the board. Before the patient laid down on the board, a
respiratory gating belt was placed around his abdomen to monitor his respirations during the
scan. After the patient was recumbent, a knee sponge was placed under the patient’s knees and
indexed in place. The patient needed to be simulated with his arms up due to the location of the
tumor, so he was asked to hold the handles that were attached to the wingboard above his head.
At this point the vaclok bag was molded around him, and the air was removed so it would retain
the same shape until it was re-inflated after the patient completed his treatments. A Clam-Lok
cushion was placed over the distal femurs and attached to the board in order to restrict movement
and maintain a consistent treatment position. Finally, a compression belt was placed over the
patient’s abdomen to slightly limit his ability to take in deep breaths and limit tumor movement
with respiration.
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The locations of all devices were recorded for reproducibility, and external marks were
placed on the patient’s skin for set-up purposes. A 4-D CT scan was obtained with the patient in
the treatment position. For this scan a radiation therapist, physicist, and dosimetrist were present
to ensure proper immobilization was used and correct parameters were selected for the scan. The
patient’s breathing was assessed prior to the start of the scan to ensure consistency, and once
appropriate, the gated scan was obtained.
Anatomical Contouring: After the CT scan was completed, it was imported into the Varian
Eclipse treatment planning system, and the images were registered with the PET/CT scan from
December 8, 2017, to aid in the contouring of the treatment volume. The physician used the
gated images from the treatment planning CT, which demonstrated the range of motion of the
tumor during respiration as well as the images from the PET/CT to ensure proper contouring of
the ITV and PTV structures. The physician also contoured the right bronchial tree, which was
very close in proximity to the PTV volume.
The dosimetrist was responsible for contouring the remaining normal structures. These
structures included right and left lungs, heart, esophagus, descending aorta, chest wall, skin, and
spinal cord. Also necessary for IMRT planning is the construction of optimization structures,
which allow dose to be manipulated within the plan. For this particular plan, optimization
structures were created for the bronchial tree, heart, right lung, total lung, as well as a ring
structure that would be used to help control dose around the PTV.
Beam Isocenter/Arrangement: The patient received his treatment on a Varian Trilogy linear
accelerator with a 6MV Rapid Arc treatment plan. For Rapid Arc SBRT treatments, volumetric
modulated arc therapy (VMAT) planning is used. This type of planning combines inverse
planning, intensity modulation, and arc therapy for treatment delivery, allowing for simultaneous
multileaf-collimation and gantry movement, providing optimal dose distributions.4
Two half-beam rotations were selected for treatment with angles rotating from 0 to 181
degrees and back again along the patient’s right side. A collimator rotation was also necessary,
and a 30-degree rotation was used for each beam, resulting in a 30-degree collimator angle for
the first arc and a 330-degree rotation for the second arc. These changes allowed the MLCs to
better conform to the tumor volume, helping to create a tighter margin and decreased dose to
healthy lung tissue. The half beam rotations were chosen to help limit dose to the left lung by
only having entrance dose on the right side of the patient’s body. After the beam angles were
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selected, the isocenter was placed in the center of the PTV volume to provide uniform coverage
during the arc treatment.
Treatment Planning: The VMAT treatment planning for this patient was performed using
Varian Eclipse version 11.0 treatment planning software, and RTOG 0813 was referenced for
fractionation and dose constraints. RC’s lung tumor is considered to be a centrally located tumor
because it is less than 2cm from the proximal bronchial tree. Due to its central location, a
smaller than 5-fraction delivery was not recommended and the prescription was written for 50Gy
in 5 fractions. An advantage to SBRT treatments using arc therapy is the conformal coverage that
can be obtained while also limiting dose to surrounding structures.
Optimization structures are created and used within a plan to help achieve optimal dose
distribution. For RC’s plan, a ring was created that placed a 1-cm margin around the PTV in
order to help confine dose to within this volume. Two critical structures were included within
the expanded 1-cm margin, the heart and bronchial tree. Portions of the bronchial tree were also
included within the PTV volume, so two new structures were created that separated the bronchial
tree into two parts, inside and outside the PTV. Separating the structures in this manner allows
the dosimetrist greater control over how dose is distributed throughout the organ. A separate
heart contour was also made that cropped the heart away from the ring, allowing a lower dose
limit to be put on the heart outside the volume being treated and affectively lowering the overall
dose to the organ. All critical structures located within the PTV volume are allowed to receive
prescription dose so that coverage is not compromised; however, none of the critical structure
should receive over 105% of the prescription.
A final 2-cm ring was placed around the volume to evaluate the dose fall off. Ideally, the
50% isodose line should be kept as tight as possible to the PTV volume. Having all of the 50%
isodose line within the 2-cm ring was almost completely achieved with this plan, significantly
reducing the dose to surrounding lung tissue.
All dose constraints were met for this patient using the SBRT treatment method. The V20
for the total lung sub PTV should be kept below 10% and for this plan the V20 was 8.2%. The
average dose to the heart was 5.2Gy, and the average dose to the bronchial tree was 21.6%.
Minimum dose to the PTV was 93.3% and 95% of the volume was covered by the prescription
dose. Other critical structures that should be considered when treating with SBRT include the
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great vessels and brachial plexus; however, due to the location of RC’s tumor, these structures
were not of concern.
Quality Assurance/Physics Check: The first quality assurance check for SBRT treatments is
done by dosimetry by means of a mu second check using a program called IMSure. Plan data is
exported to this software, where a separate calculation is done to verify the mu that will be
delivered. The difference in mu must be below 5% or the plan must be reviewed to determine
why. With RC’s second check calculation the deviation in the two beams was 0.1% and 1.8%.
After this verification is done by dosimetry, physics copies the plan into a separate course that
they use to export the beam data to the treatment machine in order to perform a final QA check.
This check is done using MapCheck, a diode array from Sun Nuclear. The MapCheck device is
placed on the treatment table while the beam is delivered and provides physics with an absolute
dose measurement as well as a beam fluence information. The deviation from this third check
was 3%, which is below the 5% limit for treatment. The plan was reviewed, along with both sets
of second checks, and the plan was approved by physics, so the patient could be scheduled for
treatment.
Conclusion: Stereotactic body radiation therapy is an appropriate form of treatment for those
with inoperable lung cancer. With SBRT treatments it is possible to deliver the prescription dose
to a tumor volume in a shorter time frame, which has been shown to increase long-term survival
compared to standard fractionation. This case study helped me to better understand how an
SBRT plan is created and how optimization structures can be utilized to achieve the dose
distribution that is most desirable. Having SBRT as a treatment option for our patients is truly an
advantage because the volume of lung receiving lower doses is minimized, which is critical for
patients, like RC, who have COPD and other lung problems.
I have not performed a lot of treatment planning using our VMAT software, and I feel
that this is a weakness of mine. Since doing the research for this case study, I feel I have a better
understanding of what structures are necessary for the planning of SBRT patients; however, I do
not fully understand how to adjust the lower and upper constraints within the software to perfect
the dose distribution. I look forward to learning more about this in the upcoming months as I
progress through my clinical practicum.
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References
1. What are the risk factors for lung cancer? Centers for Disease Control and Prevention Web
site. https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm. Updated May 31, 2017.
Accessed March 18, 2018.
2. Bezjak A, Bradley J, Gaspar L, et al. Seamless phase I/II study of stereotactic lung
radiotherapy (SBRT) for early stage, centrally located, non-small cell lung cancer (NSCLC) in
medically inoperable patients. Radiation Therapy Oncology Group (RTOG). Published 2012.
Accessed March 20, 2018.
3. Onishi H, Shirato H, Nagata Y, et al. Stereotactic body radiotherapy (SBRT) for operable
stage I non-small-cell lung cancer: can SBRT be comparable to surgery? Int J Radiat Oncol Biol
Phys. December 2011;81(5):1352-1358. http://dx.doi.org/10.1016/j.ijrobp.2009.07.1751
4. Chen H, Craft DL, Gierga DP. Multi criteria optimization informed VMAT planning. Med
Dosim. Spring 2014; 39(1):64-73. https://dx.doi.org/10.1016/j.meddos.2013.10.001
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Figures

Figure 1. Full body image showing patient on Body Pro-Lok Board

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Figure 2. Superior view showing patient’s arm and hand position.

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Figure 3. Anterior/Posterior digitally reconstructed radiograph indicating isocenter placement.

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Figure 4. Right lateral digitally reconstructed radiograph indicating isocenter placement.

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Figure 5. Axial view of VMAT plan showing direction and orientation of the two arc beams.
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Figure 6. Coronal view of VMAT plan showing isodose distribution.

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Figure 7. Sagittal view showing isodose distribution tightly surrounding PTV volume.
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Figure 8. Dose constraints from RTOG 0813 protocol.

Figure 9. Dose constraints continued from RTOG 0813 protocol.

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Figure 10. Excel spreadsheet showing the planning parameters were met.

Figure 11. Dose volume histogram showing the organs of greatest interest and PTV for RC’s
SBRT treatment.