1

Heather Maurer
February Case Study
February 22, 2014
Parallel Opposed Fields for Whole Brain Radiation Therapy
History of Present Illness: Patient DH is a 48 year old male with a history of melanoma as of
November 2011 with recent metastatic disease including multiple brain metastases. The initial
diagnosis of Melanoma in November 2011 was confirmed with a biopsy of a left chest lesion
showing melanoma with ulceration and satellitosis with an 11 mm Breslow depth. Breslow is a
classification system for melanoma based on the depth of penetration.
1
On December 15, 2011
DH underwent a wide local excision (WLE) and left axillary lymph node dissection (ALND)
with pathology showing residual well circumcised deep dermal melanoma, negative margins,
and 2 out of 29 lymph nodes positive. DH received treatment with high dose Interferon starting
in February 2012 and states they were doing well for nearly two years when increased fatigued
started in early 2014. In January 2014 DH received a CT of the chest, abdomen, and pelvis
showing multiple bilateral pulmonary nodules, retroperitoneal nodes, and metastases to the
adrenal gland and gallbladder. There was also a biopsy of a scalp lesion showing melanoma. A
Brain Magnetic Resonance Imaging (MRI) was performed on February 1, 2014 which revealed
the presence of multiple (at least 10) enhancing lesions in the bilateral cerebral hemispheres,
right intraconal, and infratentorial cerebral parenchyma with partial obstruction of the aqueduct
and fourth ventricle showing signs of hydrocephalus. Due to this finding DH was admitted to
the Neuro ICU and started on Decadron (Steroid) and Keppra (anti-seizure med). On February
5, 2014 DH underwent a procedure to place a right frontal VP shunt without complications.
Past Medical History: DH reported no additional medical history personally other than
allergies to Latex, natural rubber, and adhesives.
Social History: DH is a truck driver who currently smokes with a 30 pack year smoking history,
one pack a day for the past 30 years. There is a history of Melanoma in a maternal great uncle
and a paternal grandmother with breast cancer. He lives in a rural town with a spouse.
Medications: DH is taking the following medications: Dexamethasone 2mg tablets twice a day
(BID), docusate sodium (Colace) 100mg capsules twice a day while taking narcotics,
2

hydrocodone-acetaminophen (Norco) 5-325mg tablets every four hours as needed for pain,
ranitidine (Zantac) 10mg tablets twice a day (BID), vitamin D, and vitamin B12.
Diagnostic Imaging: In January 2014 DH received a CT of the chest, abdomen, and pelvis
showing multiple bilateral pulmonary nodules, retroperitoneal nodes, and metastases to the
adrenal gland and gallbladder. A Brain MRI was performed in February 2014 which revealed
the presence of multiple (at least 10) enhancing lesions in the bilateral cerebral hemispheres,
right intraconal, and infratentorial cerebral parenchyma with partial obstruction of the aqueduct
and fourth ventricle showing signs of hydrocephalus.
Radiation Oncologist Recommendations: After reviewing DHs medical history including
surgical history, and pathology the radiation oncologist spoke with DH and his spouse. Due to
the number of lesions seen on the MRI the radiation oncologist advocated for whole brain
radiotherapy rather than stereotactic radiosurgery (SRS). The Whole brain radiotherapy
treatment would consist of a right and left lateral parallel opposed fields. It was also stated that
SRS could still be considered in the future should any of the lesions enlarge after whole brain
radiotherapy.
The Plan (prescription): The radiation oncologists recommendation to DH was whole brain
radiation using parallel opposed fields. These beams were equally weighted with an isocenter at
mid plane depth (MPD). The prescription was for a total of 30 Gy in 3 Gy per fraction for 10
fractions.
Patient Setup/Immobilization: In February 2014 DH underwent a CT simulation in preparation
for radiotherapy treatment. DH was placed in a supine position on the head and neck board
which was attached to the CT table. DH also had an angled cushion under the knees, thin egg
crate cushion under the back, and the head on specific headrest under the head which was fixed
to the head and neck board. DH was visually aligned from head to toe while an aquaplast mask
was made over the whole head stopping just superior to the shoulders (Figure 1).
Anatomical Contouring: After the CT simulation, the data set was transferred into the Eclipse
treatment planning system (TPS). The resident assigned to the staff radiation oncologist for this
case contoured in the lens of the eyes and the cribriform plate.
3

Beam Isocenter/Arrangement: The simulator staff set an isocenter that was roughly centered
in the brain but MPD laterally. This isocenter was approved by the resident and staff physician.
The field size was established by using the jaws and MLCs in Varians Eclipse TPS. For this
case the physician used a 90 degree gantry angle with no collimator rotation. The jaws were
adjusted to flash the brain 1.5cm superiorly, anteriorly and posteriorly. The inferior border was
placed between C2 and C3 (Figure 4). MLCs were then placed to block out the eyes, especially
the lenses, and any other area not in need of treatment such as the facial bones, yet include the
cribriform plate (Figures 6 & 8). The field was then parallel opposed to create a mirrored field at
270 degrees (Figures 7). The physician checked over the new field and blocking before
approving the fields. The physician prescribed 6 MV energy on each field for treatment on a
Varian EX linear accelerator. Lower energies are often used in whole brain treatments to avoid
underdosage to the lateral brain.
2

Treatment Planning: The physician filled out a planning directive for the medical dosimetrist
requesting a calculation be done for the fields the physician had previously set in Varians
Eclipse TPS. The physician specified the use of 6MV, delivering 3 Gy per fraction to a total of
30 Gy with the 95% isodose line covering 100% of the brain +/- 5%. The physician did allow for
customized beam weighting or wedges though the fields ended up being equally weighted
(Figures 2-5 &8).
Quality Assurance/Physics Check: The monitor units (MUs) for the plan were checked using
the Mobius software. Mobius also checks the planning objectives and dose volume histograms
(DVHs). Once the plan has passed the Mobius check the physics staff will do a visual check
against the requests on the directive and make sure the plan is ready for treatment.
Conclusion: Creating a reproducible setup that the patient could tolerate was the first challenge
encountered with this treatment. It was important to keep the head straight while making the
mask so additional rotation on the gantry would not be needed. This was a relatively simple case
for the medical dosimetrist with the physician setting the fields and designating energy, but it
was still their job to assure the physicians objectives were met. Knowing that a lower energy is
desired to improve dose coverage at the skin surface and being able to know what to
include/exclude is critical.
4

References
1. Alexander J. Diagnosis and staging In: Otto, S ed. Oncology Nursing. fourth ed. St.
Louis, Mo: Mosby 2001: 88.
2. Bentel Treatment Planning-central nervous system and pituitary gland. In: Bentel G,
Radiation Therapy Planning 2
nd
ed. New York, NY: McGraw-Hill; 1996: 336.
5




Figure 1. Patient positioned on CT table in Civco head and neck board with 3 point mask
6


Figure 2. Four panel scre2wen shot showing isocenter placement and dose distribution.


Figure 3. Single panel axial view of isocenter placement and dose distribution.
7


Figure 4. Single panel sagittal view of isocenter placement and dose distribution.


Figure 5. Single panel coronal view of isocenter placement and dose distribution.
8


Figure 6. MLC placement on LLAT field at 90 degrees


Figure 7. MLC placement on RLAT field at 270 degrees
9


Figure 8. Single panel axial view demonstrating beams divergence and blocking of lenses.