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A.J.

Kressin
April Case Study
April 4, 2014
Anteroposterior and Posteroanterior Fields for the Treatment of Palliative Thoracic Spine
Lesions
History of Present Illness: Patient JR is a 62 year-old female who noted chest and back pain in
February 2014. She underwent a chest x-ray that same month. The x-ray showed some
abnormality in the left lung. In March 2014, JR underwent a computed tomography (CT) which
revealed dense tissue consolidation of a large portion of the upper left lobe with a mediastinal
mass and opacification of a left upper lobe bronchi. There was an apparent destructive mass in
the inferior sternum. The findings were felt to be consistent with endobronchial carcinoma with
mediastinal invasion and possible metastatic disease. JR underwent a positron emission
tomography (PET) CT scan in March 2014. This revealed widespread cancer with disease in
the colon and omentum/mesentery. There was significant adrenal metastasis and multifocal
osseous and soft tissue metastatic disease along with disease in the chest that may have been
metastatic colon cancer. There was a large left mediastinal lesion causing laryngeal nerve
paralysis. The patient underwent a bronchoscopy in March 2014, which showed the left vocal
cord was paralyzed. The left side showed some edematous mucosa collapse with mucous
plugging and some bleeding. A biopsy from the upper paratracheal nodes revealed malignant
cells most consistent with poorly differentiated adenocarcinoma. Additional sampling was taken
from the 4
th
lumbar vertebra region that revealed malignant cells most consistent with
differentiated adenocarcinoma. Thyroid transcription factor 1 (TTF1) and Napsin A were
positive. Immunohistochemistry using TTF1 has been known to be effective in determining lung
adenocarcinoma to be of pulmonary origin.
1
Napsin A has been shown to have a greater
specificity for lung adenocarcinoma than TTF1.
2
However, the use of Napsin A in conjunction
with TTF1 has been shown to be the most effective in diagnosing lung adenocarcinoma
compared to using either Napsin A or TTF1 by itself.
1
The immunohistochemical stains
supported the diagnosis of pulmonary adenocarcinoma. The worsening pain along JRs left back
radiating underneath her left breast has been the most problematic for her. She has some pain
along her right upper back that extends into her right arm and reports difficulty with the use of
her right hand. JR also notes that lying on her side seems to make the pain in her chest worse and
has noticed an increase in hoarseness over the past few months. The patient was diagnosed with
stage IV malignancy that is incurable.
Past Medical History: JR has a past medical history of peripheral artery disease, hypertension,
diabetes mellitus, dyslipidemia, peripheral neuropathy, anemia, thrombocytopenia, alcoholism,
chronic kidney disease, gastroesophageal reflux disease, myocardial infarction, coronary artery
disease, and upper gastrointestinal bleeding. JR has a past surgical history of femoral to popliteal
bypass graft in both femurs, 2 extracapsular cataract extractions, and transmetatarsal amputation.
The patient also reports allergies to non-steroidal anti-inflammatory drugs and Penicillins.
Social History: The patient has an extensive family history of diabetes. She is married with 2
children and has a father and mother who are both deceased with histories of diabetes. She has 3
sisters who have died with heart problems and diabetes and 2 brothers who have died with liver
disease. She has one surviving sister and one brother, both of whom have diabetes. JR is a former
smoker who smoked 1.5 packs per day for 49 years, but reports no use of smokeless tobacco,
alcohol, or drugs.
Medications: JR uses the following medications: acetaminophen with codeine, amlodipine,
aspirin, BD insulin syringe ultrause, cholecalciferol, vitamin D3, escitalopram, glucose,
hydrocodone-acetaminophen, insulin aspart, insulin glargine, losartan, methadone, metoprolol-
XL, multivitamin tablet, omeprazole, pravastatin, pregabalin, sertraline, tiotropium, and
torsemide.
Diagnostic Imaging: In February 2014, JR underwent a chest x-ray, which showed an
abnormality in the left lung. Subsequently, she underwent a CT scan in March 2014. This
imaging revealed a dense soft tissue consolidation of a large portion of the left upper lobe with a
mediastinal mass, additional rounded mediastinal soft tissue densities, and borderline lymph
nodes in the paratracheal space. There was also some opacification of the left upper lobe bronchi
and an apparent destructive mass in the inferior sternum. A PET-CT scan was performed in
March 2014, showing wide-spread cancer with disease in the colon and omentum/mesentery
along with significant disease in the chest. There was a right adrenal metastasis and multifocal
osseous and soft tissue metastatic disease. There was a large left mediastinal lesion causing
recurrent laryngeal nerve paralysis. A bronchoscopy was performed in late March 2014. The left
side showed some edematous mucosa collapse with mucous plugging and some bleeding. A
biopsy was taken from the upper paratracheal nodes revealing malignant cells most consistent
with poorly differentiated adenocarcinoma. TTF1 and Napsin A were positive. The
immunohistochemical stains supported the diagnoses of pulmonary adenocarcinoma.
Radiation Oncologist Recommendations: The radiation oncologist had a long thorough
discussion with the patient about her clinical situation. JR was told that she appears to have stage
IV incurable malignancy. The radiation oncologist discussed the risks, benefits, and alternatives
to a course of palliative radiation treatment. The goal of radiation treatment, which would be to
try to diminish the pain, was also discussed. The radiation oncologist recommended a course of
palliative radiotherapy directed at the regions of the 1
st
, 3
rd
, and 10
th
thoracic vertebrae with the
possible inclusion of some of her lung disease. JR consented to proceed with the above
recommendations.
The Plan (prescription): The radiation oncologists treatment recommendation to JR was to
palliatively treat the regions of the 1
st
, 3
rd
, and 10
th
thoracic vertebrae along with some of her
lung with a basic anteroposterior (AP)/posteroanterior (PA) setup. The prescription for the plan
was a total of 3000 cGy at 300 cGy per fraction for 10 fractions.
Patient Setup/Immobilization: In late March 2014, JR underwent a CT simulation scan for
radiation therapy treatment. The patient was placed in the supine position on the CT simulation
couch in a Vac-Lok bag with arms at the sides on arm boards (Figure 1). The patient also had a
knee cushion. Radiation therapists placed BBs on the patient for treatment planning localization
purposes.
Anatomical Contouring: After completion of the CT simulation, the CT data set was
transferred to the Philips Pinnacle version 9.0 radiation treatment planning system (TPS). The
radiation oncologist contoured the gross target volumes (GTVs) in the T1, T3, and T10 regions,
and in the lung. The medical dosimetrist contoured the organs at risk (ORs) which included the
esophagus, right and left lungs, spinal cord, heart, liver, and stomach. The medical dosimetrist
was verbally given the prescription and goals to begin treatment planning.
Beam Isocenter/Arrangement: The radiation oncologist placed isocenter approximately 5.5 cm
anterior to the spinal cord (Figures 2-3). The placement of the isocenter corresponded to roughly
mid-depth of the patient and approximately medial (Figures 4-6). The beams were setup in AP
and PA directions utilizing 10 megavoltage (MV) beams. The AP and PA fields used gantry
angles of 0 and 180 degrees respectively. Both beams had collimator angles of 0 degrees and no
couch rotations. The field apertures were determined by the radiation oncologist and designed to
encompass all the GTVs (Figures 7-8). Each field had a multi-leaf collimator blocking pattern
that was designed by the radiation oncologist. The MLC blocking was designed to block out
portions of the lungs, heart, liver, and stomach. The medical dosimetrist assigned the prescription
to the 2 treatment fields.
Treatment Planning: The radiation oncologist outlined the prescription dose and one major
objective for the treatment plan. The goal was to keep the maximum dose to the spinal cord less
than 3150 cGy, while maintaining a homogenous dose distribution throughout all contoured
GTVs (Figures 9-11). The prescription dose was prescribed to a calculation point placed by the
medical dosimetrist. The AP beam delivered 56% of the prescribed dose, while the PA beam
delivered 44%. In addition, the organs at risk (ORs) dose constraints were: the esophagus mean
dose was to be less than 3500 cGy, the right and left lung mean doses were to be less than 2000
cGy, the heart volume at 4000 cGy (V4000) was to be less than 100%, the maximum stomach
dose was to be less than 5400 cGy, the maximum spinal cord dose was to be 3150 cGy, and the
volume of liver at 3000 cGy (V3000) was to be less than 100%. Once the adequate prescription
dose coverage was achieved to all GTVs, the medical dosimetrist reviewed the OR doses, the
isodose lines, and the dose volume histogram (DVH) (Figures 12-13). The DVH reflected a
mean esophagus dose of 2140 cGy, a right lung mean dose of 1759 cGy, a left lung mean dose of
330 cGy, a V4000 heart dose of 0%, a maximum stomach dose of 2781 cGy, a maximum spinal
cord dose of 3136 cGy, and a V3000 liver dose of 0%. The radiation oncologist also reviewed
the plan.
Quality Assurance/Physics Check: The monitor units (MUs) for the plan were double checked
using the MUcheck program. Our department tolerance between the TPS MUs and the MUcheck
MUs is 5%. The MUs for each field fell within this tolerance. The blocks for each segmented
field were verified using the Dose Lab program. The department requirement is that 95% of the
motor counts be within 2 mm between the TPS MLC positions to the delivered MLC positions.
The completed plan was reviewed by a medical physicist for a final check before treatment
began.
Conclusion: The major challenge of the plan for the medical dosimetrist was keeping the
maximum dose to the spinal cord less than 3150 cGy. In order to accomplish this objective, the
medical dosimetrist had to adjust beam weights, delivering more dose from the AP field than the
PA field. However, only so much weight could be placed on the AP field before dose coverage
of the GTVs became compromised, as 2 of the GTVs were located posteriorly, directly adjacent
to the spine. Segmented fields were then used in order to eliminate any remaining areas in the
spinal cord receiving 3150 cGy.



















References
1. Bishop JA, Sharma R, Illei P. Napsin A and thyroid transcription factor-1 expression in
carcinomas of the lung, breast, pancreas, colon, kidney, thyroid, and malignant mesothelioma.
Human Pathol. 2010;41(1):21-25. http://dx.doi.org/10.1016/j.humpath.2009.06.014
2. Turner BM, Cagle PT, Sainz IM, Fukuoka J, Shen SS, Jagirdar J. Napsin A, a new marker for
lung adenocarcinoma, is complimentary and more sensitive and specific than thyroid
transcription factor 1 in the differential diagnosis of primary pulmonary carcinoma. Arch Pathol
Lab Med. 2012;136:163-171.

Figures

Figure 1. Patient position in Vac-Loc at CT simulation.



Figure 2. Anterior view of isocenter placement.

Figure 3. Right lateral view of isocenter placement.

Figure 4. Isocenter (green point) placement in the axial view.

Figure 5. Isocenter placement in the sagittal view.

Figure 6. Isocenter placement in the coronal view.

Figure 7. AP treatment field with MLC blocking.

Figure 8. PA treatment field with MLC blocking.

Figure 9. Dose distribution of GTVs T1 and T3.

Figure 10. Dose distribution of lung GTV.

Figure 11. Dose distribution of GTV T10.

Figure 12. DVH 1 of 2 for palliative thoracic spine and lung treatment plan.


Figure 13. DVH 2 of 2 for palliative thoracic spine and lung treatment plan.

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