Brain Module Worksheet

Site: BRAIN
Student Name: Raymond Hove Date: 1/05/19

Patient Info:
Age: Gender: M

Presentation:
1. Six week history of migraine, memory, fatigue and unexplained short-temperedness.
a. Raised ICP from the tumor pushing onto the brain would have resulted in the following
symptoms

Diagnosis:
1. Right temporal-parietal Grade 4 Glioblastoma Multiforme
a. most common type of astrocytoma that occurs in adults)

Prognosis
1. Very aggressive = median survival is 9-12 months with RT that is followed by surgery.
2. Infiltrative nature + proximity to critical structure makes surgical resection not feasible without
compromising neurological function and also it makes hard to determine tumour margins accurately

Medical history/comorbidities:
1. not a surgical candidate due to his co-morbidities (ischaemic heart disease)
2. Biopsy is also not possible therefore tumor cannot be graded

Prescription: Long course: 60Gy in 30#, 2Gy/#, I#/day over 6 weeks to the ICRU Reference
point

Intent: Curative dose with a palliative Intent of prolonging pt life

Other treatments for this diagnosis: concurrent chemotherapy (TMZ) which a

radiosensitizer

Department of Radiation Therapy, University of Otago Wellington 2019

CT:
Positioning/Immobilisation:
How would this pt be set-up in your department?
1. HFS
2. H/N Board
3. Thermoplastic mask
4. Mattress
5. NRM
6. LR
7. HOA + ring

CT preparation required:
Is there anything this pt needs to do to prepare for CT in your department?
Contrast

Scan Levels:
What anatomy needs to be included in the scan and why?
1. Scano: SUP margin of H/N Board to Mid chest
2. Scan Levels: SUP same as Scano & INF to just below the shoulders
a. For vertex beams and below the shoulders for planners if they want couch kick and ensure we
got all OARS

Do any markers/wires or bolus or packing need to be placed for CT?:

1. Angiocaths
a. Ant M/L forehead
b. 2 Laterals in general location we’re treating (stable position)

Planning:
Volumes:
List the volumes present, what is included in each (including margin size) and whether the
margin seems appropriate.
1. CTV
2. PTV – has a uniform margin around the CTV of approximately 1cm in the
anterior, left and right aspect of the CTV however in the post margin its around
1.8cm
For the PTV note the size, shape and location (this will influence beam arrangement)
o Size: Medium
o Shape: circular
o Location: Right, slightly inferior and posterior

Department of Radiation Therapy, University of Otago Wellington 2019

OAR:
List the OAR present and their tolerance doses (use departmental tolerance doses where
applicable). Indicate which structures will need to be contoured.

OARs Departmental tolerances

(max dose)
Brainstem <60Gy
Optic nerves <60Gy
Lens <6Gy cataract
Optic chiasm <60Gy

Inhomogeneities:
List inhomogeneities present and their RED’s. Indicate if any density overrides are required.
1. Soft Tissue = 1.0
2. Bone = 1.3 -1.8

Proposed Beam Arrangement:

Consider size, shape and location of PTV as well as surrounding OAR - draw a diagram
below: 3 Field arrangement = LPO + RAO + RPO

Energy:
Considering depth to the PTV and entry and exit dose to OAR, indicate which energies you
think you will use for each beam
1. Considering size, shape, and location of tumour – 6/10MV (tumor is relatively more
superficial)

Weightings:
Considering depth to the PTV and entry and exit dose to OAR, list your beams below in order
of expected weighting, highest to lowest
1. Right will be weighted the highest because its closer to PTV so have the highest dose
affecting less amount of tissue
2. evenly weighted: RPO contributing dose to the most tissue therefore low weight to
decrease dose to OARs

Wedges:
List the beams which will require wedges, note the orientation and estimate the size (this may
just be “large” or “small”)
1. LPO and RAO will have 45o EDW due to the beam arrangement to alter dose
distribution to medial aspect of PTV. The beams are fairly close to each other causing
beam overlaps = high dose regions hence why we need large wedges

Department of Radiation Therapy, University of Otago Wellington 2019

Treatment:
Isocentre position:
What information will you need to give treatment so that they can locate the planned
treatment isocentre? Think about the process you have seen in your department on day 1 of
treatment.

Imaging:
What kind of imaging would this patient receive whilst on treatment if they were to be treated
in your department? How frequent would this imaging be? What structures would be matched
to?
1. Daily KV/KV imaging
a. Matching to orbits for L/R and S/I
b. Matching skull A/P and S/I

Treatment preparation:
Is there anything this pt needs to do to prepare for treatment in your department?
1. Because we’re treating the brain, pt may need to take Dex prior to tmt mitigate the
effects of encephalitis which present as headaches, nausea and vomiting, loss of
balance, blurred vision and seizures

Clinical Acceptability:
On completion on your plan state whether or not you think it is a clinically acceptable plan
and why. You will need to consider:
 Dose distribution
o ICRU dose variation (dose coverage and CSM)
o Dose homogeneity
o Dose conformity (including hotspots)
 Dose to OAR
o Acute reactions that will occur
o Endpoint reactions that will occur

Overall the Plan is clinically acceptable:

1. Dose distribution: CSM is under 107% and it is where I would I expect it to be (where the beams
overlap).
2. Coverage: my 95% is covering 98% of PTV and the minimum of where it is lacking is in location
we’re treating.

Department of Radiation Therapy, University of Otago Wellington 2019

 3. Dose is homogenous/even around PTV
4. Dose conformity; - more achievable on lateral aspect of PTV but not medial aspect due to having
square isodose due to beam arrangement but in my plan, I have no hotspots

Dose to OARs
1. all under the dose tolerances so wont expect any endpoint reactions
2. Expect skin reactions – will progress to dry desquamation + temporary hair loss

Additional notes
1. 10 mv is more of an efficient energy because not only does it reduce dose to skin but also
surrounding periphery tissue
2. 10MV less entry but more dose on exit but POP with 10MV, the amount of low entrance from the
entrance outweighs the exit from the exit so therefore less dose on the periphery
3. RPO Contributes more to brain tissue so lower the weighting what about the energy
4. What changes shape of the isodose shape = beam arrangement
5. Note that there is going to be a bolus effect inside the ear and outside so expect some ear reactions

What symptoms is he going to Depended on the part of the brain which is

exhibit
What are the problems with
using MRI fused CT
Why can’t you plan on MRI
affected
Pt won’t be in exact position as there
were in CT (not immobilised to
equipment.
Don’t give information on electron
densities which is what we rely when
planning

Department of Radiation Therapy, University of Otago Wellington 2019