Zemenfes Semaie

Radiation Oncology
Case Study
7/14/2014

Radiation Therapy
Case Study
Thyroid Cancer

Radiation Therapy: Case Study

Thyroid Cancer

1. General Patient identification and brief summary of Medical History: (gender, age,
medical/social history relevant to diagnosis)
 Zemenfes Semaie
Radiation Oncology
Case Study
7/14/2014
This patient is a 45 years old female with a past history of papillary thyroid carcinoma, for which
she underwent a total thyroidectomy in 2009. This was followed by treatment with radioactive
iodine for ablation. In the past few months, she had noticed masses in her neck. She had a PET
scan performed at Georgetown in 2012 which demonstrated hypermetabolic soft tissue in the
thyroid bed consistent with recurrent disease.
She also had 3 hypermetabolic nodes, 1 in the left cervical and 2 in the left upper mediastinal
region consistent with metastic disease. She was seen and evaluated in 02/2014. She
subsequently underwent bilateral neck dissection. The surgical pathological findings were as
follow: there was papillary thyroid carcinoma involving skeletal muscle. There was involvement
of fibroadipose tissue. She had lymphovascular space invasion. She had positive margins. The
patient is now referred for evaluation for adjuvant radiation therapy.
2. Presenting Signs/ Symptoms of patient:
The patient reports residual pain at her surgical site. She has a sore throat but denise difficulty
swallowing. She has noticed no changes in her voice. She denise eye symptoms. She has had no
weight gain or weight loss. The rest review of systems was negative.
- Cough
- Difficulty swallowing
- Shortness of breath
- Must sit up to breath
- Hoarseness or changing voice
- Neck swelling
- Chronic cough
- Appetite loss

3. Diagnostic/Clinical Detection and Work-Up: (Imaging procedures, lab, biopsy, surgery)

- Ultrasound – 01/30/2014
- Revealed multiple hypoechoic masses bilaterally, new compare to the prior study. These
findings were felt to be compatible with adenopathy.
            Surgical Pathology
-          The left anterior neck mass showed thyroid carcinoma with involvement of skeletal
muscle. Left superior neck mass showed papillary thyroid carcinoma with involvement of
skeletal muscle. Right superior neck mass showed papillary thyroid carcinoma with
involvement of fibroadipose tissue. The pretracheal mass showed papillary thyroid
carcinoma with involvement of skeletal muscle and positive margins. The left inferior
neck mass showed thyroid carcinoma with lymphovascular invasion and involved
margin.
 Zemenfes Semaie
Radiation Oncology
Case Study
7/14/2014
CT
-          CT of the chest was preformed and demonstrates no filling defects in the pulmonary
arteries to suggest acute pulmonary symbolism. There is no aneurismal dilatation of the
thoracic aorta or aortic dissection. The heart is at the upper limits of normal for size.
There is no evidence of pericardial or pleural effusion.
-          Two small ill-defined heterogenous foci noted at the thyroid bed, one anterior to the
trachea measuring approximately 1 x 2 cm and the second on the left side and measure
approximately 3 x 2.7 cm. There is diffuse decrease attenuation of the liver, maybe
secondary to steatosis. No prior studies are available for comparison.
4. Diagnosis: (Histopathology, staging, grading) 
Two small ill-defined heterogenous foci noted at the thyroid bed, one anterior to the trachea
measuring approximately 1 x 2 cm and the second on the left side and measure approximately 3
x 2.7 cm.
Final Diagnosis – Recurrent papillary carcinoma of the thyroid
5. Adjuvant Therapies: (Surgery, Chemotherapy, Immunotherapy)
This patient has been on thyroid replacement hormones since 2009.
6. Dose, fractionation scheme, treatment modality, beam arrangement, reduced/cone down fields,
etc.
The patient total planed/delivered dose was 60 Gy. For each of the 30 fractions that were to be
delivered, the patient received 2 Gy. The treatment modality is IMRT with 6X (MV) energy and
IGRT.
 Doses/Fractionation
-          30 fractions
-          2Gy per fraction
-          60Gy in total 
7. Planning Simulation/Localization Procedures: (immobilization devices, beam alignment,
anatomical borders, patient positioning, field sizes, Target volume, contrast media, skin
markers/tattoos)
Immobilization Devices
- Mask
- Head Board
- Q3 Head Rest
Skin Markers/tattoos
- 2 marks on both sides of the mask, L/R Laterals
- 1 mark on the anterior of the mask
Shifts
 Zemenfes Semaie
Radiation Oncology
Case Study
7/14/2014
- 10 cm inferior shift
Field Sizes
-          Refer to question #9                          
8. Treatment Unit Information: The patient will be treated using- (treatment type, stationary,
fixed field, arc, IMRT, SRS, number of ports, beam energy, beam alignment, treatment/gantry
angles, beam modifying devices, couch angle, etc.)
TX Plan/Consideration 
-          IMRT/IGRT
-          Delivering dose to the Thyroid Gland   
-          2Gy per fraction
-          6Gy in total  
Treaments Fields
Gantry Angles  Field Sizes Cough Angles Coll. Angles              
  X1/X2 – 6.5/9.0    
LPO - 155 Y2/Y1 – 8.7/9.0 0 0
  X1/X2 – 6.0/7.0    
LPO - 110 Y2/Y1 – 8.9/9.0 0 0
  X1/X2 – 6.5/8.0    
LA - 055 Y2/Y1 – 8.9/8.8 0 0
  X1/X2 – 8.0/8.0    
APO - 0 Y2/Y1 – 8.9/8.7 0 0
  X1/X2 – 4.0    
RAO - 309 Y2/Y1 – 3.0 0 0
  X1/X2 – 4.0    
RPO - 258 Y2/Y1 – 3.0 0 0
  X1/X2 – 4.0    
RPO - 205 Y2/Y1 – 3.6/3.0 0 0
 
Beam Energy
-          6X (MV) Photon

9. Organs At Risk (OARs) and Tolerance Doses:

As this patient is getting treatments, there are several organs that may be at risk and we have to
carefully make sure that they are not receiving the maximum dose that will cause harm to the
patient. Some of the organs at risk are as follows: Larynx, esophagus and the spinal cord.
TD 5/5
- Larynx – 45Gy
 Zemenfes Semaie
Radiation Oncology
Case Study
7/14/2014
- Esophagus – 45Gy
- Spinal Cord – 40Gy max
10. Explanation of treatment rationale for planning and accuracy /field verification techniques:
The treatment rationale for this patient's treatment of receiving external beam irradiation is to
decrease the risk of local recurrence. Therefore, the plan is to give a dose between 60 – 66Gy to
the tumor bed and the lymph node-bearing areas in the neck.
The accuracy of the dose delivered to the patient is verified using two independent methods. The
first is the Mapcheck device and the second is the Chamber measurements in a phantom. These
measurements are performed to check the monitor units in each beam generated in the treatment
planning computers.
 
11. Acute and Chronic Possible Radiation Side Effects/Complications and Patient Education
Strategies for prevention, healing, and comfort:
Some of the possible side effects that a patient may experience during treatment are as follows:
sore throat and/or mouth, difficulty swallowing, hoarseness, loss of taste, stuffy ears, dry mouth,
skin burn.
As expected, the patient may always experience side effects after the treatment is over as well.
Here are some of the possible side effects after the treatment: cough, shortness of breath, spinal
cord damage, injury to the heart, rib fracture, food passage narrowing, and reduced thyroid
function.
Patient Education for Side Effects
Fatigue — Fatigue may occur later in radiation therapy treatment. Therefore, consider taking a
nap during the day. If working, consider decreasing work hours or taking a leave, if possible.
However, try to maintain a level of physical activity and a well-rounded diet. .
Skin irritation — If it occurs, do not rub or scratch the area. Avoid clothing that rubs and avoid
alcohol-containing lotions. You may use topical creams or lotions to relieve the symptoms.
 
13. Critical Thinking: Reflection of your interactions with the patient/family, clinical
instructor(s), issues and concerns:
My interaction with the patient was very positive. The patient was an Ethiopian female, so I was
able to connect with her very fast because our culture is very similar in many ways. Therefore, I
didn’t have any trouble understanding her behavior or her way of thinking. I was also able to see
her in the nursing station and I got the opportunity to take her vital sings and also talk to her
about how her treatment was going and how she was feeling at the time. Because at the time I
met her, her treatment had been stopped due to the severe side effects she was experiencing.
Some of the side effects she had were that she couldn’t breath well and she couldn’t eat because
her airway was blocked, as a result of the swelling she had on her neck. Therefore, the doctor
 Zemenfes Semaie
Radiation Oncology
Case Study
7/14/2014
talked to her and gave her and gave her time for the swelling to come down and soon after she
continued her treatment.
 

Reference:
Howard University Hospital, Radiation Oncology Department. Retrieved 7/14/14