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Kristen Dezell

Clinical Oncology Assignment

Clinical Oncology I, DOS 531

April 24, 2022

Introduction

Lung cancer is the deadliest type of cancer and the third most common cancer in the
United States, preceded by skin cancer, prostate cancer in men, and breast cancer in women.1
60% of patients diagnosed with lung cancer pass away within one year, and 75% pass away
within just two years.2 Most lung cancer begins in the lining of the bronchi, and many patients
are diagnosed around 70 years of age. Most lung cancer can be attributed to cigarette smoking,
and the risk of cancer increases with the length of time and number of cigarettes smoked per day
along with the nicotine content of cigarettes smoked and the use of unfiltered cigarettes.2

This patient was diagnosed with adenocarcinoma, the most common cell type for non-
small cell lung cancer (NSCLC) and all lung cancer in the United States.2,3 The patient is a 78
year old female that originally presented with dyspnea or difficulty breathing while otherwise
living a normal, active lifestyle. The patient reported smoking for 5 to 10 years (5 pack years)
and quit in 1988. They are from the United States with no other history of cancer or radiation.
They did not have a pacemaker.

A chest x-ray was taken in February of 2022 which revealed a mass in the medial left
upper lobe of the left lung silhouetting the aortic arch. A chest CT was then obtained that
showed a 4.2 cm spiculated mass with multivascular abutment of the aortic arch and a level 5
lymph node measuring 4 mm. A PET CT scan was obtained next using fluorine 18
fluorodeoxyglucose (FDG) and resulting in FDG uptake in the left upper lobe mass and level 5
AP window lymph node metastasis as well as s small FDG uptake in a sclerotic bone metastasis
within the L4 vertebral body. Furthermore, the PET CT scan revealed primary schwannoma of
the stomach and primary squamous cell carcinoma of the left base of tongue. An MRI of the
brain was completed to check for brain metastases, but this did not show any brain lesions.
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An endobronchial ultrasound (EBUS) was taken in March of 2022 that showed invasive
adenocarcinoma. In April of 2022, another chest CT was taken that showed that the left upper
lobe spiculated mass had grown to 4.4 cm and the left subaortic level 5 lymph node measured 8
mm, doubling in size within just two months. At this point, the patient had significant dyspnea
but no hemoptysis, no cough, no hoarseness, no back or bone pain, and no headaches, nausea,
vomiting, or seizures. The patient was staged using the TNM system as Stage IIIA cT2bN2M0
adenocarcinoma of the left lung. Based on the staging system, T2b means that the tumor is
larger than 3 cm but less than 5 cm in size, N2 means that the cancer spread to mediastinal or
hilar lymph nodes on either side of the body from the main tumor, and M0 means that there is no
distant metastasis to other parts of the body.4

Given the clinical stage, the patient was offered concurrent combined modality definitive
treatment using chemotherapy with weekly carboplatin and paclitaxel and radiation with 60 Gy
in 30 fractions. Per the patient’s physician, side effects of radiation include cough, dysphagia,
odynophagia, and lethargy, and long-term side effects include an increased risk of coronary
artery disease and lung fibrosis. Following chemoradiation, the intent is to offer the patient
adjuvant immunotherapy with durvalumab for 1 year maintenance to reduce the risk of
recurrence per the Pacific trial, aiming to increase her 5-year overall survival.5,6

Patient Positioning

This patient was positioned in a supine orientation. An upper vaclok was utilized to form
the shape of the patient’s arms above the body while being supported by an indexed wingboard
as seen in Figure 1. The patient’s elbows were measured at 50 cm separation, and that
measurement is consistently checked for each treatment to ensure position reproducibility. The
vaclok also is useful for overall upper body positioning of the head, neck, and shoulders to
maintain a consistent setup each day. The patient’s chin was left in a neutral position for comfort
and did not require chin extension for dose sparing to the oral cavity. The patient used a knee
cushion for lower body stability and comfort, and a toe strap was used as a reminder for the
patient to remain still during treatment. A 4DCT simulation was obtained in this position to take
into account the patient’s breathing amplitude and cardiac motion and their corresponding impact
on target motion.
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Figure 1: Upper vaclok immobilization with supportive knee cushion

Target Dose and Fractionation

The target dose for this plan was prescribed to 6000 cGy in 30 fractions (200 cGy per
fraction) to be delivered daily, Monday through Friday. This prescription was based on the
Pacific regimen treatment for Stage III N2 disease combined with concurrent weekly carbotaxol
(carboplatin and paclitaxel) chemotherapy followed by adjuvant immunotherapy with
durvalumab. This trial aims to increase progression free survival in patients with unresectable
non-small cell lung cancer after receiving combined chemoradiation.6

The physician’s conventional lung target dose objectives included PTV D95% < 100% and
V110% < 1%, and both objectives were met for this case. The CTV was created with a 5 mm
expansion from the ITV, and the PTV was expanded an additional 5 mm from the CTV per the
physician. According to the Radiation Therapy Oncology Group (RTOG) 9410, long term
overall survival is increased by using concurrent chemoradiotherapy compared with sequential
chemoradiotherapy.7 Furthermore, RTOG 0617 determined that 60 Gy in 30 fractions is the
current best standard of practice for thoracic radiation in unresectable stage III NSCLC.8,9

Avoidance Structures

The organs at risk for this patient included the cord, esophagus, healthy ipsilateral lung
tissue, contralateral lung tissue, and heart. The physician also reported to the spinal cord
planning organ at risk volume (PRV) with a 5 mm expansion to further minimize dose to the
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spinal cord and avoid myelopathy which has a less than 1% risk over 50 Gy.10 The esophagus
included a high priority on keeping out all 105% prescription (6300 cGy) to avoid esophagitis
which has a 10% risk with more than 30% over 60 Gy,10 and an additional avoidance structure
was created including any esophagus plus 1 mm margin within the PTV to contain excess dose in
these areas in the optimization process (Figure 2). Furthermore, an avoidance structure was
created in the ipsilateral lung to help with dose conformality around the target and reduce low
dose spillage in healthy left lung tissue to help avoid symptomatic pneumonitis.10 This left
avoidance structure was cropped 2 cm from the PTV to allow adequate target coverage and dose
falloff outside of the PTV (Figures 3 and 4). The heart was located 1 cm inferior to the last slice
of the PTV, but dose was still optimized to be as low as possible to avoid pericarditis and long
term cardiac mortality.10

Figure 2: Axial view of avoidance structures

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Figure 3: Coronal view of avoidance structures

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Figure 4: Sagittal view of avoidance structures

The following table represents dose constraint goals for each organ as indicated by the
physician prescription as well as applicable QUANTEC objectives.11 All objectives were met for
this plan.

Avoidance Physician Objectives QUANTEC11 Achieved

Structure

Spinal Cord Max < 50 Gy Max < 50 Gy 12.89 Gy

Spinal Cord Max < 55 Gy 17.59 Gy

+ 5 mm PRV V55Gy < 0.1 cc 0 cc
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Esophagus Max (report) 62.93 Gy

Min (report) 0.63 Gy
Mean < 34 Gy Mean < 34 Gy 23.45 Gy
D0.03cc (report) 62.46 Gy
DC0.03cc (report) 0.64 Gy
V35Gy < 50% V35Gy < 50% 25%
V50Gy < 45% V50Gy < 40% 11.4%
V55Gy <= 40% 8.3%
V60Gy < 5% 4.5%
V70Gy < 20%

Lung - Left Mean (report) 17 Gy

DC500cc (report) 1.7 Gy
DC1000cc (report) 35.11 Gy
V10Gy (report) 41.2%
V20Gy (report) V20Gy <= 30% 36.7%

Lung - Right Mean (report) 4.83 Gy

DC500cc (report) 0.87 Gy
DC1000cc (report) 6.28 Gy
V10Gy (report) 17.5%
V20Gy (report) V20Gy <= 30% 1.1%

Lung Total Mean < 15 Gy 10.34 Gy

V5Gy (report) 42.7%
V10Gy < 35% 28.2%
V13Gy (report) 22.9%
V20Gy < 25% V20Gy <= 30% 17.2%
V30Gy (report) 13%

Heart Max < 50 Gy 11.55 Gy

Mean < 20 Gy Mean < 26 Gy (pericardium) 0.95 Gy
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V5Gy (report) 0.7%

V25Gy < 10%
V30Gy < 46% V30Gy < 46% (pericardium) 0%
V40Gy < 33% 0%

Lymph Nodes

The left lung typically drains into the subaortic and paraaortic lymph node chains, and the
rate of early metastasis to the aortopulmonary (AP) window lymph node is high in patients with
left lung adenocarcinoma near the apex of the lung.12 AP window lymph nodes are located
lateral to the ligamentum arteriosum and medial to the left pulmonary artery, shown in Figure
5.13 To examine the extent of disease involving lymph nodes in patients with non-small cell lung
cancer, the National Comprehensive Cancer Network recommends a PET CT scan with FDG to
be the standard of care.14

A PET CT scan was obtained in February 2022, and the ipsilateral level 5 subaortic AP
window lymph node was found to have mild FDG activity, measuring 4 mm in size (Figure 6).
Typically, level 5 nodes are located along the ascending aorta, which is the case for this patient.15
This classified the nodal metastasis in the patient as N2. The staging of N2 includes the
ipsilateral mediastinal, midline prevascular, retrotracheal, and subcarinal nodes.13 By April
2022, this subaortic node doubled in size to 8 mm. Although there was concern for rapid
enlargement, the physician and patient discussed procedural options but ultimately chose to
pursue radiation and chemotherapy alone due to surgical risks.
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Figure 5: Nodal spread for lung cancer staging13

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Figure 6: CT fusion with PET CT scan showing the patient’s node included within the
GTV

Treatment Field Borders

Anatomical boundaries of this superior lung target can be described per the International
Association for the Study of Lung Cancer (IASLC) Lymph Node Station system.16 This patient’s
disease was confined to station 5 with the subaortic lymph node located laterally to the
ligamentum arteriosum. The upper border of station 5 is the lower border of the aortic arch, and
the lower border of station 5 is the upper rim of the left main pulmonary artery, which can be
seen in Figures 7 and 8.

Overall treatment field borders were clinically determined by the physician. As

mentioned previously, they utilized a 4DCT simulation scan to assess target motion within the
patient’s breathing cycle, and this helped the physician to contour the internal target volume
(ITV). The CTV was created with a 5 mm expansion from the ITV, and the PTV was created
with a 5 mm expansion from the CTV per the physician’s clinical determination.
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Figure 7: Station 5 lymph node borders16

Figure 8: Coronal and Sagittal views of the patient’s station 5 lymph node
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Treatment Technique

The radiation treatment technique for this patient included an intensity modulated
radiation therapy (IMRT) with volumetric modulated arc therapy (VMAT) on a Varian
Truebeam. Isocenter was set near the middle of the target with a 4 cm shift laterally, 3 cm shift
anteriorly, and 14 cm shift superiorly from the user origin set at simulation. IMRT and VMAT
techniques allow a more conformal dose distribution around the target compared to 3D
techniques, but there can also be more integral dose in the body due to the beam arcing around
the entire body. To help reduce integral dose, especially to the contralateral lung, I used three
partial arcs for this plan, spanning from 179 - 340 degrees (20 degrees past midline). I could
have stopped the arcs with the gantry at 0 degrees anteriorly, but this specific target was on the
larger side and located near midline, necessitating the additional 20 degrees past midline on the
contralateral side. To ensure that the contralateral lung dose was kept as low as reasonably
achievable (ALARA), I immediately started pushing on the right lung in the optimizer using
upper objectives and upper gEUDs. Physicians at my clinic like to keep the 2000 cGy as
conformal to the target as possible, as seen by the dark brown 2000 cGy line in Figure 10. .

This patient was of average size, and 6X photon energy was used for each field. The
collimator was rotated to 5 degrees for Arc 1, 355 degrees for Arc 2, and 90 degrees for Arc 3.
The MLCs were fit to 0.5 mm around the PTV with the jaws tracking as close as possible to the
MLCs throughout each arc (Figures 9 and 10). This plan did not require any couch rotations.

The dose limiting annulus (DLA) was created with a 3 cm expansion from the PTV and a
2 mm crop from the PTV, allowing adequate target coverage along the PTV edge while trying to
limit intermediate and integral dose to the surrounding tissue. I completed this plan after three
optimizations using hot and cold structures to eliminate 105% in the esophagus and fill in
prescription throughout the target volume. Also, I pushed on the esophagus and cord structures
to keep dose ALARA. The global dose maximum on the final plan was 109.2% (6550 cGy) and
was located within the PTV and under the V110% constraint from the physician (Figure 11). The
monitor units from Arc 1 totalled 199 MU, Arc 2 totalled 171 MU, and Arc 3 totalled 202 MU,
with a grand total of 572 MU for the entire plan (Figure 12).
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Figure 9: Field margins around the PTV

Figure 10: VMAT Field Design

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Figure 11: Global dose maximum of 109.2% (6550 cGy)

Figure 12: Monitor Units

Conclusion

As shown on the final dose volume histogram (DVH), all target and normal tissue
constraints were met for this IMRT plan. The highest priority for target coverage included D95%
> 100%, and 100.5% (6033 cGy) was achieved. The other high priorities for target coverage
included D99% > 93%, and 99% (5938 cgy) was achieved; as well as V110% < 1%, and this was
completely minimized to 0% throughout the plan (Figures 13 and 14). The spinal cord and
esophagus are serial organs where organ failure will occur if even a small portion is damaged, so
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the maximum point was important to keep in mind for these structures. The lungs are considered
more of a parallel organ where the organ will lose functionality only if a certain volume of the
organ is damaged, so the mean, V10, and V20 were all important to minimize as much as possible.
The heart can be considered both a serial and parallel organ, as the coronary arteries are serial
and the myocardium is parallel.17 Each of the normal tissue dose objectives can be viewed in
Figure 15.

Figure 13: Final DVH

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Figure 14: Final target objectives

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Figure 15: Final normal tissue objectives

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References

1. Centers for Disease Control and Prevention. Lung cancer statistics.

https://www.cdc.gov/cancer/lung/statistics/index.htm. Accessed April 12, 2022.
2. Chao, K, Perez, C, Brady, L. Radiation Oncology Management Decisions. 3rd
Philadelphia, PA: Lippincott Williams & Wilkins; 2002. ISBN-10: 1-60547-911-X
3. American Cancer Society. Understanding your pathology report: lung cancer.
https://www.cancer.org/treatment/understanding-your-diagnosis/tests/understanding-
your-pathology-report/lung-pathology/lung-cancer-pathology.html. Accessed April 12,
2022.
4. American Cancer Society. Non-small cell lung cancer stages.
https://www.cancer.org/cancer/lung-cancer/detection-diagnosis-staging/staging-
nsclc.html. Accessed April 12, 2022.
5. A global study to assess the effects of MEDI4736 following concurrent chemoradiation
in patients with stage III unresectable non-small cell lung cancer (PACIFIC).
ClinicalTrials.gov. identifier: NCT02125461. Updated April 13, 2022. Accessed April
17, 2022. https://clinicaltrials.gov/ct2/show/study/NCT02125461
6. Antonia SJ, Villegas A, Daniel D, et al. Durvalumab after chemoradiotherapy in stage III
non-small-cell lung cancer. New England J of Medicine. 2017;377(20):1919-1929.
https://doi:10.1056/NEJMoa1709937
7. Curran W, Scott C, Langer C, et al. Long-term benefit is observed in a phase III
comparison of sequential vs concurrent chemo-radiation for patients with unresected
stage III NSCLC: RTOG 9410. Proc Am Soc Clin Oncol. 2003;22:621. abstr 2499.
8. Higgins KA, Puri S, Gray JE. Systemic and radiation therapy approaches for locally
advanced non-small-cell lung cancer. J Clin Oncol. 2022;40(6):576-586.
https://doi.org/10.1200/JCO.21.01707
9. Bradley JD, Hu C, Komaki RR, et al. Long-term results of NRG oncology RTOG 0617:
standard- versus vigh-dose chemoradiotherapy with or without cetuximab for
unresectable stage III non-small-cell lung cancer. J Clin Oncol. 2020;38(7):706-714.
https://doi: 10.1200/JCO.19.01162
10. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation.
2013;21(1):109-122. https://doi:10.1016/0360-3016(91)90171-y
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11. Hristov B, Lin SH, Christodouleas JP. Appendix: Normal Tissue Constraint Guidelines.
In: Radiation Oncology - A Question Based Review. Wolters Kluwer Health; 2014
12. Citak N, Sayar A, BBüyükkale S, Metin M, Gurses A. The prevalence of metastasis to
the aortopulmonary window lymph nodes (stations 5 and 6) in patients with left lung
carcinoma: A retrospective analysis of 566 patients. European Respiratory Journal.
2013;42(57):452.
13. Ko JP, Drucker EA, Shepard JO, Mountain CF, Dresler C,Sabloff B, McLoud TC. CT
depiction of regional nodal stations for lung cancer staging. AJR Am J Roentgenol.
2000;174(3):775–782. https://doi:10.2214/ajr.174.3.1740775
14. Ettinger DS, Wood DE, Aisner DL, et al. Non–small cell lung cancer, version 5.2017:
clinical practice guidelines in oncology. J Natl Compr Canc Netw 2017;15(4):504–535.
https://doi.org/10.6004/jnccn.2017.0050
15. Kelley L, Petersen C. Sectional Anatomy for Imaging Professionals. 4th ed. Elsevier Inc;
2018:326-328.
16. El-Sherief AH, Lau CT, Wu CC, Drake RL, Abbott GF, Rice TW. International
association for the study of lung cancer (IASLC) lymph node map: RadiologicReview
with CT Illustration. RadioGraphics. 2014;34(6):1680-1691.doi:10.1148/rg.346130097
17. Diez P, Hanna GG, Aitken KL, As NV, Carver A, Colaco RJ, Conibear J, Dunne EM,
Eaton DJ, Franks KN, Good JS, Harrow S, Hatfield P, Hawkins MA, Jain S, McDonald
F, Patel R, Rackley T, Murray L. UK 2022 consensus on normal tissue dose-volume
constraints for oligometastatic, primary lung and hepatocellular carcinoma stereotactic
ablative radiotherapy. Clin Onc. 2022;34(5):288-300.
https://doi.org/10.1016/j.clon.2022.02.010