FIELDWORK II:

INTERESTING CASE
MPNST: Malignant peripheral nerve sheath tumor
 Uncommon - Less than 10% of all soft tissue sarcomas
 Aggressive – common for early distant metastasis
 Challenging to treat – difficult to find an affective therapy
 Treatment
 Surgery: standard of care
 Radiation Therapy: possibly pre or post op
 Chemotherapy: generally not beneficial
STAGE 3 MPNST OF THE LEFT RETROPERITONEUM
GTV: left RP tumor
CTV: GTV + 2cm sup/inf, 1.5cm radially, cropped off of kidney and liver and only allowing 0.5cm
Expansion into the small bowel
PTV: CTV + 0.5cm
OARs: Spinal Canal, kidneys, and small bowel
Rx: 50.4Gy in 28fx’s

Goal: PTV V95% > 95%

Initial plan: 3D
3D dose distribution
Field segments
Organs at Risk Desired Planning Objective Planning Objective Outcome

Spinal Canal Max < 45Gy 35.8Gy

Kidneys, R+L V20Gy < 50% 45%
Liver BioNTCP < 5% 0%
Small Bowel V54Gy < 1cc 0cc – max of 53.1Gy

OAR: constraints met

Small bowel: V51Gy < 5cc ?

VMAT?
VMAT
 2 arcs

 Optimization structures

 zPTV(+1mm)-sb(+1mm)
- left kidney (+1mm)
Optimization Objectives
VMAT dose distribution
Organs at Risk Desired Planning Objective Planning Objective Outcome

Spinal Canal Max < 45Gy 34.8Gy

Kidneys, R+L V20Gy < 50% 36%
Liver BioNTCP < 5% 0%
Small Bowel V54Gy < 1cc 0cc – max of 54
V51Gy < 5cc 2.7cc

Objectives met; including additional small bowel constraint

 DVH COMPARISONS

SMALL BOWEL: VMAT ADVANTAGE

DVH COMPARISONS

RIGHT KIDNEY: VMAT ADVANTAGE

DVH COMPARISONS

LEFT KIDNEY: VMAT ADVANTAGE

DVH COMPARISONS

LIVER: 3D ADVANTAGE
DVH COMPARISONS

PTV: VMAT ADVANTAGE

CONCLUSION
VMAT chosen over 3D
o More conformal
o Generally less meaningful dose to critical structures
o Able to scoop out small bowel & kidney

Patient update
o Tolerated treatment “well”
• Abdominal pain
• Mild diarrhea - controlled
o Ultimately decided not to pursue surgery or further treatment