1 Krzysztof Karteczka March Case Study March 24, 2012

Sarcoma of the Thigh Present Illness: The patient is a 100 year old man who was initially presented in November of 2011 with a two month history of a right inner thigh mass. A radiograph of the right femur showed only degenerative changes. Magnetic Resonance Imaging (MRI) of the right thigh showed 5.2 centimeters (cm) mass in the medial aspect of the thigh within or immediately adjacent to the sartorius muscle. There was some obliteration of the fat plane where the mass abuts the adductor magnus muscle. There was no bony involvement. The patient was evaluated by orthopedics at University of Chicago. Biopsy of the right thigh mass reportedly revealed a high grade pleomorphic sarcoma. Computed Tomography (CT) of the chest showed a stable 2.8 cm right lower lobe mass-like consolidation. Currently, the patient notes mild right thigh pain with ambulation. He is ambulating with a walker. He denies any weakness or numbness of the extremity. He denies any lower extremity edema. Past Medical History: The patient has a medical history of hypercholesterolemia, hypertension, chronic kidney disease, osteoarthritis, gout, Meniere's disease, and shingles. Past Surgical History: The patient has a surgical history status post cataracts. Allergies: The patient is allergic to Sulfa, amlodipine, diltiazem, and lisinopril. Medications: The patient uses following medications: lasix, allopurinol, mobic, metoprolol, losartan, omeprazole, and colace. Diagnostic Imaging Studies: The patients workup included a radiograph of the right femur followed by an MRI, which revealed 5.2 cm mass in the medial aspect of the thigh within or immediately adjacent to the sartorius muscle. CT scan of the right femur and chest has demonstrated additional 2.8 cm mass in the lower lobe of the right lung. Family History: There is no family history of cancer. Social History: The patient is widowed for 4 years. He has 3 children. He denies any use of tobacco and alcohol, and denies drug abuse. He is originally from China. The patient is retired from office work.

2 Review of Systems: The patient denies any significant symptoms referable to the respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, endocrine, hematological, head, ears, eyes, nose and throat, skin, or neuropsychiatric systems. Assessment and Recommendations: The patient is a 100 year old man with a T2bN0M0 stage III high grade pleomorphic sarcoma of the right thigh status post biopsy. The patient has no definite evidence of metastatic disease. The patient and his family are not sure whether to undergo surgery given the patient's age and medical problems. The doctor discussed with the patient and his family the rationale, risks, and benefits of radiation therapy. They discussed the use of adjuvant radiation therapy following surgery to reduce the risk of local recurrence especially in the setting of high grade tumors. They discussed that surgery is the only curative option. The Plan (Prescription): The doctor discussed that radiation therapy alone could be used to shrink the tumor but it is not curative and re-growth of the tumor could occur at some point. Given the high grade of the tumor and large size it can potentially happen as soon as several months following treatment. The plan is to deliver a total dose of approximately 5000 centigray (cGy) in 25 fractions conventionally to a field encompassing the mass. The doctor has referred the patient to surgical oncology at NorthShore for a second opinion regarding surgery. The patient and his family were also encouraged to discuss the case further with their Primary Care Physician, to determine if the patient would even be a surgical candidate from a medical standpoint. Patient Setup/Immobilization: The patient was simulated in the supine position on a wingboard, and B type headrest. For immobilization of lower limbs vac-fix bag was used. A treatment planning computed tomography (TPCT) was completed with 4.0 millimeters (mm) slice spacing from iliac crest to the knee. Marks were placed on the skin using the leveling lasers on the CT scanner. Fiducial markers were placed over these marks. The axial CT images were transferred to the Varian Eclipse treatment planning system. Anatomical Contouring: The scan was imported from the CT scanner to the treatment planning computer. Contouring was minimal with this setup. The doctor contoured the gross tumor volume (GTV) and I added external contour. Beam Isocenter/Arrangement: The doctor assigned the isocenter during the CT simulation. It was placed in the middle of the mass. This isocenter was used for treatment planning. According

3 to the prescription, the physician wanted two field arrangements, photon beam energy 6 megavolts (MV) used on Varian Clinax iX. I began on the anterior side of the patient with the left anterior oblique (LAO) beam placed at 338 degrees and continued on the posterior side with the right posterior oblique (RPO) beam at 158 degrees. This beam arrangement allowed me to spare femur from unnecessary radiation dose. Treatment Planning: The treatment planning system used was Eclipse 8.9. The objective of the treatment was to conform the dose distribution to the GTV, while minimizing the dose to surrounding tissues. To reach that goal I created two additional field in field for the RPO field, another field in field was created for the LAO field. Multi-Leaf Collimator (MLC) was also created to block hot spots. I achieved proper dose distribution by changing a weight factor of my fields. I weighted my posterior fields 0.37, 0.05, and 0.04. Anterior fields were weighted 0.51 and 0.03. This helped me in minimizing a hot spot and keeping it at 107%. Dose was calculated using the analytic anisotropic algorithm (AAA) of the treatment planning system. See figures 1 and 2 below for graphic illustrations.

Figure 1: Axial, Sagittal, and Coronal slices of Isocenter location

5 Figure2: Dose Value Histogram

Monitor Unit (MU) Check: After the plan was approved by the physician, the physicst performed a monitor unit check before the first day of treatment. A program called RadCalc was used to take the treatment parameter data from the treatment plan in Eclipse. For RPO field monitor unit output value was 105, a 0.6 % difference from plan MU, MU for LAO was 122 (0.8 % difference). At NorthShore University Health Systems, percentages over +/- 5% are unacceptable for treatments. See Figure 3 for Photon Monitor Unit Calculation Sheet.

Figure 3: Photon Monitor Unit Calculation Sheet.

Quality Assurance Check: To verify that the dose produced on the accelerator was the same as what was planned in the Eclipse treatment planning system, diodes were used within the first three fractions. The mobile Mosfet Dose Verification System was used, with 1.5 cm bolus placed on the top of the dosimeter. For the LAO field, the expected diode range was 133.0 to 147.0 cGy. The reading dose was 139 cGy, which was within the limits.

7 Conclusions: I chose this case study because it was a very interesting one. Having studied this case, I have a better understanding of the application of field in field technique, dose distribution, and complexity of treatment planning. Additionally, the plan helped me gain confidence in the weighting of the fields. Overall, I feel really good about working on this case and I have learned a lot from it. I look forward to learning and getting to plan even more challenging cases in the future.