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Heather Schultz September Case Study September 30, 2012

Larynx Three Field History of Present Illness: DM, a 60-year-old male, reported with the complaints of progressive hoarseness, loss of appetite and weight for the last eight months. For the last six months, he noticed a periodic difficulty in swallowing solid food that increased with time. The patient had been smoking two packs of cigarettes per day for the past 25 years. Direct laryngoscopy revealed a two centimeter (cm) growth covering the left vocal cord, right pyriform fossa, ventral aspect of epiglottis, and adjacent area of the lateral pharyngeal wall. The surface of the growth was irregular, nodular, ulcerated and bled on touch. Magnetic Resonance Imaging (MRI) of the neck showed growth in subglottic region, and Computed Tomography (CT) scan of the thorax and abdomen showed no lesions suggestive of metastasis. Past Medical History: The patients past medical history is significant for hypertension and Coronary Obstructive Pulmonary Disease, COPD, both well controlled with medication.

Diagnostic Imaging Studies: A biopsy was taken from the lesion, and histopathological examination led to the diagnosis of small cell carcinoma. A cranial nerve examination appeared normal. There was mild biphasic stridor with deep inspiration and expiration, but the patient had no difficulty breathing at rest, and breath sounds were clear.

Family History: The patient has no family history of cancer.

Social History: Retired veteran with a long history of tobacco chewing, 25 years of smoking, and social alcohol use.

Medications: The patient is taking antihypertensive medications and prescribed medication for COPD.

Recommendations: Treatment recommendations for this patient include radiation therapy treating the entire larynx. Side effects were covered by the Physician, and the patient agreed to proceed with treatment.

The Plan (Prescription): The plan is for the patient to receive a total of 6525 centigray (cGy), 29 fractions, 225 (cGy) per fraction to the contoured target. The plan is an external beam treatment technique consisting of a right anterior inferior oblique, a left anterior inferior oblique, and an anterior field. The beams eye view for all three treatment fields can be seen in figure 1. Dose was prescribed to a prescription point just off laterally to the simulation isocenter, and the plan was normalized to the 95% isodose line in order to ensure adequate coverage. The prescription is also scheduled for the patient to be treated once per day, and five fractions per week, for a total of 29 fractions.

Patient Setup/Immobilization: DM was simulated in the supine position with a bolster under his knees and a band around his toes. A long Aquaplast mask, reaching past his shoulders, was used in order to ensure shoulder immobilization and to aid in making sure that the shoulders were in a position to enable optimal beam arrangements. While creating the mask, shoulder pulls were used in order to help the patient keep the shoulders out of the way while the mask hardened. The patients arms and hands were placed upon his chest holding a foam ring. A treatment planning CT scan was performed to include the anatomy from mid lung to the top of the skull.

Anatomical Contouring: Prior to the planning CT scan importation into the treatment planning system, a simulation isocenter was selected within the projected volume of interest. The scan was then imported into the treatment planning software, Pinnacle. From there, the simulation isocenter coordinates were imported and labeled accordingly. A prescription point off axis was created and used for dose prescription. The radiation oncologist contoured the planning target volume, larynx, and also the gross tumor volume. Upon importing, the external contour was created, so I contoured the cricoid cartilage and the spinal cord. The cricoid will be used for determining field borders.

Beam Isocenter/Arrangement: The simulation isocenter was still used for the treatment field isocenter, but a prescription point was created off axis. Beam angles were decided on based upon staying off of the shoulders. This was done by slight couch kicks on the two lateral oblique fields and having them both at an angle that was not straight lateral. Field borders were decided on by the anterior boney spine as the posterior border (following a collimator angle), inferiorly to the cricoid cartilage superiorly to about the middle of the thyroid notch, and anteriorly with a small amount of flash. The field borders were patient specific due to his anatomy, and the borders were approved by the Physician.

Treatment Planning Initially, I created a two field plan consisting of two oblique lateral opposed beams. Both beams had wedging with heels anterior and were weighted accordingly. There was also a couch kick in order to maintain the avoidance of the shoulders. This plan was acceptable, but there was a lot of normal tissue being treated, and my coverage was not as good as anticipated, the transverse isocenter slice can be seen in figure 2. From there, I created a new plan that utilized three beams, which ended up with better coverage seen in Figure 3, and a dose volume histogram showing coverage and critical structure doses can be seen in Figure 4. The same two lateral obliques from the two field plan were used, but an anterior field with a wedge pulling dose inferiorly was added. All beams were six megavoltage (MV) and the weighting was fairly equal with the two obliques (slightly favoring the affected side), and only 14.5% to the anterior. The oblique beams had couch kicks and a slight angle on the collimator to follow the anterior edge of the spine, and had 45 degree wedges. The anterior beam had no couch or collimator kick with a 45 degree wedge as well. Multi-leaf collimation was not used due to the small fields. Further beam characteristics can be seen in Figure 5.

Monitor Unit (MU) Check: The treatment plan for this patient was reviewed by a dosimetrist and physicist. The dosimetry review included reviewing the reference fields, reference points, reference localization, radiation script, contours, dose volume histogram, and isodose line. MUCheck was used to check the doses by computer. The information for the equivalent path length wedge factors and off axis factors were entered per field, and the treatment field size was selected. The deviation percentages from actual planned MUs are evaluated by showing how

accurate the reading is. At the VA in Minneapolis, MN, percentages over +/-3% are unacceptable for treatments.

Quality Assurance Check: Monitor units were calculated, and then compared with the planned monitor units in order for quality assurance to be completed.

Conclusion: I chose this case because I have not had the opportunity previously to plan a 3-D conformal plan for a larynx. It was a great learning opportunity because I was able to do some reading about traditional beam arrangement and dosing prior to creating the treatment plans. I felt that this case allowed me to explore various paths to get to the same outcome, all while continuing to work with Pinnacle treatment planning.

Figure 1. Beams eye view for three fields.

Figure 2. Transverse isocenter slice of the initial two field plan. This image shows the increase in normal tissue treated.

Figure 3. Transverse isocenter slice of the three field plan. This image shows a more conformal plan, sparing more normal tissue.

Figure 4. Dose Volume Histogram for three field plan. Dose statistics listed below.

Figure 5. Beam characteristics.