1 Spencer Arnould September Case Study September 16, 2013 Neuroendocrine Distal Esophageal Carcinoma History of Present Illness:

Patient T is a 74 year old man !"o "as been recently dia#nosed !it" "i#" #rade neuroendocrine distal esop"a#eal carcinoma$ Patient T%s "istory be#an !"en "e started e&periencin# some retrosternal and epi#astric pain !it"in t"e last 'e! years, !"ic" "e attributed to !orsenin# stress$ ()er t"e last 'e! mont"s, t"e pain became pro#ressi)ely !orse !it" all si#ns pointin# to!ards dysp"a#ia$ A'ter an initial consult !it" "is primary care p"ysician, Patient T !as sent 'or an esop"a#oscopy on *uly 26, 2013, !"ic" s"o!ed a + centimeter ,cm- esop"a#eal mass$ A biopsy !as ta.en and sent to T"e /ni)ersity o' 0ic"i#an !"ere it !as re)ie!ed and positi)e 'or "i#" #rade neuroendocrine carcinoma !it" 'eatures su##estin# small cell or lar#e cell tumor$ A'ter t"is dia#nosis, Patient T !as sent 'or a positron emission tomo#rap"y ,P1T- scan on Au#ust 6, 2013, !"ic" demonstrated a 'leurodeo&y#lucose ,234- a)id esop"a#eal mass to!ards t"e #astroesop"a#eal ,41- 5unction$ Patient T also "ad a barium s!allo! procedure done on Au#ust 14, 2013, !"ic" s"o!ed an appro&imately 6$+ cm lon# middle to distal esop"a#eal narro!in# !it" irre#ular mucosal sur'ace e&tendin# do!n to t"e 41 5unction$ A'ter Patient T !as 'ully in'ormed o' "is dia#nosis, "e !as t"en re'erred to bot" medical and radiation oncolo#y to discuss de'initi)e c"emoradiation 'or t"e neuroendocrine esop"a#eal carcinoma$ Past Medical History: Patient T%s medical "istory includes lumbar disc de#eneration, art"ritis, "ypertension, "iatal "ernia, di)erticulosis, di)erticulitis, #astroesop"a#eal re'lu& disease ,4163-, and an&iety$ Patient T also "ad cataract sur#ery and a si#moid colectomy 'or di)erticulitis and abscess$ Social History: Patient T is married and !or.s in t"e real estate business !it" "is son$ 7e "ad a 1+ pac. year "istory o' smo.in#, but 8uit 43 years a#o$ 7e also stated t"at "e rarely drin.s alco"ol$ Medications: Patient T used t"e 'ollo!in# medications: aspirin, calcitriol, lisinopril, losartan, potassium, rosu)astatin ,Crestor-, sertraline ,9olo't-, tra:odone, and :olpidem ,Ambien-$ Diagnostic Imaging: A'ter t"e initial assessment and consultation !it" "is primary care p"ysician, Patient T !as sent 'or an esop"a#oscopy on *uly 26, 2013, !"ic" s"o!ed a + cm mass

2 !it"in t"e middle to distal re#ion o' t"e esop"a#us$ A biopsy !as ta.en 'rom t"is e&am and t"e results prompted bot" a re'erral to medical oncolo#y and 'urt"er testin# o' "is neuroendocrine esop"a#eal carcinoma$ (n Au#ust +, 2013, Patient T !as sent 'or a c"est computed tomo#rap"y ,CT- scan !"ic" indicated concentric esop"a#eal t"ic.enin# in t"e mid distal esop"a#us !it"out local in'iltration$ T"is e&am also prompted a re'erral 'or a P1T scan on Au#ust 6, 2013, t"at su##ested an 234 a)id mass in t"e 41 5unction, and also a paraesop"a#eal and #astro"epatic lymp" node$ 0ost mali#nant tumors o' t"e esop"a#us metaboli:e #lucose at a "i#"er rate t"an normal tissue !"ic" in turn causes an increased accumulation o' t"e #lucose analo# 'lourodeo&y#lucose ,234- in mali#nant tissues$1 ;n addition to t"ese procedures, Patient T also "ad a barium s!allo! on Au#ust 14, 2013, t"at indicated a 6$+ cm lon# distal esop"a#eal narro!in# to!ards t"e 41 5unction and t"ic.enin# o' t"e mucosal !alls in t"e esop"a#us$ Radiation Oncologist Recommendation: A'ter re)ie! o' Patient T%s neuroendocrine distal esop"a#eal carcinoma, t"e radiation oncolo#ist recommended t"at "e recei)e de'initi)e c"emoradiation$ Patient T "ad already met !it" bot" t"e medical oncolo#ist and t"oracic sur#eon !it" attempts at discussin# t"e possibility o' trans"iatal esop"a#estomy, but stated t"at "e continue !it" c"emoradiation alone$ A'ter a complete discussion about t"e rare nature o' "is neuroendocrine tumor and t"e lac. o' data speci'ic to t"e tumor, t"e radiation oncolo#ist re)ie!ed t"e lo#istics, ris.s, bene'its, and also t"e lon# and s"ort term side e''ects !it" recei)in# bot" radiation and c"emot"erapy$ T"e radiation oncolo#ist ultimately recommended t"at Patient T recei)e +$+ !ee.s o' daily radiation treatment, or 2< treatment sessions #i)en + days a !ee., in addition to c"emot"erapy !"ic" !ould most li.ely be sc"eduled around normal treatment sessions$ The Plan Prescription!: T"e radiation oncolo#ist treatment recommendation 'or Patient T !as to treat t"e lo!er middle to distal portion o' t"e esop"a#us, includin# t"e 41 5unction to a total dose o' +0$4 4ray ,4y- in 1$< 4y 'ractions daily$ Alt"ou#" Patient T "as 'or#one t"e pat" o' postoperati)e c"emoradiation, t"e combined modality o' c"emot"erapy and radiation t"erapy "a)e pro)en to be a muc" better solution t"an one sin#le t"erapy alone$ ;n a study by 7ers.o)ic et al2 speci'ic cancer t"erapy modalities includin# c"emot"erapy and radiation t"erapy !ere e)aluated$ T"e a)ailable 'indin#s su##ested t"at combined t"erapy resulted in not only better control o' local tumors and 'e!er distant metastases, but also o)erall sur)i)al$ 6adiot"erapy

3 also relie)es dysp"a#ia !it" 'e! complications and is #reat 'or palliation, but t"e use o' radiot"erapy as a sin#le de'initi)e treatment !it" curati)e intent is not recommended$3 Patient Immo"ili#ation: (n September 3, 2013, Patient T under!ent a CT simulation scan 'or radiation t"erapy$ 7e !as placed on a Ci)co t"ora& board ,2i#ure 1-, !"ic" included "is arms abo)e "is "ead, restin# !it"in ad5ustable arm cups 'or support$ An e## crate cus"ion and .nee cus"ion !ere placed underneat" "is bac. and .nees 'or additional support$ =e'ore t"e actual CT scan !as ta.en, t"e radiation t"erapist #a)e Patient T some barium sol)ent ,in li8uid s"a.e 'ormbe'ore scannin# t"e t"ora& re#ion$ T"is barium solution !as en"anced on t"e CT scan and "i#"li#"ted t"e entire esop"a#eal passa#e and entrance into t"e stomac", ma.in# t"e locali:ation muc" easier$ A'ter t"e scan !as complete, t"e radiation t"erapist placed re'erence te#aderms on t"e patient in order to "elp !it" ali#nment on t"e 'irst day$ (ne te#aderm !as placed 1+ cm belo! t"e superior sternal notc" ,SS>- ,2i#ure 2, 3- and t!o di''erent te#aderms !ere placed on eit"er side o' t"e patient 'or side le)els$ T"e radiation t"erapist also placed strai#"tener mar.s on t"e patient ,one superior and one in'erior o' t"e CT re'erence mar.- to ma.e sure t"at "e !ould line up strai#"t on t"e able$ $natomical Contour: A'ter t"e scan !as completed, t"e ima#es !ere sent to t"e 3i#ital ;ma#in# Communications o' 0edicine ,3;C(0- con8uest ser)er, !"ic" can import and e&port ima#es to t"e necessary treatment plannin# stations$ T"e ima#es 'rom Patient T%s scan !ere trans'erred to t"e 1clipse contourin# station 'or t"e p"ysicians and residents to contour )olumes$ =ot" t"e p"ysicians and residents contour t"e #ross tumor )olume ,4T?-, and sometimes t"e clinical tar#et )olume ,CT?-, !"ile also contourin# t"e necessary anatomic structures t"at need to be a)oided$ A'ter t"is process, t"e p"ysician and resident decide on an ade8uate e&pansion )olume .no!n as t"e plannin# tar#et )olume ,PT?-$ ;n t"is speci'ic case, t"e p"ysician decided t"at "e !anted to e&pand t"e 4T? by 1 cm circum'erentially and radially in order to delineate a suitable PT? 'or plannin# mar#in$ A'ter bot" t"e resident and p"ysician appro)e t"e e&pansion )olumes, a plannin# directi)e !as dictated 'or t"e medical dosimetrist to 'ollo!$ 3ependin# on t"e anatomical location o' t"e PT?, t"e medical dosimetrist decided to contour t"e normal structures t"at included t"e e&ternal body, spinal cord, lun#s, "eart, and bot" t"e .idneys and li)er due to t"e len#t" o' t"e e&pansion )olume e&tendin# in'eriorly to!ards t"e stomac"$ %eam Isocenter&$rrangement: A'ter t"e contours "ad been dra!n and t"e )olumes e&panded, t"e CT scan !as t"en e&ported to t"e con8uest ser)er, and re imported into /0Plan treatment

4 plannin# so't!are$ A'ter t"is process is completed, t"e medical dosimetrist obtained t"e treatment plannin# directi)e in order to t"e 'ollo! bot" t"e p"ysician and departmental #uidelines on ade8uate dosin# 'or t"oracic patients$ T"e medical dosimetrist be#an by desi#nin# a 'our 'ield bo& tec"ni8ue plan t"at essentially #a)e dose t"rou#" 'our di''erent an#led beams allo!in# 'or acceptable co)era#e around t"e PT?$ Alt"ou#" t"is type o' desi#n !or.s in many esop"a#eal cases, t"is speci'ic case did not allo! 'or suc" plannin# due to t"e e&tent and len#t" o' t"e PT? !it"in t"e esop"a#us$ T"e medical dosimetrist tailored t"e treatment plan by mo)in# t"e le't lateral 'ield do!n to 102@ and t"e ri#"t lateral 'ield do!n to 26<@ ,2i#ure 4-$ Since t"e esop"a#us and 41 5unction on t"is patient !as 'airly !ide and elon#ated, t"e medical dosimetrist needed to use a se#ment on all 'our 'ields in order to ade8uately co)er t"e tar#et )olume$ Treatment Plan: T"e plannin# system used to calculate t"e treatment plan !as /0Plan$ A"en startin# to plan t"is type o' treatment, t"e medical dosimetrist usually starts out !it" 6 me#a)olta#e ,0?- beam ener#y, and e)aluates t"e necessity 'or "i#"er ener#ies$ ;n t"is speci'ic distal esop"a#eal case, t"e PT? runs 'rom t"e lo!er middle to distal portion o' t"e 41 5unction, #i)in# rise to a more elon#ated tar#et )olume t"at runs t"e distance o' t"e t"ora& ,2i#ure +, 6-$ Ait" t"e separation o' t"e patient and t"e len#t" o' t"e PT?, t"e medical dosimetrist c"ose to use 16 0? beams in t"e ma5ority o' t"e beam an#les$ As 'i#ures 7 t"rou#" < demonstrate, all o' t"e non se#mented 'ields 'or t"is plan "ad a 0$< cm bloc.in# mar#in around t"e PT?, and t"e se#mented 'ields !ere s"aped in accordance to t"e )arious "ot spots around t"e re#ion$ /sin# all o' t"ese 'ields pro)ided enou#" co)era#e to con'orm and distribute dose around t"e tar#et )olume$ T"e medical dosimetrist also !ei#"ted t"e 'ields based on t"e dose to t"e spinal cord, lun# tissue, and "eart$ Since t"e AP and PA 'ields did not encompass as muc" lun# tissue, a "i#"er !ei#"t !as used in comparison to t"e t!o obli8ue lateral 'ields$ A"en plannin# 'or t"ese types o' cases, t"e medical dosimetrist also "as to consider t"e inter'ractional displacement o' bot" t"e esop"a#us and 41 5unction$ Accordin# to a study by Aan# et al4 t"ere is substantial c"an#e in t"e position o' t"e distal esop"a#us, not only !it"in 'ractions, but also bet!een 'ractions related to t"e respiration o' t"e patient$ T"is study re)ealed "o! t"ere can be a considerable di''erence in t"e treatment plannin# compared to t"e actual treatments bein# administered$ T"e o)erall normal tissue complication probability ,>TCP- 'or t"is case !as 13$74B, !"ic" 'alls !it"in our clinics tolerance le)els o' 1+B$ T"e o)erall ma&imum dose to

+ t"e PT? treatment )olume !as +4$6 4y, !it" t"e "eart recei)in# a mean dose o' 32$4 4y, and t"e spinal cord recei)in# a ma&imum dose o' 43$C 4y ,2i#ure C-$ 'uality $ssurance: T"e monitor unit calculation and monitor unit c"ec. !ere completed in bot" t"e do!nload ,t"rou#" /0Plan- as !ell as t"e second c"ec. t"rou#" a medical p"ysicist$ A medical p"ysicist ta.es not only calculates t"e plan t"rou#" anot"er so't!are pro#ram, but also sometimes "and c"ec.s bot" t"e monitor units and bac. up time to ma.e sure t"e plan a#rees !it" t"e tolerance t"at !as set$ T"e monitor units on t"is < 'ield esop"a#us tec"ni8ue !ere !it"in tolerance and !it"in t"e bac. up time associated !it" t"e department tolerance #uidelines$ Conclusion: Alt"ou#" t"is case may seem out o' t"e ordinary bein# t"at is "as more t"an 4 treatment 'ields, occasionally special circumstances pro)e to be substantial !"en it comes to treatment plannin#$ T"ere are many di''erent aspects to esop"a#eal treatment plannin# and one plan is ne)er t"e same as t"e ne&t$ T"ere are al!ays c"allen#es to t"ese types o' plans because t"e medical dosimetrist and p"ysician !ant t"e best possible outcome !it" t"e least possible side e''ects to t"e patient$ (ne o' t"e bi##est c"allen#es in plannin# t"is case !as c"oosin# t"e appropriate beam an#les in order to spare critical structures and normal tissue$ T"ese beam an#les !ere c"osen in order to spare as muc" normal lun# tissue as possible !"ile also .eepin# ade8uate dose to t"e PT?$ Anot"er issue t"at came up in plannin# t"is case !as t"e comparison bet!een usin# t"is 3 dimensional con'ormal treatment plan ,33C6T- )ersus an ;06T treatment plan$ Alt"ou#" t"e department usually stays !it" 33C6T esop"a#eal plannin#, an ;06T plan 'or t"is speci'ic case !ould be "elp'ul in brin#in# t"e o)erall dose do!n on critical structures$ /ltimately t"e 33C6T plan !as t"e c"oice due to outside patient 'actors$ ()erall, t"is case pro)ided a #reat opportunity to !or. !it" bot" t"e p"ysician and resident !"ile utili:in# some critical problem sol)in# s.ills in t"e treatment plannin# process$ T"is case also #a)e #reat e&amples and .no!led#e t"at could possibly be used in 'uture esop"a#eal cases$

(igures

(igure )$ Patient T is on a Ci)co T"ora& board !it" a .nee cus"ion and e##crate under "is bac.$

(igure *$ Patient T !it" a side le)el te#aderm$

(igure +$ Patient T !it" a CT re'erence and superior strai#"tener mar.$

(igure ,$ A&ial )ie! o' isocenter on Patient T$ T"e Pin. color indicates t"e +0$4 4y or 100B isodose line, and t"e (ran#e color indicates t"e 47$< 4y or C+B isodose line$

10

(igure -$ Sa#ittal )ie! o' Patient T$ T"e Pin. color indicates t"e +0$4 4y or 100B isodose line, and t"e (ran#e color indicates t"e 47$< 4y or C+B isodose line$

11

(igure .$ Coronal )ie! o' Patient T$ T"e Pin. color indicates t"e +0$4 4y or 100B isodose line, and t"e (ran#e color indicates t"e 47$< 4y or C+B isodose line$

12

(igure /$ /pper De't: PA =eams 1ye ?ie! ,=1?-$ /pper 6i#"t: PA Se#ment =1?$ Do!er De't: De't Posterior (bli8ue ,DP(- =1?$ Do!er 6i#"t: DP( Se#ment =1?$

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(igure 0$ /pper De't: AP =1?$ /pper 6i#"t: AP Se#ment =1?$ Do!er De't: 6i#"t Posterior (bli8ue ,6P(- =1?$ Do!er 6i#"t: 6P( Se#ment$

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(igure 1$ 3ose ?olume 7isto#ram ,3?7- s"o!in# t"e )arious structures t"at !ere contoured in t"e plan$

1+ References 1. C"ao E, Pere: C, =rady D$ Radiation Oncology Management Decisions$ 3rd ed$ P"iladelp"ia, PA: Dippincott, Ailliams F Ail.insG 2011:3+7 371$ 2. 7ers.o)ic A, 0art: E, Al Sarra' 0, et al$ Combined c"emot"erapy and radiot"erapy compared !it" radiot"erapy alone in patients !it" cancer o' t"e esop"a#us$ New Eng J Med$ 1CC2G326,24-:1+C3 1+C<$ 3. 7eat" 1, 7eitmiller 6, 2orastiere A$ 1sop"a#eal Cancer$ ;n: 7all D, ed$ Clinical Oncology$ Atlanta, 4A: American Cancer SocietyG 2001:331 343$ 4. Aan# *, Din S, 3on# D, et al$ Huanti'yin# t"e inter'ractional displacement o' t"e #astroesop"a#eal 5unction durin# radiation t"erapy 'or esop"a#eal cancer$ Int J Rad Onc$ 2012G<3,2-:e273 <0$ doi: 10$1016I5$i5robp$2011$12$04<$