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Wael Mekhael

Clinical Practicum I
February 13, 2015
Left Foot Liposarcoma
History of the present illness: Patient BJ is a 38 years old gentleman who presented to Wyckoff
medical center on 10/14/2014 after several months of pain and swelling in his left foot, which he
ignored for a while until it became painful. On August 8, 2014, he had an MRI on the left foot
which showed an irregular mass measuring 11 x 9 x 6 cm. The mass was on the plantar surface
of the foot extending superiorly between the first and second metatarsal bone and between the
second and the third metatarsal bone to the dorsum of the foot. It has caused marked deformity of
the second and third metatarsal bone with fracture of the diaphysis of the second metatarsal bone.
On September 29, 2014, BJ had surgery and excision of this mass. It was 98 g, measuring 7 x 6 x
4cm. The final pathology report showed it was an atypical lipomatous tumor; well differentiated
liposarcoma which is a rare malignancy of the fat cells.1The tumor abuts several margins of
resection. Post-surgery, the patient had a PET/CT scan which showed swelling of the left
intrinsic foot and a FluoroDeoxyGlucose (FDG) activity of 2.8, which is unclear whether it is
postsurgical or reflects residual low grade sarcoma. There was no evidence of other metastasis.
There are no lymph nodes superficially palpable. There is no inguinal femoral lymph node
palpable. Examination of the left foot revealed the scar which is about 10cm and is completely
unhealed with a lot of discharge from the incision. The patient was referred to Wyckoff medical
center for consideration of a postoperative course of external radiation therapy as a combination
of surgery and radiation therapy has been shown to prevent recurrence.2
Past Medical History: The patient has never had any medical issues before. On examination his
pulse is 71, and blood pressure is 136/90. The patient is alert and oriented. He is in very good
health. The chest is clear to percussion and auscultation.
Social History: The patient is married and has 2 children. He has worked as supermarket
associate for 5 years. He sleeps 8 hours a day, and has no family history of any type of cancer.
The patient is a non-smoker and has never used tobacco. The patient states that he does not drink
alcohol and denies any drug use. His parent are still alive and in good health.
Medications: no medications.

Diagnostic Imaging: On 8/8/2014, an MRI examination of the left foot indicated a soft tissue
mass and fracture. There is a large mass on the plantar surface of the foot extending superiorly
between the first and second metatarsal bones and between the second and the third metatarsal
bones, extending to the dorsum of the foot. This is an irregular shaped mass which is difficult to
measure accurately. It measures approximately 11 cm by 9cm by 6cm. The mass is essentially
composed of fat, but also contains fibrous tissue and inflammatory edema, perhaps superimposed
infection. This lesion has been present for a long time, perhaps years. It has caused marked
deformity of the second and third metatarsal bone. There is a fracture of the diaphysis of the
second metatarsal bone. There is edema in the marrow of the second, third and fourth metatarsal
bone and the mass itself, with enhancement following contrast injection raising the possibility of
superimposed infection.
Medical Oncologist Recommendations: Surgery: On 9/29/2014 the patient was brought to the
operating room, the entire soft tissue mass was removed and did not involve any neurovascular
components. It appeared to be large yellow well encapsulated lipomatous mass measuring
approximately 8 x 7.5 x 4 cm. The soft tissue mass was tagged at the dorsal distal aspect with
nylon and sent as specimen to pathology for analysis. The sites were then inspected for any
residual soft tissue mass and none was found.
The patient tolerated anesthesia and procedure well and without complications. The patient was
instructed to be strictly nonweight bearing to the left foot at this time with crutches for
ambulation if necessary.
The final diagnosis was an atypical lipomatous tumor, well differentiated liposarcoma. The
tumor abutted several inked margins of resection. For this case, there is a high risk of recurrence.

PET/ CT scan: On 10/20/2014, a whole body PET/CT scan was performed from the skull vertex
down to the toes. Prior to PET imaging, a diagnostic CT scan of the brain, neck, chest, abdomen,
pelvis and lower extremities was performed with and without IV contrast for attenuation
correction and anatomic localization. Diffuse swelling of the intrinsic musculature along the
plantar aspect of the left foot extending into the inter-metatarsal space between the first, second
and third proximal metatarsals is evident. The soft tissue swelling demonstrates low grade FDG
activity with SUV Max 2.8. Its unclear if the finding represents postsurgical change or residual

neoplasm, sclerotic reaction seen in the second and third metatarsal, likely reflecting healed
fracture deformity.
Brain: no abnormal intracranial activity seen. CT reveals no intracranial mass.
Neck: no abnormal FDG uptake. CT reveals no neck mass or pathologic lymphadenopathy.
Chest: No abnormal pulmonary, pleural or nodal uptake. CT reveals no parenchymal mass,
pleural disease or pathologic thoracic lymphadenopathy. 7mm calcified granuloma at the lateral
lung base.
Abdomen and pelvis: Normal homogenous activity in the liver, normal activity in the spleen.
Physiologic uptake in the urinary tract, no abnormal bowel activity, CT reveals no adrenal mass,
pathologic abdominal or pelvic lymphadenopathy, ascites or carcinomatosis, small fat containing
umbilical hernia.
Osseous Structures: Aside from the soft tissue and osseous changes in the left foot, no other bony
abnormality seen.
Impression: Swelling of the left intrinsic foot musculature with mild FDG activity. Its unclear if
this all postsurgical or reflects some component of residual low grade sarcoma. Correlation with
the details of surgery recommended. No evidence of metastatic disease.
Radiation Oncologist Recommendations: Radiation Therapy: The patient presented with low
grade liposarcoma of the left foot which is surgically excised; however, all margins or many
margins were positive. The lesions have been there for a while, and neglect caused damage to the
metatarsal bone which includes a fracture. The physician strongly recommended that the patient
get a postop course of external radiation therapy to deliver a high dose to the affected foot. He
recommended an IMRT conformal treatment plan to homogenize the dose and try to prevent as
much fibrosis as possible which is going to affect him especially when he is walking. The case
was discussed in detail with the patients primary oncologist and the surgeon. A decision was
made as to start his treatment as soon as the wound heals completely. Side effects and benefits of
the treatment were explained to the patient at length. The patient consented for the treatment. He
will be seen as soon as there is full healing.
The Plan (prescription): The radiation oncologists treatment recommendation to BJ was an
IMRT plan that consisted of four beams for the primary treatment to the left foot. In addition, the
radiation oncologist recommended an IMRT cone down boost to the tumor bed following

primary treatment. The IMRT boost plan incorporated four photon beams targeting the tumor bed
region located within the left foot. The prescription dose for the initial left foot plan was 45 Gray
(Gy) at 1.8Gy per fraction for 25 fractions. The boost prescription dose to the tumor bed region
was 18Gy at 1.8Gy per fraction for 10 fractions. The composite dose to the left foot tumor region
was 63Gy. For the evaluation of this case study, the primary left foot IMRT plan and the IMRT
boost will be discussed.
Patient Setup/Immobilization: Immobilization devices should be designed to help decrease
setup error and patient motion during the treatment; this may reduce the margin that needs to be
placed around the tumor (PTV) therefore decreasing dose to normal tissue. On December 9,
2014, BJ underwent a computed tomography (CT) simulation scan for radiation therapy
treatment. The patient was placed in the supine position feet first on the CT simulation couch
with his left foot straighten and positioned above the couch and inserted in a custom made alpha
cradle. The patients arms were fixed on the chest. The radiation oncologist marked the superior,
inferior, medial, and lateral regions of the left foot tissue with BBs. In addition, the tumor scar
was outlined on the patients foot skin surface with CT wire to identify the location of the scar on
the CT simulation scan.
Anatomical Contouring: After completion of the CT simulation scan, the CT data set was
transferred into the Philips Pinnacle v9.6 radiation treatment planning system (TPS). The
radiation oncologist contoured the left foot PTV volume on the TPS that included the superior
portion of the patients left foot tissue extending through to the inferior portion of the foot tissue.
In addition, the radiation oncologist contoured the tumor bed in the left foot by locating the scar
that was wired at the time of CT simulation and identifying the seroma from the surgery
procedure on the CT data set. The location and size of the tumor was verified from the operative
reports. Furthermore, the left foot volume was adjusted 0.5cm all around the volume PTV
surface. 0.5 cm bolus was used to eliminate skin sparing and give more doses to surface. The
medical dosimetrist was given a prescription objective sheet to begin treatment planning.
Beam Isocenter/Arrangement: The Siemens Primus linear accelerator was used for this
treatment. The medical dosimetrist placed an isocenter in the middle of the PTV. The primary
plan utilized four beams all with 6MV energy. A left posterior oblique (LPO) with a gantry angle
of 245, right posterior oblique with a gantry angle of 150, an anterior gantry angle of zero, and
a right anterior oblique with a gantry angle of 55. The medical dosimetrist assigned the

prescription of 180 cGy per fraction to 100% of the PTV. The TPS determined and automatically
adjusted the field sizes of each beam in relation to the treatment objectives in order to
accomplish the desired dose distribution around the target volume. For the boost plan the same
four beams were used but the LAO and RAO gantry angle changed to 310 and 50 respectively.
Treatment Planning: The Philips Pinnacle v9.6 was used. The radiation oncologist outlined the
dose prescription and objectives for the IMRT plan. The objective was to use the IMRT fields to
maintain an adequate and homogenous dose distribution throughout the PTV. The prescription
dose for the IMRT and the boost fields was prescribed to the isocenter placed by the medical
dosimetrist within the PTV. Beams were assigned to the isocenter point and computed to deliver
the daily prescription dose which was delivered as a mean dose to the PTV with the IMRT fields.
The patient received a total of 180 cGy per day for 25 fractions. The objectives for the left foot
volume that were entered into the IMRT module of the TPS were a uniform, minimum, and
maximum dose corresponding with the prescribed dose. The TPS utilized the direct machine
parameter optimization (DMPO) feature with 30 segments to accomplish the primary IMRT
objectives and parameters, and 30 segments for the boost plan. Objectives were maximum dose
of 4750 cGy, minimum dose of 4200 cGy, and uniform dose to 4500 cGy. Once adequate
prescription dose coverage was achieved to the left foot volume with this IMRT plan, the
medical dosimetrist reviewed the isodose lines, and the dose volume histogram (DVH). The
IMRT plan of the left foot achieved adequate prescription coverage and a homogeneous dose
distribution throughout the left foot tissue. The radiation oncologist also reviewed the plan and
assigned a normalization of 95% to each prescription of the treatment plan.
Quality Assurance/Physics Check: The monitor units (MUs) check for the plan was completed
with a quality assurance (QA) plan delivered on the linear accelerator. Our department tolerance
for the TPS MUs and the ion chamber dose readings is 3% for each field. The proper opening of
the MLC was checked by the film, and this plan fell within this tolerance. The completed IMRT
treatment plan was reviewed by a medical physicist for a final check before treatment began.
Conclusion: When discussing this plan with the physician, he mentioned that this patient was
not as hard from the point of treatment planning. There is no critical structure in the path of the
beam that we should be worry about, or have to meet its tolerance. It was beneficial for me to be
introduced to Liposarcoma which is a rare cancer of connective tissues. Liposarcoma is a
malignancy of fat cells, and in adults it is the most common soft tissue sarcoma. It is a highly

pleomorphic disease whose outcome is determined by its histologic subtype. Surgery and
radiation achieve excellent local results with relatively little metastatic risk for patients with
well-differentiated liposarcoma. Combination of surgery and radiation therapy has been shown to
prevent recurrence at the surgical site in about 85-90% of liposarcoma cases. These results vary
depending on the subtype of sarcoma that is involved. Radiation therapy may be used before,
during or after surgery to kill tumor cells and reduce the chance of the tumor returning in the
same location. Radiation therapy that is given before surgery may be more beneficial, but it can
also make it more difficult for surgical wounds to heal. Cumulative toxicity and tolerance depend
mainly on the patients general status. Image-guided radiation therapy (IGRT) is essential,
irrespective of the IMRT technique used. Definitive radiotherapy should be considered in clinical
situations where no acceptable surgical option is available.3 Also when discussing liposarcoma
with the physician; he mentioned another patient was diagnosed with liposarcoma, who
underwent radiation therapy because he refused surgery. Unfortunately, the tumor was not
responsive to radiation therapy. Lung metastasis developed one year later. Combination of
surgery and radiation therapy has been shown to be the most effective course for liposarcoma
treatment.
References:
1- Clark MA, Fisher C, Judson I, et al. Soft-tissue sarcomas in adults. New Engl J Med.
2005;353:701711. http://dx.doi.org/10.1056/NEJMra041866
2- Cormier JN, Pollock RE. Soft tissue sarcomas. CA Cancer J Clin. 2004;54:94109.
http://dx.doi.org/10.3322/canjclin.54.2.94
3- Kepka, L, Delaney, TF, Suit, HD, Goldberg, SI Results of radiation therapy for
unresected soft tissue sarcomas. Int J Radiat Oncol Biol Phys 2005; 63:852.
http://dx.doi.org/10.1016/j.ijrobp.2005.03.004

Figures:

Figure 1: Patient position with foot alpha cradle at CT simulation.

Figure 2: Isocenter placement. AP and LAT view.

Figure 3: Primary IMRT plan 4 beams setup.

Figure 4: Boost IMRT plan 4 beams setup.

Figure 5: isodose lines of the primary IMRT plan in the axial view.

Figure 6: isodose lines of the primary IMRT plan in the sagittal view.

Figure 7: isodose lines of the primary IMRT plan in the coronal view.

Figure 8: isodose lines of the boost IMRT plan in the axial view.

Figure 9: dose volume histogram of the primary IMRT plan.

Figure 10: dose volume histogram of the boost IMRT plan.

Figure 11: isodose lines of the primary plus boost IMRT plan composite in the axial view.

Figure 12: dose volume histogram of the primary plus boost IMRT composite plan.