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Amanda Lisher
February Case Study
February 28, 2015
Modified Fractionation for Stereotactic Lung Treatment
History of Present Illness: FL is a 59-year-old man diagnosed with sarcomatoid carcinoma of
the left upper lung in late December 2014. FL has a history of lung disease, including a bleb that
resulted in pneumothorax in 2011 which required talc pleurodesis for seal. He is managed by his
primary care physician for severe COPD. A routine CT of the chest on November 12, 2014
revealed a new 4.2cm mass in the left upper lobe. Numerous additional chronic findings, such as
pleural thickening and bronchiectasis, were also noted. A follow-up PET scan on December 3,
2014 revealed significant metabolic activity in the new lung lesion, with an SUV of
approximately 30. Incidentally, there was a range of uptake in several pleural densities, which
the pulmonologist explained is a result of his talc pleurodesis, and is benign. FL was not
considered at risk for pneumothorax, and the new lung lesion was biopsied December 22, 2014.
Findings were consistent with Stage T2aN0M0 sarcomatous carcinoma. CT staging of the head
was negative for metastatic disease. Currently FL is on 2-3 liters of continuous oxygen. At the
time of consultation he had no malaise, but described a feeling of early satiety due to dyspnea
upon eating a full meal. He had approximately a five pound weight loss over the previous six
months. He denied a significant cough, chest pain, or difficulty swallowing. He had no fever or
chills. He did describe occasional muscle tenderness at a previous thoracic wedge resection site.
Past Medical History: FL has a prior history of depression, small hiatal hernia, COPD and
emphysema. Surgical history includes an appendectomy, pilonidal cyst resection in 1974,
surgical correction of facial trauma in 1992, and cardiothoracic surgery in 2011. FL reports an
allergy to Roflumilast.
Medications: FL currently uses Albuterol Sulfate as needed, vitamin D3, Fumarate nebulizer,
and Budesonide.
Family History: The patients mother is alive at 89 years old, with a prior history of breast
cancer. His father died at the age of 57 of lung cancer. He has three siblings; a brother who died
at age 60 of pancreatic cancer, and two reportedly healthy sisters, ages 65 and 66.
Social History: FL has lived in the area all of his life. He smoked approximately two packs a
day for 40 years and quit in 2012. He completed high school. He worked as a cabinetmaker for

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20 years, and then as an electrician for 20 years. He is currently disabled. He occasionally walks
on the treadmill at the hospital for exercise. He has three adult children; a 32-year-old son, a 30year-old daughter, and a son who died at age 28 of a prescription pain killer overdose. FL
currently lives with his mother.
Diagnostic Imaging Studies: In addition to routine chest CT scans for management of COPD,
FL underwent a PET scan on December 3, 2014 which revealed uptake in a new 4.2cm pleural
lesion. CT staging of the head was completed in December 2014, and was negative for metastatic
disease. A planning CT scan was also obtained in the radiation oncology department prior to
treatment planning.
Radiation Oncologist Impression and Plan: FL is a 59-year-old man with asymptomatic
sarcomatoid carcinoma of the left upper lung. His estimated five-year survival is approximately
40-50%. Based on FLs poor lung function resulting from severe COPD, the radiation oncologist
did not feel he was a reasonable candidate for surgical resection. He did, however, recommend
stereotactic body radiation therapy (SBRT), which would offer an equal opportunity for local
control, in the range of 80-85%, with a 10-15% chance of developing regional nodal disease
and/or metastatic disease in distant organs by five years. The radiation oncologist explained that
SBRT is an ideal treatment option in this case, given its equivalent control rates and risk of acute
pulmonary toxicity. The physicians major concern for FL was a possible loss of lung function in
the treated area. Due to FLs history of lung disease, a 5% decrease in lung function could have a
significant clinical impact. The radiation oncologist estimated FLs risk of developing worsening
breathing function in the range of 10-20%. Due to the lateral location of the tumor in the left
lung, the physician also explained the risk of radiation-induced rib fracture to be in the range of
10-20% as well. FL verbalized his understanding and desire to proceed with SBRT. A simulation
was scheduled, in preparation for a course of SBRT to the left upper lung.
Radiation Plan/Prescription: FL was prescribed a course of SBRT to the left upper lung,
5000cGy total dose to be delivered over 5 days, 1000cGy per fraction. However, the treatment
planning CT revealed interval progression of the tumor, which was then approaching 5cm with
invasion into the chest wall and adjacent ribs. The radiation oncologist determined that SBRT
would be unsafe in this case, due to the risk of chest wall injury and subsequent chronic rib pain.
Alternatively, he prescribed a slightly longer course of therapy with the same radiobiologic dose

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effect, but with less risk of normal tissue injury. The final radiation prescription called for a total
dose of 7004cGy to be delivered in 17 days, 412cGy per fraction.
Patient Setup/Immobilization: CT simulation was performed on January 12, 2015. A custom
Medical Intelligence BodyFIX vac-loc was constructed for immobilization. FL was positioned
on the CT table supine, with both arms above his head, supported by the vac-loc. A pillow was
placed under his head, and an angle sponge under his knees for comfort. After the vac-loc was
made, a full-body plastic sheet was placed over FL and attached to the BodyFIX with doublesided adhesive. A vacuum was applied to the space between the bag and the plastic, essentially
sealing FL inside to limit movement during his stereotactic treatments (Figure 1). A GE
LightSpeed CT scanner was used for the simulation. Images were obtained at 2.5mm intervals
throughout the thoracic region. Scans were acquired during quiet breathing, inspiratory breath
hold and expiratory breath hold to assess tumor movement.
Anatomic Contouring: Following simulation, the CT data sets were uploaded to the Philips
Pinnacle3 9.8 radiation treatment planning system (TPS). Normal anatomic structures were
contoured by the dosimetrist, including the spinal cord, heart and great vessels, right and left
lung, combined lung, trachea and main bronchus, and the left chest wall. The radiation
oncologist contoured the GTV and expanded PTV.
Beam Isocenter/Arrangement: Treatment was completed on a Varian 23iX linear accelerator.
Position was verified daily with KV image guidance (Figure 2). A KV cone beam CT (CBCT)
was completed once each week to check tumor volume and contours. FL was treated with a 6MV
IMRT technique, delivered via 8 isocentric beams. There were no collimator or couch angles
required.
Treatment Planning: The Philips Pinnacle3 TPS version 9.8 was utilized for treatment planning.
The dosimetrist placed the isocenter roughly in the center of the GTV, approximately 2cm from
the left lateral chest wall. The dosimetrist also set appropriate field sizes for each treatment
angle. The TPS determined multi-leaf collimator (MLC) arrangements based on treatment
objectives to maximize dose to the PTV while limiting dose to the surrounding lung (Figures 3
and 4). Dose constraints to organs at risk included: dose to 30% of combined lung volume less
than 20Gy, dose to 40% of esophagus less than 50Gy, dose to 50% of the heart less than 30Gy,
maximum dose to the spinal cord less than 45Gy. The standard lung SBRT protocol constraint
limits dose to the chest wall at less than 30cc receiving no more than 30Gy. This constraint was

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impossible to achieve with the standard SBRT fractionation of 1000cGy in 5 fractions to a total
dose of 5000cGy. In order to reduce chest wall toxicity the radiation oncologist changed the
prescription to a modified fractionation of 412cGy in 17 treatments to a total dose of 7004cGy.
According to the physician and physicist, this fractionation pattern supplies an equal biological
dose to the tumor while sparing the chest wall. Heterogeneity corrections factors were applied, to
account for differences in attenuation in the various tissue densities in the thorax. The dose was
normalized at 97%, resulting in an actual PTV mean dose of 7216cGy. All plan dose constraints
were met (Figure 5).
Quality Assurance Check: The final Pinnacle3 treatment plan monitor units (MU) were verified
with the RadCalc second check software. Actual MU quality assurance measurements were
obtained on the 23iX linear accelerator with a MapCheck diode array. Department protocol
requires that all second checks agree with the plan MU to within 3%. All individual fields and
the composite lung plan met that requirement. The completed IMRT plan and QA reports were
reviewed and approved by the medical physicist and radiation oncologist prior to treatment start.
The radiation therapist verified all plan information in the MOSAIQ treatment management
system before the patient arrived for his first treatment.
Conclusion: This treatment plan was an excellent learning opportunity for a student dosimetrist.
It was interesting to hear the discussion regarding SBRT dose constraints and the risk for chest
wall injury. The physician felt strongly that this particular patient needed an accelerated course
of treatment, due to his rapidly growing tumor and subsequent rib invasion. There was
considerable discussion between the physician and medical physicist regarding fractionation
patterns that would adequately achieve the prescribed goals while limiting chest wall toxicity and
long term pain for the patient. From the treatment planning perspective, I was able to observe the
dosimetrist contouring the chest wall, and how she included the GTV and PTV in the planning
volumes. I was able to watch the programming of IMRT treatment planning objectives and the
application of various tissue and dose rings to push the dose directly around the target volume.
This case was a perfect example of how we must weigh treatment objectives with patient
limitations. We could have possibly provided better tumor control with a standard 5 fraction
SBRT. However, it would have been at great cost to the patient, who would have suffered
chronic rib pain and possibly fracture as a result of radiation treatment. Ultimately, our

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responsibility is to the patient. The radiation oncologist worked closely with the entire treatment
planning team in this case, to ensure the best outcomes from both perspectives.

Figure 1: FL positioned on the CT table in the Medical Intelligence BodyFix

Figure 2: Left lateral and AP DRRs used for daily image guidance

Figure 3: Isocenter placement

Figure 4: Dose distribution and tumor placement relative to left chest wall

Figure 5: Dose volume histogram for FL 412cGy x 17fractions to 7004cGy