Patient information – state following

Ms. Sanders is 44-year-old woman from Rotorua who lives with by herself. She has one
daughter who lives with her mother. She was referred to our cancer service from Rotorua
hospital, following a mass found in her mediastinum.

Statistics
1. She has a long history of smoking she started when she was 18, smoking 15-20
cigarettes/day.
2. Statistics: Smoking cigarettes is the main cause of lung cancer.
3. People who do not smoke can still develop lung cancer, but their risk is much lower.
4. Around 9 out of 10 people who get lung cancer (90%) are smokers or ex-smokers.
About 1 in 10 people who get lung cancer (10%) have never smoked

Presenting symptoms
1. She presented SOB on exertion (dyspnea); upper airway compression associated with
a high pitch cough – this would explain her chief complaint with central chest
discomfort
2. Her energy levels dropped began to drop off significantly as a result has had to stop
working where she is a gardener by occupation which would explain why she had a
ECOG performance status of 2 = 2 which tells us capable of all self-care but unable to
carry out any work activities
3. The ECOG performance status is a scale used to assess how a patient's disease is progressing, assess
how the disease affects the daily living abilities of the patient, and determine appropriate treatment and
prognosis

Investigations undertaken
1. CT: centrally mass in mediastinum that was 5.9cm x 5.7cm in size. Due to its
location, it was compressing the trachea and SVC
2. Subsequent PET CT followed which further confirmed a mediastinal mass located on
the right paratracheal region
3. Subsequently followed by Biopsy obtained with an EBUS – found tumor + for CK7
and assessed to be a stage 3B poor differentiated carcinoma with a stage of TxN3M0.
The tumor being a carcinoma supports literature which states that most carcinomas
tend to be central
a. Staging: Lung cancer is staged using the TNM staging system with T = size,
N= lymph node involvement, M= metastasis
i. Tx – no definite primary lung tumor; this was most likely to be a
primary lung cancer with mediastinal lymphadenopathy
ii. N3 – ipsilateral mediastinal lymph nodes
iii. M=0 no metastasis to distant regions

Intent: Curative/Radical with the intent of eradicating the disease. Dr Seel let the pt know
that the chances however are very low estimating her chances of being cured to be less than
10%.
She will also commence concurrent chemo with the drugs being a combination of
Cisplatin/etoposide
Other medical history
1. Left laryngocele – air sac in the larynx which could contribute to the upper airway
obstruction – she is awaiting surgery for this
2. She had bilateral breast fibroadenomas removed
3. Right ovarian pain which has been present on and off for a few months
4. Total abdominal hysterectomy – removal of uterus thru abdomen incision
5. Thyroidectomy for grave thyroiditis

Medications
1. Omeprazole - Gastroesophageal reflux disease
2. Paracetamol and ibuprofen
3. Laxsol – laxative
4. Ondansetron – nausea
5. M-Elson (pelvic pain)
6. Metronidazole & doxycycline (antibiotics)
7. Ferro gradumet – iron deficiency anaemia – which will help with her fatigue
8. Ventolin and Symbicort inhalers – bronchodilators that relaxes muscles in the airways
and increase airflow to lungs
Computed Tomography
RO requested contrast + 4DCT
1. I wasn’t able to find out what agent was used but I suspect it was omnipaque which is
contrast that is administered Intravenously. Shows up in blood vessels and improves
nodal definition. Visipaque is another contrast agent used but not for lung pts
2. 4DCT - Lung malignancies may undergo significant shift due to breathing
3. this ensures the need for large ITV expansions to account for intrafraction motion.
This can be overcome with two techniques: 4D CT and respiratory gating.
a. 4D CT allows accurate determination of the ITV and reduction (hopefully!) of
treatment volumes. where CT through every slice is acquired at different
phases of respiration.
b. Respiratory Gating allows further reduction in the ITV by only delivering
treatment when the tumour is in a particular phase of respiration.

Before setting up pt, ensure pt doesn’t have

1. Pacemakers - radiotherapy can interfere with how your pacemaker works so you find that we these
type of pts their pacemakers will be monitored during and after tmt
2. Metal around chest area
3. Chance they could be pregnant – usually not given during pregnancy as even a low dose may harm
the developing baby

Pt set up:
 Provide patient comfort (comfortable patients are less likely to shift position)
 Are reproducible (to enhance radiation accuracy)
 Are custom fitted (enhancing comfort and reproducibility)

Setup
1. Head first= the location we’re trying to treat is closer to the gantry
2. Supine = patients are more comfortable supine rather prone
3. Vacbag which is molded around the patient allowing an imprint to be made of the
patient = secured in position by an indexed shuttle board I suspect this will be at H2 to
ensure we’re treating thru the lockbar. What does this ensure? Ensures that the pt is in
the same place L/R + S/I
4. LR used to help pt maintain their position by supporting their knees and back + is also
that is also indexed, ensures pt is in the same place L/R + Sup/Inf
5. 3x Chest marks with angiocaths@ Z=0 – reference marks/plane and will show up on
the scan with the angiocaths
6. 3 x Chest tattoos
Measurement to be taken
1. Couch/lateral laser – ensures where we are A/P

Scan levels: above supraclavicular fossa to below diaphragm ensuring entire lungs are scanned.
Planning
Prescription: 60Gy/30#, 2Gy/#, 1#/day 5#/week over 6 weeks to the ICRU reference point

The International Committee on Radiation Units and Measurements (ICRU) provides

guidelines for working with radiation.
1. The ICRU reports 50 and 62 provide specific information for guiding radiation
treatment.
2. These recommendations suggest various volumes which are useful for planning
radiation treatments, as well as a reference point where the dose should be calculated.

Volumes
1. The GTV is the volume that contains the visible or clinically detectable tumour
2. The CTV is the volume which has been determined to require radiation treatment.
This includes the GTV as well as areas of clinical risk – such as lymph node groups or
the region about the GTV that may have microscopic involvement
3. ITV - Internal Target Volume - includes a margin to account for patient movements
that are unable to be accounted for during treatment e.g. respiration. The margin for
ITV is known as the internal margin
4. The PTV is an expansion from the ITV to account for external treatment inaccuracies.
Improving the external factors which lead to treatment inaccuracies may reduce the
external margin and allow for smaller PTV expansions.

ICRU Reference Point

The ICRU recommends reporting the dose at a single point within the PTV.
1. The point should be clinically relevant, easily defined, and placed in a region of
uniform dose (away from steep dose gradients or inhomogeneities if possible).
2. The point should be at the center of the PTV and at the intersection of the beam axes
if possible.

Inhomogeneities
The inhomogeneities I have in this plan are soft tissue, lung and bone. Bone is represented by
the sternum in this plan and considering it is more spongey bone, it is more at the 1.3 end of
the spectrum. There isn’t a lot of bone in the path of the beam therefore the impact it is
having on the plan is minimal. The tissue that is having a significant impact on the dose
distribution is the lung tissue. It has a RED of 0.3 which means it is difficult to deposit dose
into the lung

SHOW PLAN
Clinically significant maximum (CSM) – maximum dose in the plan which exceeds 1.5cm
in its minimum dimension. Ideally this is situated in the PTV = 103%
Hotspots an isodose value that exceeds 100%, is located outside of the PTV and exceeds
1.5cm in its minimum dimension
Beam arrangement
Influenced by size, shape and location of PTV
1. Size = Medium shape
2. Shape = Irregular circle
3. Location: More ANT than post and slightly more sup + its more situated to the right
of M/L
4. Central tumor but because it slightly crosses right of M/L its why you’d have this
RPO

Wedges are used for 4 reason. BA, weighting, patient contour and inhomogeneities
1. Beam arrangement – beam overlap on the right hand side of the plan causing dose
overlap. They are evenly spread out, and not as tight hence the use of fairly small
ones. Ensures dose is distributed to left hand side for more coverage

Energy (At Waikato all radical lungs are planned with 6MV)
1. 6MV on all beams – provide better coverage compared to higher energies. Dmax =
1.5cm therefore more entry dose = more skin dose + dose to peripheral tissue

Weighting
1. LPO is lowest going thru spinal cord

Dose homogeneity
1. Dose is quite homogenous around the PTV and quite centralised in the PTV
Treatment setup
Reference marks
1. 3x Chest Tattoos @ Z= 0 Vacbag marks
2. Match M/L marks with Cross hairs
3. Move to Z=0 marks, making sure they line up on both sides ensures Vacbag rotation
(transverse plane) (S/I)
4. Match latt tattoos with Coronal (A/P) + transverse (S/I) and ANT tatt with sagittal
(L/R) and transverse (S/I)
5. Makes isoshifts to move to isocentre = 8 Sup + 2 Right

Imaging verification can be online or offline

Online is when images are checked before pt has their tmt (it allows RTs to make small
adjustment to the treatment couch that ensures accurate treatment)
1. whilst offline after pt has had their treatment.
2. Protocol at Waikato for lung pt is daily online review and weekly offline review
during weekly checks = tolerance = 0.5cm if it is out of tolerance – a statistical
analysis is made and the out of tolerance numbers over the first 3 days is made – the
average value is the move required permanent move

Online Imaging
1. Daily KV/KV known as an orthogonal pair every non CBCT day where the primary
match is a bone match. What does this allow: it allows matching in all 3 directions
S/I, L/R & A/P Structures to match include
2. CBCT are performed weekly every Wednesday where the primary match is bone and
secondary match assesses contours/soft tissue and OARs. Also, able to access disease
progression
Side effects

Critical structures
Table 2. Critical Structures, Dose Tolerances and Endpoint Reactions
Critical Acute Side Endpoint Dose Dose
structure effects/Dose Reactions Tolerances Structures
Tolerances receiving
Skin 20-25Gy → Progress to
Erythema 30-35Gy dry
→ Dry desquamation
Desquamation 40-
45Gy → Moist
Desquamation
Oesophagu 20–25Gy → Grade ≥ 3 acute Dmean≤45Gy Within PTV
s Oesophagitis, Pain, oesophagitis
Reflux
Lungs 20–30Gy → Grade 2+ radiation Waikato (Dr M Dmax =63Gy
Pneumonitis – Rubin pneumonitis Seel) to keep
risk <20
V5≤50%
V30≤20%
Dmean 15-
20Gy

Spinal 40–45Gy → Myelopathy Dmax≤45Gy Dmax=49.868

Cord Lhermitte’s Sign (PRV
(shock like sensation (+0.2cm)
down spine, tingling) 3DCRT)
– Rubin

Fatigue is highly likely to be expected. The patient has already presented with fatigue before
treatment and I suspect this will be exacerbated by the treatment. Advice for this patient
would be to rest when feeling tired, maintaining an adequate hydration and diet and if
possible, going for a short walk.

Lungs
Lungs are receiving maximum dose of 63Gy which means he will get acute pneumonitis
which presents as a dry cough associated with shortness of breath and pain on exertion.
Advice we would recommend to patients is mild pain relief such as paracetamol and
ibuprofen. If that is not working patients would be seen by the nurses or RO will prescribe
moderate pain relief such as codeine. Corticosteroids such as prednisolone is recommended at
Waikato.

Skin
patient is at risk of acute side effects. At doses between. At 14-16Gy they will get faint
erythema which will likely progress to erythema at 20Gy and dry desquamation.
Management for this is to use aqueous based cream known as cetamacrogol to keep the skin
moist. I am particular concerned because where he is likely to get this skin reaction is at the
back of his body which is difficult location to apply the cream on by herself so that is
something her support person will have to help her with. I don’t expect the skin reaction to
progress to moist desquamation at 40Gy.

Oesaphagus
Is within the PTV he will get oesophagitis which will present as heart burn.

Spinal cord
Dmax≤50Gy, Her spinal cord = 44Gy so it is below

CURRENT
1. Bowels not opening
2. Nauseated from chemo – ondansetron, maxalon, Cyclizine
3. Grade 2 chest reaction on back and chest