Amanuel Negussie Clinical Practicum I Feb 23, 2013 Metastatic Orbit History of Present Illness: HG is a 69-year-old male with

stage IVB diffuse large B cell lymphoma (DLBCL) with bone marrow involvement, generalized lymphadenopathy, massive splenomegally, right ureteral obstruction, and orbital involvement. He initially presented in August 2012 with an enlarged left cervical lymph node, elevated creatinine, and renal ultrasound revealing a mass. Fine needle aspiration (FNA) of his cervical spine revealed DLBCL. Computed tomography (CT) and positron emission tomography (PET) noted multiple areas of hypermetabolic adenopathy. HG took four lines of chemotherapy treatment since diagnosis, the most recent being Dexamethasone, Cytarabine, Platinum (DHAP). In follow up prior to his second cycle of DHAP, the patient complained on a one-week history of blurred vision, left eye pain, and open bottom eyelids. Ophthalmology evaluated the patient and noted bilateral lower and upper eyelid masses, consistent with orbital involvement and no sign of intra ocular involvement. Magnetic resonance imaging (MRI) was obtained which noted enhancement in his right lacrimal gland, left lacrimal gland, medial right orbit, right orbital wall, right orbital septum, right inferior and oblique muscles, left medial orbital wall, and bilateral inferior recti muscles. A week after the exam, HG noticed his left lower eyelid turned out and reported pressure and pain in his eyes bilaterally but worse on the left eye. He underwent ocular evaluation, which noted that the left eye was red with clear drainage. The patient also complained of being fatigued and slight dizziness when standing. Past Medical History: HG has a medical history of stage IV DLBCL, hyperlipidemia, diabetes mellitus type II, glaucoma, hammertoe, peripheral nerve disease, and cataract extraction. The patient has no known allergies. Diagnostic Imaging Studies: HG had orbit MRI with and without contrast and brain MRI with and without contrast. He also had a CT scan of the head region in radiation oncology during the simulation process. Family History: HGs mother had a cerebrovascular accident (CVA) in her 70s. The patient has a deceased father from lung cancer and a deceased brother for unknown reason. His sister has breast cancer and heart conditions.

Social History: HG is a retired mechanic who lives with his wife. The patient quit smoking tobacco 10 years ago and denied any alcohol and drug use. Medication: HG takes Acetaminophen, Dexamethasone, Guaifenesin, Insulin, Lorazepam, Magnesium Hydroxide, Morphine, Potassium Chloride, Prochlorperazine, Senokot, Timolol, Artificial Tears Solution, and Lubricating Ointment. He also takes Ondansetron and Vancomycine injection. Recommendations: Considering the signs and symptoms and the reports from ophthalmology, HG is a candidate for palliative radiation to his bilateral orbits. As a result, the patient was recommended to receive radiation therapy for the treatment of his orbits. Possible side effects of the treatment were discussed with the patient including erythema, fatigue, dry and red eyes, hair loss of the eyelashes and eyebrows, acute conjunctivitis, chronic keratitis, and possible long-term risk of radiation-induced cataracts. The Plan (Prescription): It is usually effective to treat palliative cases with a higher dose in fewer fractions and a larger field size that includes the entire tumor.1 As a result, the treatment was prescribed to 3060 centigray (cGy) at 180 cGy per fraction to the 100% isodose line for 17 fractions using three dimensional conformal radiation therapy (3D-CRT). Patient Setup/ Immobilization: HG was simulated in a supine position with his head towards the scanner. His head was fixed in a neutral position by using a headset. Aquaplastic mask was made by warming a thermoplastic mesh in a water bath and stretching it over the patients face and neck gently (Figure 1). After simulation, the mask was labeled with the patients name for identification purpose. This customized mask will be used to reproduce the same head position and restrict movements during his treatment. The patient was holding a plastic ring and had a small sponge under his knees for comfort. A Philips large bore 16-slice CT machine was used for the simulation. Head images were taken at 0.3 centimeter (cm) slices. Anatomic Contouring: After the simulation was completed, the CT slice images were imported to the Pinnacle3 9.0 radiation treatment planning system (TPS). The radiation oncologist then contoured the gross tumor volume (GTV) and planning target volume (PTV) using the TPS. The dosimetrist contoured the brain, left and right eyes, and left and right lenses. The purpose of these contours is to evaluate the dose delivered to the radiosensitive anatomical structures while planning to deliver the desired dose to the PTV.

Beam Isocenter/ Arrangement: A Varian 21 IX 3501 linear accelerator (Linac) machine was used to treat the patient. During simulation, the radiation oncologist put the isocenter posterior from the nasal cavity. A four field, two right lateral and two left lateral, beam arrangement was used (see Figure 2). Each lateral field consisted a combination of 6 megavolts (MV) and 18MV energy photon beams. The gantry was set at 270o for the right lateral fields and 90o for the left lateral fields, and the collimator was set at 0o for all fields. Treatment Planning: Each field has a multileaf collimator (MLC) blocking pattern constructed by the physician to define the treatment field. The dosimetrist picked a new calculation point 3cm anterior from the isocenter, because the isocenter was located outside the treatment field (see Figure 3). The plan was primarily calculated with a two 6MV right and left lateral field weighted equally; but, the anterior part of the GTV was not getting adequate coverage of the dose. Therefore, a 0.5cm bolus was used to pull the dose anteriorly (see figure1). A field-in-field beam was created for both lateral fields using 18MV to reduce the maximum dose and decrease the hot spot (see figure 4). In addition, a 15o enhanced dynamic wedge (EDW) was used on all fields to account for the curvature of the head and reduce the hotspot. Both primary beams of the right lateral and left lateral were weighted 47% each; whereas, each field-in-field beams were weighted 3%. The plan was completed with a total monitor unit (MU) of 297, maximum dose of 3571cGy, and a hot spot of 16% located within the bolus. After the plan was completed to the dosimetrists satisfaction, it was saved for the physician to evaluate. The physician approved the plan after reviewing and ensuring that the 100% isodose line sufficiently covered the GTV and the dose to the lenses was below 500 cGy (see Figure 5). Quality Assurance Checks The MU check was performed using the MuCheck 8.2.0. Software. At our clinical site, a 3% deviation in MU is the tolerance for any 3D-CRT plans. Anything outside this range needs to be recalculated and fixed by dosimetrists or physicists prior to treatment. This plan was approved with -2.2% for the primary right lateral field, -1.45% for the field-in-field right lateral field, -2.61 for the primary left lateral field, and -1.01% for the fieldin-field left lateral field. The treatment plan was then reviewed and evaluated by the medical physicist before the patient began his treatment. Conclusions: It was interesting working on this case since metastatic orbit cases are not seen more often. Planning this treatment with a lower maximum dose and adequate dose coverage of the PTV was challenging. This was the first real case I planned using a bolus. I was able to learn,

observe, and examine the use of bolus in modifying dose for superficial structures. I also learned the appropriate use of field-in-field techniques to improve dose distribution.

Figures

Figure 1: 0.5cm bolus taped to an aquaplast mask

Figure 2: right lateral and left lateral beam arrangement

Figure 3: the simulation isocenter and the calculation point on a transverse CT slice

Right lateral field in field BEV

Left lateral primary field BEV

Right lateral primary BEV

Left lateral field in field BEV

Figure 4: Beams eye view (BEV) of the lateral primary and field-in-field fields

Figure 5: Dose volume histogram (DVH)

References 1. Bentel GC. Radiation Therapy Planning. 2nd ed. New York: McGraw-Hill;1996: 490-526.