Krzysztof Karteczka June Case Study June 6, 2012 Adenocarcinoma of the Gallbladder Present Illness: The patient is a 73 year

old woman, initially presented with Right Upper Quadrant (RUQ) abdominal pain. Ultrasonography (U/S) of the abdomen showed a thick gallbladder fold and gallstones; Hepatobiliary Iminodiacetic Acid (HIDA) was normal. Additionally, bone scan showed some degenerative changes. Due to increasing episodes of RUQ pain, the patient underwent a laparoscopic cholecystectomy. Pathology revealed a poorly differentiated adenocarcinoma with transmural invasion and formation of a 1.0 centimeter (cm) mass in adherent fatty tissue. There was high grade dysplasia, tumor focally extended to the surgical margin, and two positive lymph nodes (LNs). While visiting family in California, the patient developed increased liver function (LFTs) and jaundice. She underwent endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct (CBD) stent placement. Recently, she was re-admitted to a hospital and underwent a second CBD stent placement. Computed Tomography (CT) of the abdomen showed post-operative changes with edema in the gallbladder fossa, possible portal vein narrowing, and multiple prominent LNs in the perihilar, periportal, and mesenteric regions. Another ERCP showed a malignant appearing mid extrahepatic bile duct stricture, indwelling stent, purulent bile, and cholangitis. She was evaluated by surgical oncology and radiation oncology who recommended chemo-radiation therapy with possible surgery depending on response. Currently, the patient is off antibiotics for prior cholangitis, notes slight abdominal pain, chronic mild pain in the upper and lower back, and constipation. She is tolerating a regular diet, notes a stable weight, and denies any nausea or vomiting. Past Medical History: The patient has a history of hypertension (HTN), osteoarthritis (OA), kidney stones, gastroesophageal reflux disease (GERD), and chronic urinary tract infections (UTIs). Past Surgical History: The patient has a history of status post (s/p) laparoscopic cholecystectomy. Allergies: The patient has no known drug allergies.

Medications: The patient currently takes the following medications: colace, buesonide, lisinopril, omeprazole, and senna. Diagnostic Imaging Studies: The patients workup included Ultrasonography (U/S) of the abdomen, bone scan, endoscopic retrograde cholangiopancreatography (ERCP), and Computed Tomography (CT). Family History: The patients brother was diagnosed with lung cancer in 2001. Social History: The patient quit smoking tobacco products in 1970; previously she was smoking one pack of cigarettes a week. However, she admits occasional alcohol consumption. She is married and has four children. Review of Systems: The patient is status post (s/p) colonoscopy. Last mammography result was negative. She denies any significant symptoms referable to the respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, endocrine, hematological, head, ears, eyes, nose and throat (HEENT), skin, or neuropsychiatric systems. Assessment/Recommendations: Ms. V. is a 73 year old woman with a T3N1M0 stage IIIB adenocarcinoma of the gallbladder s/p laparoscopic cholecystectomy with poorly differentiated disease. The disease is characterized by transmural invasion, positive surgical margin, positive pathologic LNs, and malignant appearing mid common bile duct stricture s/p stent placement. She underwent recent treatment for cholangitis. The doctor recommended that the patient will be treated with concurrent chemoradiation therapy. The rationale, risks, and benefits of therapy were discussed in detail with the patient and her husband. The Plan (Prescription): The plan is to deliver a total dose of approximately 4500- 5000 centigray (cGy) in 25 fractions using three-dimensional (3D) conformal radiation therapy to gallbladder tumor bed, bile duct and regional lymph nodes. This should be followed by 900 cGy boost to the gallbladder. The patient is going to be re-evaluated following completion of therapy for possible surgery depending on the response. As the patient will be receiving concomitant cytotoxic chemotherapy, she will need special medical attention beyond what is typically expected and due to the toxicity of this dual modality therapy extra time and effort will be needed to develop the radiation treatment plan. Patient Setup/Immobilization: The patient was simulated in the supine position, with arms above the head holding poles, wing board and B type headrest. For immobilization of lower limbs vac-fix bag was used, large sponge under the knees. A treatment planning computed

tomography was completed with 2.5 millimeter slice spacing, starting from the xyphoid tip to the iliac crest. Marks were placed on the skin using the leveling lasers on the CT scanner. Fiducial markers were placed over these marks. The axial CT images were transferred to the Varian Eclipse treatment planning system. Anatomical Contouring: The scan was imported from the CT scanner to the treatment planning computer. The external contour, heart, liver, both kidneys, lungs, spinal cord, and planning tumor volume (PTV) were contoured. Beam Isocenter/Arrangement: The doctor assigned the isocenter during the CT simulation. It was placed in the center of the PTV. This isocenter was used for treatment planning. I began by setting treatment fields. For this patient I used a three beam arrangement; they were positioned in
the anteroposterior (AP), right anterior oblique (RAO) and left anterior oblique (LAO) directions. The oblique fields were positioned at an angle of maximum cord separation, 290 and 60 degrees

respectively. Photon beam energy of 10 megavolts (MV) was used on Varian Clinax iX linear accelerator. Treatment Planning: The treatment planning system used was Eclipse 8.9. The objective of the treatment was to have conformal dose distribution to the PTV, while minimizing the dose to surrounding tissues. I placed the calculation point inferior from isocenter in the caudal portion of the PTV. To obtain proper dose distribution I created a Multi-Leaf Collimation (MLC). MLCs
were adjusted to provide a 1cm margin around the PTV using Fit to structure tool. A 45 degree enhanced dynamic wedge (EDW) was incorporated in the oblique fields to achieve better dose distributions. The collimator for the two oblique fields had to be rotated 90 degrees to account for the MLC movement for the EDW. The field weights were adjusted to ensure adequate coverage of the PTV. Additionally, I created Field in Field for AP field to reduce a hot spot. The dose distribution in the

PTVs was 105.2% and a hot spot 105.7%. Finally, the dose volume histogram (DVH) was reviewed
to ensure dose delivered to surrounding structures are within limits. Dose was calculated using the

analytic anisotropic algorithm (AAA) of the treatment planning system. See figures 1, 2, and 3 below for graphic illustrations.

Figure 1: Axial, Sagittal, and Coronal slices of Isocenter location

Figure 2: Dose Volume Histogram

Figure

3: Beams Eye View of LAO Field

Monitor Unit (MU) Check: After the plan was approved by the physician, the physicist performed a monitor unit check before the first day of treatment. A program called RadCalc was used to take the treatment parameter data from the treatment plan in Eclipse. For AP field monitor unit (MU) output value was 57.9, a 2.2 % difference from plan MU, MU for LAO was 111 (0.9% difference), and RAO 98 MU (1.0% difference).At NorthShore University Health Systems, percentages over +/- 5% are unacceptable for treatments. See Figure 4 for Photon Monitor Unit Calculation Sheet.

Figure 4: Photon Monitor Unit Calculation Sheet

Quality Assurance Check: To verify that the dose produced on the accelerator was the same as what was planned in the Eclipse treatment planning system, diodes were used within the first three fractions. The mobile Mosfet Dose Verification System was used, with 1.5 cm bolus placed on the top of the dosimeter. The reading dose was within the acceptable limits.

Conclusions: I chose this case study because it was a very interesting one. Having studied this case, I have a better understanding of the application of wedges, field in field technique, dose distribution, and complexity of treatment planning. I learned a lot from this patients plan and feel I am capable of creating treatment plans of similar cases in the future. Our department has a lot of patients with similar abdominal cases and I look forward to applying the skills I learned from this case.