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Cinira Johnson
Clinical Practicum I
February 27, 2014
Whole Brain Treatment Planning Case Study
History of Present Illness: AH is a 44 year old female ith adenocarcinoma sta!e III" status#
$ost concurrent chemoradiation thera$y com$leted on July 201%& A 'a!netic (esonance
Ima!in! )'(I* study of the brain done in 'arch 2014 shoed !roth of a solitary brain lesion
and + ne brain metastasis lesions&
Past Medical History:
,ncolo!y history- In January 201%, AH $resented ith .ta!e II" /eft 0$$er /obe )/0/* lun!
adenocarcinoma ith associated lym$hadeno$athy& A small solitary metastatic lesion as also
noted but not treated at that time& AH recei1ed chemoradiation thera$y treatment for the /0/
lun! lesion&
2he $atient3s $ast 'medical history includes- !astroeso$ha!eal reflu4 disease )56(7*,
de$ression, fati!ue, abnormal $a$#smear, aller!ic rhinitis, $ain in 8oint and leiomyoma of uterus&
Past sur!ical history- tonsillectomy and tubal li!ation&
Family History includes- % li1in! sisters ith thyroid cancer and diabetes, and $aternal and
maternal !randmothers ith breast cancer&
Social History: AH is a sin!le mother ith 4 children& AH is a former smo9er& Patient used to
smo9e 0&2$ac9s:day for %0 years& Patient currently uses mari8uana&
Medications: Ibu$rofen ;00 m!, 'e!estrol 400m!, <icotine $atch 7 m!:24 hours& $atch,
,4ycodone + m!, Percocet %2+ m!, 6la1il 2+ m!, 6mend ;0 m!, Calcium 1itamin 7, =yrtec 10
m!, ,ne#a#day 1; m! and Com$a>ine 10m!&
Diagnostic Imaging Studies: Patient had a brain '(I ith contrast done in <o1ember 201%, a
Com$uteri>ed 2omo!ra$hy )C2* chest:abdomen ith contrast done in <o1ember 201%, a C2
chest done ith contrast in January 2014, a barium sallo ith s$eech thera$y study done in
January 2014, a 2 1ies of 4#rays of the chest done in January 2014, and a brain '(I done ith
and ithout contrast in 'arch 2014&
Radiation Oncologist Recommendations: The (adiation ,ncolo!ist offered to treat the hole
brain or to treat all ? brain lesions ith stereotactic radiosur!ery ).(.*&
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After len!thy discussion
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about side effects and effecti1eness of both treatments,
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AH elected to recei1e hole brain
treatment instead of .(.&
The Plan Prescri!tion": 2he dose $rescribed for this $alliati1e hole brain as %,000 c5y in
10 fractions of %00c5y each usin!& 2he treatment $lan included- 2 ? '@ lateral fields& A boost
as not $lanned for this $atient since this a $alliati1e case&
Patient Setu!#Immo$ili%ation: The $atient as simulated in the su$ine $osition on a A#Fi4 0#
frame ABua$last mas9 inde4ed to the table, ith a blac9 mat abuttin! the most inferior $art of
the 0#frame& A lar!e 9nee s$on!e as used under the 9nees, and the $atient3s arms ere across
his $el1is )Fi!ure 1*& A C2 simulation as done usin! a Philli$s "rilliance C2 simulator ith a
bi! bore in % mm slices& 2he C2 as $erformed from 1erte4 thou!h cla1icles&
&natomical Contouring: 2he medical dosimetrist student contoured both !lobes, both lenses
and the cribriform re!ion&
Beam Isocenter#&rrangement: 2he isocenter as $laced at midline:midbrain )Fi!ures 2#4*&
2he Collimator as rotated 20 de!rees to match the base of s9ull and because of the field si>e
limitation of the machine& 2he resident dre bloc9s to bloc9 the eyes& 2o ?'@ lateral
treatment fields )Fi!ures ?a and ?b* ere used&
Treatment Planning: 2he treatment $lannin! system )2P.* used as C'. CI, 4&40& 2he
structures contoured ere the both lenses, both !lobes and the cribriform re!ion& 2o lateral
?'@ treatment fields ere used ith isocenter at midline& 2here as a 1&+ cm flash around the
brain& 2he inferior border included C1& 2he 'edical ,ncolo!ists made sure to bloc9 the eyes
ith 'ultileaf Collimator or '/Cs& 7ue to field si>e limitation of the machine, the collimator
as rotated 20 de!rees& 2he dose 1olume histo!ram demonstrates that lenses and !lobes ere
bloc9ed accordin!ly )Fi!ure +*&
Monitor 'nit Chec(: 2he $hysics chec9 included a thorou!h chec9 of the ritten $lan a!ainst
the $lan in 'osaiB& 2he 'onitor 0nit )'0* calculation as chec9ed a!ain (adCalc and as
ithin the mar!in of error of 2D for a non#dynamic treatment and 10D for dynamic treatment
$lans&
)uality &ssurance )&" Chec(s: 2here is no AA chec9 done in this $lan because it as a non#
dynamic treatment $lan& At 0ni1ersity of Colorado Hos$ital )0CH* AA chec9s are only done to
1erify fluency of '0 deli1ery in $lans ith acti1e modulation of the lea1es or dynamic $lans
such as- ra$id arc, Intensity#'odulated (adiation 2hera$y )I'(2*
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Conclusion: It as 1ery interestin! to see ho the medical dosimetrist can accommodate for
machine limitations& In this case, for e4am$le, the medical dosimetrist rotated the collimator in
order to o1ercome the field si>e limitation of the machine& It as also interestin! to see the
(adiation ,ncolo!ists mani$ulate the lea1es in other to !et radiation in the cribriform re!ion
ithout com$romisin! the lenses&
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At this $oint in the internshi$ trainin!, most of the challen!es
concern $roficiency in or9in! ith the CI, treatment $lannin! system& Eith time and $ractice
$roficiency ill come&
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References
1& Patil C5, Pricola F, .armiento J', et al& Ehole brain alone 1ersus E"(2 and
radiosur!ery for the treatment of brain metastases& Cochrane Database Syst Rev. 2012
.e$ 12GH-C700?121&htt$-::d4&doi&or!:10&1002:14?+1;+;&C700?121&$ub%
2& Halas> /'& Com$arati1e effecti1eness of stereotactic radiosur!ery ).(.* 1ersus hole
brain radiation thera$y )E"(2* for $atients ith brain metastases from non#small cell
lun! cancer )<.C/C*& ,ncolin9&or! Eeb .ite& .e$tember 24, 201%&
htt$-::oncolin9&or!:conferences:article&cfmIidJ?H?1 Accessed on February 14, 2014&
%& Patil @', ,inam A., Cha9raborty ., et al& .hieldin! in hole brain irradiation in the
multileaf collimator era- 7osimetric e1aluation of co1era!e usin! .F,P !uidelines
a!ainst in#house !uidelines& J Can Res Ther 2010G?- 1+2#;&
htt$-::d4&doi&or!:10&410%:0H7%#14;2&?+2%;
+
*igures
Fi!ure 1& Patient $osition&
Fi!ure 2& A4ial 1ie of isocenter&
?
Fi!ure %& 2rans1erse 1ie of isocenter&
Fi!ure 4& Coronal 1ie of isocenter&
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Fi!ure +& 7ose @olume Histo!ram&
Fi!ure ?a& /eft treatment field&
(2 /enses
/2 /enses
(2 5lobes
/2 5lobe
;
Fi!ure ?b& (i!ht treatment field&