1

Jonathan Gonzales
Clinical Practicum I
March 1, 2015
3D Conformal Radiation Therapy: Malignant Lymphoid Cells of the Orbit
History of Present Illness: Patient AM is an 11 year-old female who underwent an eye
examination on January 8, 2015 after complaints of right eye blurriness dating back to early
December of 2014.The eye examination was performed under anesthesia and both eyes received
an intravitreal injection. An anterior chamber paracentesis was performed on the right eye which
revealed monomorphous population of malignant lymphoid cells that is consistent with Acute
Lymphocytic Leukemia (ALL). AM has a history of B-cell ALL which was originally diagnosed
in 2008 at the age of 5. In 2008, she was treated under a high-risk ALL protocol, ALL-0232,
which resulted in a complete response from the chemotherapy regimen. In 2009, AM then
developed early central nervous system (CNS) relapse in the beginning of her second cycle of
maintenance chemotherapy, which posed the need for a second course of reinduction
chemotherapy. The second course of was performed in July of 2010 along with a course of
cranio-spinal irradiation. The data records of this course of radiation therapy treatment were
unavailable. In June of 2011, AM completed both rounds of her maintenance chemotherapy and
was doing well until she developed a bone marrow relapse in October of 2011. A cerebrospinal
fluid (CSF) cytology came back negative for CSF involvement. She was given another course of
chemotherapy followed by total body irradiation (TBI) in late 2011. This course of treatment
again resulted in a rapid remission with no reported relapse. The following years, 2012 2014,
AM was followed and had routine bone marrow and spinal tap biopsies taken as a precautionary
measure. In October of 2014, AM had another bone marrow transplant and was enrolled on the
Novartis-Pen CART protocol where she received chimeric antigen receptor T-cell (CART)
infusion. During a visit with her medical oncologist, AM mentioned right eye blurriness and after
test results showed malignant lymphoid cells of the right eye, she was then referred to the
radiation oncology department. On January 26, 2015 AM consulted with the radiation oncologist
for treatment options. The physician recommended a course of radiation therapy to the right
orbit. A conversation of possible complications was discussed with the patient. Possible
complications include transient cystoid macular edema, cataract formation, retinopathy, eyelid

retraction, conjunctivitis, and dry eye.1 AM and her family decided to consent and proceed with
the physicians recommendation.
Past Medical History: AM has a past medical history of ALL, asthma, eczema, otitis media,
seizures, urinary tract infection, cataract, anemia, and candida parapsilosis. She also has
Pegaspargase and Penicillin allergies. There are no reports of any surgical procedures being
performed. AM has had several bone marrow transplants, one in 2011, and more recently in
2014. AM has also received a course of cranio-spinal radiation in 2010, although there are no
data records for that treatment. AM has also received a course of TBI to a total of 12 Gy in BID
in 2 Gy fractions in 2011.
Social History: AM lives with her paternal grandparents. Her mother is not currently present in
her life and her father is attending school in Florida. AMs father will have custody when he
returns after his schooling. AM has been home schooled for the past two years and is missing
portions of kindergarten and first grade. AM wanted to get back to school and is planning on
beginning second grade in the near future. Regarding notable family history, her maternal aunt
had a brain tumor, both maternal grandfathers were diagnosed with lung cancer, and grandmother
suffered from colon cancer. Her grandparents are her legal guardians.
Medications: Medication list is not available for review.
Diagnostic Imaging: On January 8, 2015 AM underwent an eye examination under anesthesia
with b-scan ultrasound. AM received an intravitreal Bevacizumab injection to both eyes and an
anterior chamber paracentesis of the right eye. The results showed a monomorphous population
of malignant lymphoid cells.
Radiation Oncologist Recommendations: According to the radiation oncologist, patients
presenting with similar orbital disease tend to also have effects on the brain. A typical treatment
would include the entire orbit plus brain margin, but because of the patients previous history of
cranio-spinal radiation treatment combined with the lack of data associated with that course, the
oncologist decided to restrict treatment to the right orbit and exclude the brain margin in hopes of
minimizing total brain toxicity. According to the oncologist, AM also had visible disease on the
anterior portion of her orbit and typically a lens shield would be used but in this patients case no
shielding was required because of the know existence of disease on the anterior portion of the
eye.
The Plan (prescription): The radiation oncologists treatment recommendation to AM was a 3D

conformal plan using 6 MV photon energies. The physician had the intent of using a wedged pair
technique. A dose of 24 Gy in 2 Gy fractions for 12 fractions was prescribed the PTV with 95%
IDL coverage with +/- 5% uniformity margin. According to the Ann-Arbor staging system,
lymphoma confined to the orbit is designated as Stage I and with a low-grade designation would
normally be prescribed a dose of 30 to 35 Gy.2 AM was prescribed a modified lower dosage
because of the prior course of radiation to the brain.
Patient Setup/Immobilization: On January 26, 2015, AM began the initial stages of treatment
planning by having a computed tomography (CT) simulation scan performed on a Phillips
Brilliance CT. The patient was simulated under a standard whole brain protocol. The patient was
placed in the supine position with both arms by her side (figure 1). A headrest was used to place
the patients head in a neutral position in conjunction with a head and neck board and a custommade aquaplast mask. The patient also had a sponge placed under the knees for added support.
Under the simulation directive, the patient was scanned to an upper border that included a flash
of air above the scalp and an inferior border down to C3/C4 interstitial space. 3 mm slice
thickness was chosen under the whole brain protocol. All head and neck cases have a standard
CT reference location placement at the intersection of the anterior tip of the nose to where it
crosses the external auditory meatus (EAM). Prior to scan, the therapist chose an arbitrary CT
reference position which will be used as initial position that dosimetry will plan from. This is not
the location of the isocenter (Figure 2).
Anatomical Contouring: After completion of the CT simulation scan, the data set was
transferred into the Eclipse treatment planning system (TPS). Using the TPS, the radiation
oncologist contoured the right eye, left eye, right optic nerve, left optic nerve, pituitary, and PTV
[right eye + 4 mm margin]. According the oncologist, he would normally give an orbital PTV a
margin of 3 mm, but because these cases are known to have brain involvement, he wanted to
increase the margin. The oncologist felt that a 5 mm margin was too generous, so he decided to
stay in the middle and have a 4 mm margin around the orbit to define the PTV (Figure 3). A
planning directive was completed by the physician and was ready for a dosimetrist to proceed
with the treatment planning process.
Beam Isocenter/Arrangement: A Varian Trilogy was used to treat this patient. Location of the
beam isocenter was placed in the center of the PTV. Two wedged pair field arrangements were
used, four fields total. With the couch at 0, the first wedged pair consisted of a right anterior

oblique (RAO) and a left anterior oblique (LAO) with gantry angles of 320 and 15 respectively
(Figure 4). With a couch angle at 90, the second wedged pair chosen was an anterior superior
oblique (ASO) and an anterior inferior oblique (AIO) with gantry angles of 25 and 325
respectively (Figure 5). The gantry angles of the wedged pair fields were selected to avoid
treating through the contralateral eye, and the nose, and to minimize dose to the organs at risk
(OR). All fields had a 90 collimator rotation to allow for utilization of the enhanced dynamic
wedge (EDW) along the Y-axis. The chosen wedge angles were RAO-45, LAO-45, ASO-45,
and AIO-45. For each wedged pair fields, the direction of the wedges were placed so the heels
would face each other. Given the superficial location of the target, 6-megavolt energies were
chosen. Utilizing multileaf collimation, a block margin of 0.7 mm was applied to each field
(Figures 69). The medical dosimetrist then assigned the prescription to the fields and had the
plan normalized to a reference point placed at the same location as the isocenter. The TPS then
calculated the monitor units necessary to deliver the prescription dose to that point using
Anisotropic Analytical Algorithm with a .25cm calculation grid.
Treatment Planning: Eclipse TPS was utilized to complete this treatment plan. The radiation
oncologist outlined the dose prescription and objectives as dictated in the treatment planning
directive. The directive indicated to utilization of 6-megavolt energies and suggested the use of
the wedged pair technique. The OR that were of concern to the radiation oncologist were the left
eye, optic chiasm, and pituitary gland. The left eye had a priority setting of 1 with a maximum
tolerance dose of 12 Gy. The optic chiasm had a priority setting of 1 with a maximum tolerance
dose of 20 Gy. Finally the pituitary had a priority setting of 3 with a tolerance dose of as low as
reasonable achievable (ALARA). A dose of 24 Gy in 2 Gy fractions for 12 fractions was
prescribed with 95% IDL coverage with +/- 5% uniformity margin. The radiation oncologist also
indicated that the PTV had a priority setting of 2. Because the PTV was a superficial target, the
95% IDL coverage could not be achieved on the surface due to the lack of scatter contribution
because there would be no electron build up region on the surface. The dosimetrist then added a
1 centimeter (cm) bolus to be placed on the orbital surface. This would create the necessary build
up region to bring the prescription dose to the anterior portion of the PTV. The design of the
bolus was custom in shape as to avoid overlapping onto the nose (Figure 10). The rationale for
the custom bolus was because the angle of the LAO entrance through a bolus place along the
nose would yields a bolus depth greater than 1 cm because the angle of the bolus would now run

slightly parallel with the direction of the beam. The result would cause the beam along that axis
to become more attenuated and result in insufficient coverage at depth. Initially, when the plan
was calculated to deliver dose to the reference point located at the isocenter, the 95% IDL
coverage was being achieved anteriorly. However, there was lack of coverage on the deep
posterior aspect of the PTV (Figure 11). To bring dose slightly deeper, the dosimetrist moved the
reference point about a half a centimeter deeper. Recalculating to this new reference point
location brought the 95% IDL covering the posterior portion of the PTV (Figure 12). All fields
were equally weighted and each would deliver a dose of 50 centigray (cGy) to a combined total
of 2 Gy per fraction. Once the adequate prescription dose coverage was achieved, the medical
dosimetrist then reviewed the OR through the dose volume histogram (DVH) (Figure 13). The
DVH showed that 99% of the PTV will receive 95% of the prescription dose. The left eye had a
max dose of 0.44 Gy and was well under the tolerance dose of 12Gy. The chiasm will receive a
max dose of 10.75 Gy and is under the 20 Gy tolerance dose. The level 3 priority pituitary gland
is receiving a max dose of 6.45 Gy and a mean dose of 5.44 Gy. The radiation oncologist then
reviewed the plan with the dosimetrist and approved it for treatment.
Quality Assurance/Physics Check: The second monitor unit (MU) check was performed using
Mobius3D software. The software checks the following parameters: Target Coverage, DVH
Limits, 3D Gamma, and Deliverability. All parameters passed the Mobius3D second check.
Mobius3D requires the MU discrepancy between the TPS and software to be within 5%. For
individual field monitor unit checks, the plan was well within tolerance requirements.
Conclusion: The 3DConformal wedged pair technique posed several challenges for the
dosimetrist. Selection of the proper wedge angles that would best distribute the 95% IDL
throughout the circular PTV target was the first obstacle. I learned that the wedge angle formula,
Wedge angle = 90 (Hinge angle/2) could be used to approximate wedge angle. The wedge
angle needed, or degree by which the isodose curves should be tilted, depends on the hinge
angle.3 The hinge angle is the angle separating the two central axises.3 For example, the hinge
angle between the RAO-320 and LAO-15 was 55. Using the formula would results in the use
of a 60 wedge angle, but the dosimetrist used a 45 angled wedged pair instead because it
offered better PTV coverage on the anterior portion of the volume over the suggested 60 wedge
angle. Using the 60 wedge over the 45 also kept dose low on the posterior side of the PTV,
which was more preferred by the physician because of previous radiation to the brain. The

second challenge that the dosimetrist faced was the creation of the custom bolus and how to
effectively document placement for daily treatment setup. Using the TPS editing tools, the
dosimetrist was able to modify the bolus for the plan and have it avoid being placed near the
nose. The design of the custom bolus was placed in such a way that it was not entirely covering
the treatment field. This placement had to be properly documented for daily treatment
reproducibility. To accomplish this, the dosimetrist attached an anterior posterior (AP) setup 3D
rendering of the bolus placement along with a reticule to aide in measurement (Figure 14).
Another challenge that the dosimetrist encountered was minimizing high dose to the brain. The
most common techniques for photon treatment of a single orbit used are anterior field or an
anterior wedge pair field to spare the opposite orbit.2 The addition of the second wedged pair
spared the brain from high dose by spreading the dosage out throughout more brain volume. In
other cases, if orbital disease was strictly confined to the anterior region of the eye then the
options of using electrons could be employed. For superficial small lesions confined to the
conjunctiva or eyelid, electron beam therapy with a contact lens block can be used.4 Bolus should
be used to treat superficial lesions to bring the isodose curve to the surface for adequate
coverage. 2 AM had disease throughout the entire globe which yielded the use for both photon
energies with the addition of bolus to achieve PTV coverage both superficial and deep.

References
1. Smitt MC, Donaldson SS. Radiotherapy is successful treatment for orbital lymphoma. Int J
Radiat Oncol Biol Phys. 1993 Apr 30;26(1):59-66.
http://dx.doi.org/10.1016/0360-3016(93)90173-S
2. Yadav B, Sharma SC. Orbital lymphoma: Role of radiation. Indian J Ophthalmol. 2009 MarApr; 57(2): 9197.
http://dx.doi.org/10.4103/0301-4738.44516
3. Bentel G. Radiation Therapy Planning. 2nd ed. New York, New York: McGraw-Hill;
1996:126.
4. Donaldson SS, Findley DO. Treatment of orbital lymphoid tumors with electron beams.
Front Radiat Ther Oncol. 1991;25:187-200.
http://dx.doi.org/10.4103/0301-4738.44516

Figures

Figure 1. Patient Setup

Figure 2. CT reference location

Figure 3. Contours drawn by the radiation oncologist (Not shown: Optic chiasm)

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Figure 4. RAO and LAO field arrangements and dose distribution

Figure 5. ASO and AIO field arrangements and dose distribution

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Figure 6. RAO beams eye view (BEV) with .7mm block margin around the PTV

Figure 7. LAO BEV with .7mm block margin around the PTV

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Figure 8. ASO BEV with .7mm block margin around the PTV

Figure 9. AIO BEV with .7mm block margin around the PTV

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Figure 10. Image of the 1cm bolus place on top of right orbit

Figure 11. Dose distribution with plan calculated to the reference point at isocenter, the red
contour indicates the PTV and the 95% IDL is colored orange

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Figure 12. Normalized dose to the new location of the reference point. The red outer contour
indicates the PTV and the 95% IDL is colored orange

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Figure 13. DVH with structure table showing absolute dose

Figure 14. Image of bolus placement for daily treatment setup