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Krzysztof Karteczka February Case Study February 24, 2012

Four field box technique for carcinoma of the pancreas History of Present Illness: The patient is a 47 year old gentleman with past medical history significant for hypertension, viral cardiomyopathy s/p (status post) Automated Implantable Cardiac Defibrillator placement, cardiac arrhythmia s/p ablation, now referred for consideration of Radiation Therapy for a diagnosis of carcinoma of the pancreas. The patient reports being in his usual state of health until last January when he first began to note progressive epigastric pain. He eventually brought this to the attention of his primary care physician and was subsequently referred for the gastro-intestinal evaluation. Workup included an esophagogastroduodenoscopy EGD with hyperplastic polyps and colonoscopy with adenomatous polyp. Despite this, his symptoms persisted. He lost approximately 15 pounds. A Computed Tomography (CT) scan of the abdomen was ultimately obtained and this revealed a 9 x 6 centimeter mass that appeared to be originating from the pancreas that appeared to encase the superior mesenteric artery. Later, the patient underwent an endoscopic retrograde cholangiopancreatography with cytology returning indicating mucinous neoplasm. He was not felt to be resectable and went on to be treated with several cycles of chemotherapy. Follow-up CT scan of the chest/abdomen/pelvis demonstrated poorly-defined pancreatic neck mass that was minimally smaller and new thickening of the wall of the proximal transverse colon of uncertain significance. No distant disease was seen. He was re-evaluated by the surgeon, who decided that a tumor still felt to be unresectable. Treatment options were reviewed and chemo-radiation was suggested. Currently, the patient notes generalized fatigue, moderate post-prandial cramping, minimal nausea/vomiting, and a weight loss of 40 lbs. over the past year. He denies fevers, other unusual aches/pains, unusual lumps/bumps, headaches, paraesthesias, melena, bright red blood per rectum, diarrhea, hematuria, incontinence, shortness of breath, cough. Past Medical History: The patient has a medical history of tonsillectomy, resection of benign left groin mass, and hypothyroidism. Allergy: The patient has no allergies.

Medications: The patient uses the following medications: Norco, Compazine, Celexa, Amiadorone, Mexilitine, Pepcid, Aldactone, Cozaar, bASA, Synthroid, Coreg, Ambien, MSContin. Diagnostic Imaging Studies: The patients workup included an esophagogastroduodenoscopy, a Computed Tomography scan of the abdomen (this revealed a 9 x 6 centimeter mass that appeared to be originating from the pancreas that appeared to encase the superior mesenteric artery), an endoscopic retrograde cholangiopancreatography. Follow-up CT scan of the chest/abdomen/pelvis have demonstrated poorly-defined pancreatic neck mass. Family History: The patients father was diagnosed with a mesothelioma and his mother with uterine cancer. Social History: The patient is married and resides with his wife and children. He runs a family restaurant business. He denies any use of tobacco and alcohol, and denies drug abuse. Review of Systems: The patient denied prior history of Radiation Therapy; the patient denied symptoms referable to the musculoskeletal, cardiac, respiratory, neuropsychiatric, genitourinary, endocrine or gastrointestinal systems. Recommendations: The patient is a 47 year old male with past medical history as above, now with cT4NoMo adenocarcinoma of the pancreas. History is notable for s/p chemotherapy. Despite this, his tumor remains unresectable. He would appear to be a candidate for Radiation Therapy preferably combined with chemotherapy to promote local-regional control, and possibly facilitate surgical resection. The Plan (Prescription): The doctor reviewed the findings to date with the patient, his sister, his mother and his wife. He also reviewed the treatment options, risks, potential benefits and possible acute and chronic side-effects of radiation therapy. The plan is to deliver a total dose of approximately 4500-5000 cGy conventionally to fields encompassing the offending mass and regional nodes. The patient will likely be receiving concomitant cytotoxic chemotherapy per Medical Oncology and will need special medical attention beyond what is typically expected with radiation alone. Due to the toxicity of this dual modality therapy extra time and effort will be required to generate the radiation treatment plan. Patient Setup/Immobilization The patient was simulated in the supine position, arms up above the head, with the indexed wing board and B type headrest for immobilization of his chest, arms and abdomen. A treatment

planning computed tomography (TPCT) was completed with 4.0 millimeters slice spacing through chest and abdomen region. 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, spinal canal, right and left kidneys, large bowel, heart, right and left lungs were contoured. . The Radiation Oncologist approved these structures for the treatment planning process. Beam Isocenter/Arrangement: The doctor assigned the isocenter during the CT simulation. It was placed in the middle of the pancreas GTV. This isocenter was used for treatment planning. According to the prescription, the physician wanted four field box arrangements (which includes AP, PA, Left Lateral and Right Lateral fields), photon beam energy 10MV used on Varian Clinax iX. I began on the anterior side of the patient with the AP beam placed at 0 degrees and continued around the patient with the remaining three beams, each 90 degrees apart. The AP field size measured 16x16 cm, PA 16x16 cm, LT LAT 12x16 cm, RT LAT 12x16 cm. Treatment Planning: The treatment planning system used was Eclipse 8.9. The objective of the treatment was to conform the dose distribution to the pancreas GTV, while minimizing the dose to spinal canal and kidneys. Dose was calculated using the analytic anisotropic algorithm (AAA) of the treatment planning system. To obtain proper dose distribution I created a Multi-Leaf Collimation and changed field weight factors, giving 0.22 to AP field, 0.28 to PA, and equally 0.25 to both lateral fields. This helped me in minimizing a hot spot and keep if at 107%. See figures 1 and 2 below for graphic illustrations.

Figure 1

Figure 2

Monitor Unit Check: After the plan was approved by the physician, the physicst 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 output value was 51, a 0 % difference from plan MU, MU for PA was 72 ( 1.4% difference), LT LAT 71 MU (0% difference) and RT LAT 66 MU (0 % difference). At NorthShore University Health Systems, percentages over +/- 5% are unacceptable for treatments. See Figure 3 for Photon Monitor Unit Calculation Sheet.

Figure 3 Quality Assurance Check To verify that the dose that is produced on the accelerator is the same as what was planned in the Eclipse treatment planning system, diodes will be used within the first three fractions. Conclusion:

I chose this case study because it was a challenging one. Having studied this case, I have a better understanding of the application of four field box technique, dose distribution, and complexity of treatment planning. Additionally, the plan helped me get a better grasps on the weighting of the fields. Overall, I feel really good about working on this case and I have learned a lot from it. I look forward to learning and getting to plan even more challenging cases in the future!