1

Cinira Johnson
Clinical Practicum I
April 21, 2014.
Neck Keloid Brachytherapy Treatment Planning Case Study
History of Present Illness: MN is a 14 year-old oy, !ho in 200" !as dia#nosed !ith a
thyro#lossal cyst. $i% months a&ter ein# remo'ed, the incision e#an to #ro! a (eloid. In 200),
MN !as treated !ith steroids to no e&&ect, and !as e'entually ta(en to the operatin# room *+,-
&or the remo'al o& the (eloid. .he (eloid #re! ac(, ho!e'er. Althou#h MN did not &eel any
pain, di&&iculty s!allo!in# or reathin#, he !as acutely sel&-conscious aout the scar and he
complained that his &riends made &un o& him aout it. Prior to any &urther sur#ical inter'ention,
MN/s pediatrician !anted to ma(e sure that radiation !ould e #i'en postop due to the
pro%imity o& the lesion to the thyroid #land.
Past Medical History: In 200" MN had a tonsillectomy and thyro#lossal cyst remo'al. In 200)
he had (eloid remo'al.
Social History: MN li'es at home !ith his mother and is in )
th
#rade. 0is &amily li'es in
1en'er. No past &amily history !as reported.
Medications: 0e ta(es no medication at home.
iagnostic Imaging Studies: No ima#in# !as done &or the current (eloid issue.
!adiation "ncologist !ecommendations: .he recommendation &rom the radiation oncolo#ist
!as to treat the (eloid postop &or aout 2 !ee(s &or treatments, and he !ould need a day &or
treatment plannin#. .he radiation oncolo#ist discussed !ith the patient and his mother that
radiation !ould e #i'en in smaller amounts o& radiation each treatment so that it !ould
accumulate to a total dose that !ould help pre'ent the return o& the (eloid a&ter his &urther
e%cision. ,adiation treatments !ere coordinated !ith sur#ery, so treatments started one day a&ter
sur#ery. Althou#h this !as a super&icial *s(in- treatment, the radiation oncolo#ist e%plained to
the patient and his mother that scatter radiation may cause some short-term and lon#-term
e&&ects. .he short-term e&&ects !ould increase as the radiation treatments pro#ressed and then
2
!ould #radually decline a&ter radiation treatment !ere &inished, and that includes s(in redness
and irritation, s!ellin#, sore throat and &ati#ue. ,adiation mi#ht also increase the chance o&
prolems !ith !ound healin#. 2on#-term side e&&ects that mi#ht occur months to years a&ter
radiation treatment include potential thyroid dys&unction, alon# !ith scarrin# o& normal tissue
includin# s(in, muscles, and ones. .here !as also a sli#htly increased chance o& secondary
cancers &rom the radiation itsel&.
The Plan #prescription$: the radiation oncolo#ist/s recommendation !as to treat the (eloid !ith
rachytherapy. 3lectrons !ere considered ut !hen compared to a hi#h-dose *01,- sur&ace
applicator-ased rachytherapy *4,.- a superior co'era#e o& scar and homo#eneity !as noted.
1,
2
.he sharper dose &all o&& !as also a #reat ene&it in order to (eep the radiation dose to the
thyroid lo!.

A dose o& 1500 c6y to the (eloid !as prescried in " &ractions, usin# rachytherapy
techni7ue !ith Iridium-182 as a source.
Patient Setup%Immo&ili'ation: Patient !as simulated in a Philips 4rilliance Computed
.omo#raphy *C.- machine. .he radiation oncolo#ist placed a !ire on the scar on the anterior
nec(. MN !as positioned supine on an $-&rame oard. An $-&rame mas( !as constructed &rom
his cranium to shoulders. .he C. scan !as per&ormed usin# 0.)9 mm a%ial slices &rom the orits
do!n throu#h cla'icles. Additional time !as re7uired to construct a positionin# de'ice &or "
catheters. Measurements ta(en !ith a #uide!ire at t!o locations:
;ire <1: 100.9 to tip= >).> to re&erence mar( on mas(.
;ire <2: 100.9 to tip= >).9 to re&erence mar( on mas(
;ire <": 100.1 to tip= >)." to re&erence mar( on mas(.
(natomical Contouring: .he only structure contoured !as the thyroid. At ?ni'ersity o&
Colorado 0ospital *?C0- the radiation oncolo#ist in char#e o& pediatric cases aimed to (eep the
thyroid mean dose lo!er than 24 6y.
Beam Isocenter%(rrangement: A @ari$ource, &rom @arian, !ith an Iridium -182 source !as
used &or this rachytherapy treatment. 4rachy@ision treatment plannin# system !ith
homo#enous al#orithm !as used &or plannin#. Iridium-182 had a ran#e o& ener#y 'aryin# &rom
0.2 to 0.> Me@ and a hal&-li&e o& )".5" days. .hree catheters attached to the thermoplastic mas(
"
!ere used in this treatment. An older 'ersion o& 4rachy@ision !as used to plan &or this
treatment, and &or this reason treatment had to e ro(en in 2 parts due to the numer o& d!ell
positions e%ceedin# 20 &or one o& the catheters.
Treatment Planning: .he #oal o& this rachytherapy treatment !as to pre'ent (eloid re#ro!th
y deli'erin# the prescription dose to patient/s s(in !hile minimiAin# the dose to the thyroid.
Accordin# to the radiation oncolo#ist, the mean dose &or the thyroid should e (ept lo!er than
24 6y. Accordin# to the plan/s dose-'olume histo#ram *1@0-, the mean-dose o& the thyroid !as
>0.9 c6y *&i#ure1-. Please see &i#ures 2 throu#h 4 &or more details on the plan report &or the
(eloid rachytherapy treatment.
)uality (ssurance%Physics Checks: An 01, 'eri&ication calculation !as done as part o& the
7uality assurance chec(. In this calculation a re&erence point !as placed at 5 cm &rom the center
o& the applicator source. A &ormula calculated the dose in c6y !as also used and it included
&actors such as plan acti'ity, total d!ell time and dose at the re&erence point *&i#ure 9 and >-.
.his calculation !as then 'eri&ied y a physicist.
"
Bi#ures ) and 5 are di#ital representations o&
the isodose cloud and thyroid. Bi#ures 8 throu#h 11 are the treatment plan a%ial, coronal and
sa#ittal slices o& isocenter.
Conclusion: Most o& the (eloid treatments are done y usin# electrons. 4rachytherapy can e an
option &or cases !here the treatment site is near a critical structure since its sharp dose &all o&&
!ill minimiAe irradiation to normal tissue. In this pediatric case, minimiAin# irradiation o& the
thyroid #land can pre'ent late side e&&ects such as cancer.
4
Brom a student stand point, it is 'ery
interestin# to see ho! di&&erent techni7ues are used dependin# on the case at hand. .he ene&its
&rom a 4rachytherapy treatment are essential in cases !here normal tissue sparin# is critical,
such as in pediatric cases li(e this one.
4
!eferences
1. Mohindra P, 1as ,, Anderson 4. $ur&ace mold rachytherapy: a means to achie'e
therapeutic s(in irradiation in a case o& synchronous ilateral reast cancer !ith e%tensi'e
cutaneous in'ol'ement. App Radiat Oncol. 201"= 2*2-: 29C"0.
http:DDappliedradiationoncolo#y.comDradiation-therapy-clinical-application-'olumetric-
modulated-arc-therapyD. Pulished June 12, 201". Accessed April 20, 2014.
2. Arthur 1;, Morris MM, @icini BA. 4reast Cancer: ne! radiation treatment options.
Oncology. 2004= 15: 1>21-1>28= discussion 1>28-1>"0, 1>">-1>"5.
". 1iscussion !ith 1ale .hornton, Medical 1osimetrist at the ?ni'ersity o& Colorado
0ospital/s Cancer Center. April 15, 2014.
4. ,e&eto&& $, 0arrison J, 4orisla' ., et al. Continuin# occurrence o& thyroid carcinoma
a&ter irradiation o& the nec( in in&ancy and childhood. N Engl J Med. 18)9= 282: 1)1-1)9.
1+I: 10.109>DN3JM18)9012"2820402
9
*igures
>
Bi#ure 1. 1ose @olume histo#ram.
)
Bi#ure 2. Plan report pa#e 1.
5
Bi#ure ". Plan report pa#e 2.
8
Bi#ure 4. Plan report pa#e ".
Bi#ure 9. 01, 'eri&ication calculation sheet.
10
11
Bi#ure >. Plan report &or EA.
12
Bi#ure ). AP di#ital ima#e o& treatment setup.
1"
Bi#ure 5. 2ateral di#ital ima#e o& treatment setup.
14
Bi#ure 8. A%ial ima#e o& isocenter.
19
Bi#ure 10. Coronal ima#e o& isocenter.
1>
Bi#ure 11. $a#ittal ima#e o& isocenter.