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Heather Maurer
March Case Study
March 21, 2014
Coplanar Obliques for Ewing Sarcoma in the Tibia
History of Present Illness: Patient LL is a 13 year old girl who initial complained of left leg
pain in 2013. The pain was conservatively managed without relief which prompted bilateral
lower extremity ultrasound and x-ray. These tested raised suspicions of a mass on the left leg
and an MRI was ordered. The MRI was preformed May 2013 and revealed a long segment of
abnormal bone marrow within the tibial diaphysis measuring 11cm in the craniocaudal
dimension. Connected to this abnormality was an additional soft tissue mass posterior to the
tibia measuring 3x2x11cm. A Biopsy of the soft tissue mass was obtained with results showing
a high grade Ewing sarcoma. The typical onset of Ewings sarcoma is between 15 and 30 years
of age
1
. A Computed Tomography (CT) scan of her chest was then preformed and appeared
clear for metastatic disease. Bone marrow aspirations of both the left and right iliac crests were
both negative for malignancy. She was started on chemotherapy, alternating Vincristine
Doxorubicin Cyclophosphamide (VDC) and Ifosfamide Etoposide (IE) though had some troubles
with her first rounds experiencing abdominal pain, emesis and thrush. She has also been
hospitalized multiple times since July 2013 for hypotension which has responded to fluids or
packed Red Blood Cell (pRBC) transfusions.
Another MRI was done in September 2013 of just the left lower extremity showing a decrease in
the size of the abnormality in the tibial diaphysis as well as the soft tissue mass. After 6 cycles
of chemotherapy she underwent a wide local excision of the left tibia, allograft reconstruction
and planting, soft tissue reconstruction and split thickness skin graft in September 2013.
Pathology revealed a resected high-grade Ewing Sarcoma with some effects from treatment. The
proximal and distal marrow margins were negative but there was invasion through the cortex into
soft tissue with a positive proximal margin. Patient LL recovered well from all surgeries and
continued chemotherapy.
LL was referred to radiation oncology in October 2013 for consideration of adjuvant radiation
post-chemotherapy due to the invasion of soft tissue and positive margin. At one time these
tumors were believed to be radioresistant
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. In the 1960s trials of postoperative high-dose
radiation therapy proved the residual was in fact radiosensitive
1
. With LL being a minor, options
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were discussed with her and her parents. The radiation oncologist recommended adjuvant
radiation to maximize local control while sparing a strip of tissue to help prevent edema. The
logistics, benefits and risks of the radiation treatments were explained, all questions were
answered at time of the discussion and the parents wished to proceed
Past Medical History: Prior to the above stated Ewing sarcoma LL has had an unremarkable
medical history. Since the discovery of the Ewing sarcoma in May 2013 she has had multiple
pRBC transfusions, suffers from hypotension, and underwent numerous surgeries. The surgeries
include tibia soft tissue biopsy, Broviac port placement, WLE of the left tibia, reconstruction and
skin grafts all occurring in September 2013 along with bone marrow aspirations of both the right
and left iliac crests. LL and her parents have also stated she has no know allergies.
Social History: LL is a currently an 8
th
grade student with excellent grades living at home with
her parents and siblings. LL states she has never smoked, used smokeless tobacco, or consumed
alcohol. Her mother has thyroid disease along with a maternal aunt. Her maternal grandmother
and grandfather have hypertension, heart disease, and kidney disease and her grandfather also
has prostate cancer. Her Paternal Grandfather has lymphoma.
Medications: LL has been prescribed the following medications: acetaminophen (Tylenol)
650mg, amitriptyline 25mg, cholecalciferol (vitamin D3), Dextrose 5% and 9% NaCl, docusate
sodium (Colace) 100mg, heparin flush (porcine) 10unit/mL solution, ondansetron (Zofran) 8mg,
polyethylene glycol 3350 (Miralax) 17g packet, promethazine 12.5mg, sulfamethoxazole-
trimethoprim (Bactrim DS) 800-160mg, cephalexin (Keflex) 500mg, diazepam (Valium) 5mg,
diphenhydramine (Benadryl) 25mg, oxycodone (Roxicodone) 5mg, pantoprazole (Protonix)
20mg, and senna (Senokot) 8.6mg.
Diagnostic Imaging: In May of 2013 LL underwent an MRI reveling abnormalities and a mass
in her left tibia, these were then biopsied and discovered to be Ewing sarcoma. With this finding
a CT scan was performed and appeared clear for metastatic disease. She received another MRI
in September 2013 after multiple rounds of chemotherapy showing a decrease in size of initial
abnormality and mass.
Radiation Oncologist Recommendations: After examination of LLs images, reviewing her
history and pathology and speaking with the family, the radiation oncologist recommended
adjuvant radiation post-chemotherapy. The radiation would be delivered using a simplistic plan
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of two oblique fields covering the area with a small margin of healthy tissue yet allowing a strip
of tissue to remain untreated to prevent circumferential radiation
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.
The Plan (prescription): The radiation oncologist prescribed a dose of 50.4 Gy in 1.8 Gy
fractions. The concept was to use a simplistic plan that covered 95% of the planed target volume
(PTV) with 95% of the dose while sparing at least 1cm strip of tissue. It is very important not to
treat the entire circumference of an extremity; it could cause fibrosis and compartment
syndromes
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. MLCs were used along with collimator rotation and jaws to minimize dose to the
healthy tissue. The fields were also coplanar creating a straight edge allowing more tissue to be
spared in the lateral edge of the posterior leg.
Patient Setup/Immobilization: LL partook in a CT simulation in the first part of February
2014 for planning of her radiation therapy treatments. During this procedure she laid supine on a
CT simulation couch with, feet toward the gantry. The skin graft on her left lower leg was
outlined with CT wire and wrapped in a full sheet (30 cm x 30 cm) of 5 mm Superflab.
Superflab is a commercially made material that imitates tissue when interacting with radiation,
also known as bolus
2
. A custom mold called Alpha cradle was made out of Styrofoam, a plastic
bag and some foaming agents for positioning
2
. The Alpha cradle immobilized her left leg from
mid-thigh to bottom of foot and allowing her right leg to be positioned out of the way for
imaging purposes (Figure 1). The Alpha Cradle was placed on top of a 2 cm foam pad for
patient comfort and her head rested on a pillow with hands on her abdomen (Figure 2).
Anatomical Contouring: The data set was imported into the treatment planning system (TPS)
Eclipse. The resident and staff radiation oncologist contoured the clinical target volume (CTV)
by viewing the CT scan and the wires placed around the skin graft. A planning directive was
completed requiring the medical dosimetrist to create a PTV by applying a .5 cm margin to the
CTV in all directions.
Beam Isocenter/Arrangement: The medical dosimetrist used an alignment tool in the Eclipse
TPS to place the isocenter in the center of PTV. She then tried different beam arrangements that
would allow for the best PTV coverage and at least a 1 cm strip of tissue not getting dose. The
finally result was a LAO (Left Anterior Oblique) field at 316.7 degrees and a RAO (Right
Anterior Oblique) at 141.7 degrees both with a collimation of 90 degrees. The medical
dosimetrist chose these exact angles in order to create a parallel edge with the LAO Y2 jaw and
the RAO Y1 jaw. This parallel edge, also called the coplanar edge, prevents the beam from
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diverging into the 1 cm section in the lateral/posterior portion of her leg that was to be spared
from dose as requested. Multileaf collimators (MLCs) were used to conform the beams to the
PTV with a 7 mm margin (Figures 7 & 8). This helps block the normal tissue and concentrate
the dose on the PTV. The physician prescribed 6 MV (megavoltage) energy for all fields in the
plan and treatment on a Varian EX linear accelerator. Due to the thickness of most extremities,
lower energies are often used.
Treatment Planning: As requested according to the planning directive completed by the
physician the beams were 6 MV and weighting was adjusted to allow the best coverage of the
PTV. The physician prescribed 28 fractions of 1.8 Gy for a total of 50.4Gy. It was specified that
the 95% isodose line (IDL) should cover 95% of the PTV. It was also requested to keep the hot
spots out of the fibula but not if it sacrificed coverage of the PTV. The medical dosimetrist
accomplished the desires of the physician while working with the CT scan in the Varian
treatment planning system Eclipse. The fields ended up being equally weighted and no wedges
were used (Figures 3-6). The 95% IDL covered 99.4% of the PTV and the hot spots were not in
the fibula (Figure 9).
Quality Assurance/Physics Check: The monitor units (MUs) for the plan were checked using
the Mobius software. Mobius also checks the planning objectives and dose volume histograms
(DVHs) of the plan. Once the plan has passed the Mobius check the physics staff will do a
visual check against the requests of the physician on the directive and make sure the plan is
ready for treatment (Figure 10).
Conclusion: One of the biggest obstacles in this plan was sparing at least a 1 cm strip of tissue.
Other hurdles were avoiding the opposite leg, preventing a hot spot in the fibula without
jeopardizing coverage of the PTV and immobilization of the leg. It was nice that the 1 cm strip
sparing served as my only critical structure and understanding how that could hinder lymphatic
drainage helped me understand the importance of sparing the tissue. Using an Alpha cradle for
immobilization was helpful for reproducing the angle of the leg and showing exactly where the
bolus material should go, but it does have its downfalls as well. When the physician
contemplated removing the bolus for treatment it was discussed how that would leave a gap in
the cradle around the patients leg which would allow for movement. The physician decided to
leave the bolus for reproducibility and do weekly skin checks to assure the skin is not getting too
much dose
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References
1. Antman KH, Eilber FR, Shiu MH. Soft tissue sarcomas: current trends in diagnosis and
management. Curr Probl Cancer. 1989; 13(6):340-367 http://dx.doi.org/10.1016/0147-
0272(89)90015-9
2. Coleman AM. Treatment procedures. In: Washington CM, Leaver D, eds. Principles
and Practice of Radiation Therapy. 3
rd
ed. St. Louis, MO: Mosby; 2004:183-184
3. Bentel GC. Radiation Therapy Planning 2
nd
ed. New York, NY: McGraw-Hill; 1996.






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Figure 1. Patients left leg immobilized in Alpha Cradle.

Figure 2. Patient on CT simulation table
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Figure 3. Four panel screen shot showing isocenter placement and dose distribution

Figure 4. Single panel axial view of isocenter placement and dose distribution
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Figure 5. Single panel sagittal view of isocenter placement and dose distribution

Figure 6. Single panel coronal view of isocenter placement and dose distribution
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Figure 7. LAO DRR showing MLCs formed around PTV (purple) with 7 mm margin and
isocenter placement

Figure 8. RAO DRR showing MLCs formed around PTV (purple) with 7 mm margin and
isocenter placement
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Figure 9. DVH showing 95% of dose is covering 99.4% of PTV (purple line)

Figure 10. A section of the plans second check through Mobius software