Jenny Huang

Jenny Huang
April Case Study
April 8, 2018
VMAT for Secondary Neoplasm of the Brain
History of Present Illness: The patient, CL, was a 40 year old male who first presented to
Austin Cancer Center in March 2017. He was diagnosed with Stage IV (t4 N3 M 1b) left upper
lobe non-small cell lung carcinoma (LUL NSCLC). Patient reported worsen mid to low back
pain and the bone scan revealed osseous metastasis in the cervicothoracic junction of the spine,
T3, left sacroiliac joint, left posterior 6th rib, right frontoparietal bone, right supraorbital rim and
left ischial bone. Patient started palliative radiation to his T1 to T4.
In May 2017, patient returned and reported severe pain to his right hip even with
maximum amount of pain medication. Patient underwent radiation treatment to his sacrum and
right hip. Patient completed his treatment and reported a great response and no pain.
In December 2017, patient returned for his follow-up visit. Patient’s wife reported that
patient experienced changes in cognitive ability (increasing memory loss, confusion), behavior
and headache. These presenting symptoms were very common in patient with brain cancer.
Patient had a subsequent CT and MRI head done on December 29, 2017 that revealed a large left
temporal lobe mass with surrounding edema and midline shift. On December 30, 2017 patient
underwent a temporoparietal craniotomy and the pathology showed metastatic adenocarcinoma.
To further determine the extent of the tumor, patient also had a CT of chest, abdomen and pelvis
that showed progression of metastatic disease in the bones and lungs. Patient had a follow-up
visit with his medical oncologist on January 4, 2018. Once his work up was completed, it was
concluded that CL had a secondary neoplasm of the brain and he was referred to Austin Cancer
Center to discuss WBI (Whole Brain Irradiation) and palliative radiation. After radiation, patient
might start 3rd line therapy with Taxotere, Cyramza and Zometa.
Past Medical History: Patient’s past history included pain on lower left extremity, deep vein
thrombosis, shortness of breath, bilateral pulmonary edema, osseous metastasis in the
cervicothoracic junction of the spine, T3, left SI, left posterior 6th rib, right frontoparietal bone,
right supraorbital rim and left ischial bone.

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In March 2017, patient was diagnosed with Stage IV (t4 N3 M 1b) LUL NSCLC and
underwent palliative radiation to his T1 to T4. Between March 2017 and October 2017 patient
underwent radiation treatment to his T-spine, sacrum, right hip and right cerebral lesion.
According to Lischalk et al¹, the majority of NSCLC patients are diagnosed with
metastasis disease at the time of presentation. Because of this, it is very important to decide the
best treatment option for brain mets. The pathology report in January 2018 concluded that patient
CL had secondary neoplasm of the brain. Secondary brain tumor is cancer that has spread to the
brain from another part of the body. Patient CL’s lung tumor cells could break off from the
original mass and travel through the bloodstream or lymphatic system to other areas of the body,
including the brain.
Social History: CL, a warehouse driver, is married with no children. He is a non-smoker and
non-drinker. There is no family history of primary or secondary relatives with cancer.
Medications: The patient reported using the following medications at the time of consult:
Opdivo (to treat NSCLC), Dexamethasone (to relieve inflammation and swelling), Percocet
(Oxycodone and Acetaminophen for short-term pain), Xanax (to treat anxiety and panic
disorder), Ambien (to treat imsomnia), Olanzapine (to treat bipolar disorder), Compazine (to
treat psychotic disorder such as schizophrenic), Oxycontin (to treat moderate to severe pain), and
Percodan (aspirin and Oxycodone for pain reliever).
Diagnostic Imaging: An MRI on December 29, 2017 revealed a large left temporal lobe mass
measuring 2.48 x 2.78 x 5.3 cm with surrounding edema and midline shift. A tumor was found
from the scan and patient had a temporoparietal craniotomy. The pathology report confirmed the
presence of adenocarcinoma. On the same day, patient had a CT of chest, abdomen and pelvis
that showed the progression of metastatic disease in the bones and lung.
Radiation Oncologist Recommended: Chemotherapy agents commonly are not able to cross
the blood-brain barrier. This means that chemotherapy medications will not be able to penetrate
the brain and therefore cannot kill cancer cells in the brain. Therefore, the treatment of choice for
brain metastasis is surgery and radiation therapy. Patient was also categorized as a high-risk
brain metastasis which was defined as those with a maximum diameter greater than 2cm and/ or
those located within an eloquent cortex.¹
After a thorough review of all the diagnostic imaging, the radiation oncologist prescribed
25Gy in 5 fractions with Stereotactic Body Radiotherapy - Volumetric Modulated Arc Therapy

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(SBRT – VMAT). VMAT is able to deliver radiation in a shorter time and also produces less
toxicity to surrounding tissue. SBRT has shown a favorable outcome for the treatment of small to
moderate tumors.² The radiation oncologist recommended patient to see his neurosurgeon for
consideration of resection due to solitary met and his young age.
The plan (Prescription): CL was to receive a total dose of 2500 cGy in 5 fractions. The
radiation oncologist suggested using a SBRT-VMAT techniques to deliver the dose. There was
no plan for additional boost. The intent of the radiation treatment was for palliative.
Patient Setup/ Mobilization: Patient was CT simulated in a Siemens machine on January 11,
2018 and positioned head-first supine on full pad for patient comfort and both hands on his lower
chest (see figure 1). The patient is given an S-frame with a B-headrest. During CT simulation, a
CT technician created a mask which was a mobilization device that function to keep patient in
the same position for the duration of his treatment. To make the mask, the flat plastic mesh mask
was placed in a warm water to soften the material. The CT technician would place the warm and
wet plastic mesh over patient’s face to shape it to fit around the head. There were three marks on
the mask that served as reference points that help radiation therapists to position patient on the
correct and exact place every day and also to ensure consistency and reproducible treatment
setting (see figure 2). A knee sponge was also positioned under his knees for comfort and
support. The CT technician would take several photographs of patient in simulated position for
documentation.
Anatomical Contouring: After completing the CT scan, the images were then exported to the
Pinnacle³ Treatment System Version 16.0. The dosimetrist fused the PET scan with the CT
simulation in order for the oncologist to contour the clinical tumor volume (CTV). The CTV was
the post-surgery volume and expanded 0.4 cm to create the planning treatment volume (PTV).
The medical dosimetrist contoured organs at risk (OAR) such as the eyes, lens, brain, brain stem,
optic chiasm, optic nerves and cochlea. Using the dose constraint sheet specified by the radiation
oncologist, the medical dosimetrist began planning the SBRT plan.
Beam Isocenter/ Arrangement: The beam isocenter was placed in the center of the PTV
contour in the Pinnacle³ TPS. The PTV was located posterior to the greater wing of the sphenoid
bone and medial to temporal bone. Figure 3 shows the placement of isocenter in anterior and left
lateral positions.

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The radiation treatment was done on an Elekta Infinity linear accelerator. The VMAT
plan utilized six 6MV arcs. The first beam arced in the clockwise direction and travelled from
24° to 176° (figure 4). The second beam arced in the counterclockwise direction and travelled
from 176° to 24°. The third and fifth beam arced in the clockwise direction and travelled from
54° to 176°. The fourth and sixth beam arced in the counterclockwise direction and travelled
from 176° to 54°. A 15° collimator rotation was utilized on each beam. This beam arrangements
were chosen to limit the dose to the brain stem and the optic nerves. Several beams of radiation
were given from different angles, overlapping at the tumor to give a high dose to the tumor and
very low doses to surrounding healthy tissues to help reducing the side effects. The TPS
optimization determined the modulation of the multi-leaf collimator (MLC) which was based on
the treatment volume constraints and the organ at risk (OAR).
Treatment Planning: In order to enhance local tumor control and minimize radiation toxicity to
surrounding tissue, the radiation oncologist decided to treat patient with VMAT to help to
increase the conformity of the high dose in order to treat the PTV. VMAT allowed the use of
multiple, well-collimated beam to treat a small lesion with steep dose gradient at the edge of the
beam. This technique is frequently used to treat the resection cavity of brain metastasis, like
patient CL.
The prescription dose was prescribed to the PTV using six 6 MV arcs. The PTV was
given a maximum dose objective of 109% of the prescribed dose (figure 5, 6, 7). The radiation
oncologist specified the organ constraints which included optic chiasm, optic nerves, brainstem,
cochlea and the spinal cord. Both the optic chiasm and the optic nerve were to receive a
maximum point dose of V25Gy or 15-20 Gy < 0.2cc. The brainstem was to receive 0.5cc<23Gy,
1cc<20-26Gy and a maximum point dose of V31Gy. The cochlea was to receive the mean dose
of <15Gy and a maximum dose of V25Gy. Spinal cord was to receive 0.25cc<22.5Gy and
0.5cc<13.5Gy.
The medical dosimetrist used a point dose to prescribe the dose in order to maximize the
dose distribution within the treatment field. Control points were also used to cool down the hot
spots. The 95% isodose line covered 99% of the PTV. This treatment plan was able to meet all
the dose constraints (figure 8, 9). For example, the brain stem had a maximum constraint of
31Gy and the maximum dose for the patient was 552.7 cGy. The cochlea had a protocol for the
mean dose of less than 15Gy and this plan was able to achieve a mean dose of 240 cGy (figure

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4). This VMAT plan was the best option to spare critical structures inside the cranial cavity. The
VMAT plan and the final DVH were reviewed and approved by the radiation oncologist.
Quality Assurance/ Physics Check: Our clinic uses a RadCalc as an independent check of the
calculated monitor units. The tolerance between Pinnacle TPS and RadCalc must be within 5%.
The radiation physicist conducted a double check on the plan to ensure that all treatment plans
were correct. After the monitor unit calculation was approved, the plan was ready to be uploaded
to Mosaiq treatment system. The radiation therapist was responsible to do a chart check to verify
that the TPS’ printout corresponds to what was imported into Mosaiq.
Conclusion: Lischalk et al¹ reported that the incidence of brain metastases in the US is as high as
170,000 cases per year. Lung cancer accounts for the majority (40% to 50%) of these brain
metastases with 43% of patients with NSCLC developing brain metastases alone. Based on the
study by Sapkaroski et al², the aim of this VMAT for SBRT planning was to improve dose
conformality, homogeneity, treatment time, and sparing of the OAR. Patient CL presented with
high malignancy of the brain tumor that posed a therapeutic challenge. He might have significant
comorbidities which could influence his ability to tolerate tumor-therapy. Patient CL competed
his treatment and was due for his follow-up.

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References:
1. Lischalk JW, Oermann E, Collins SP, et al. Five-fraction stereotactic surgery (SRS) for
single inoperable high-risk non-small cell lung cancer (NSCLC) brain metastases.
Radiation Oncology. 2015;10:216. Published October 26, 2015.
http://doi:10.1186/s13014-015-0525-2. Accessed March 30, 2018
2. Sapkaroski D, Osborne C, Knight, KA. A review of stereotactic body radiotherapy – is
volumetric modulate arc therapy the answer. J Med Radiat Sci. 2015;62(2):142-151.
Published May 25, 2015. http://doi:10.1002/jmrs.108. Accessed March 30, 2018.

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Figures

Figure 1. Full body image showing patient positioning with the mask, hands on chest and on a
full pad.

Figure 2. Three reference marks on patient’s mask. Two of the three marks are shown on
patient’s right lateral and anterior.

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Figure 3. The beam isocenter placement shown on Digitally Reconstructed Radiograph (DRR).

Figure 4. The Beam Eye View (BEV) of Arc A with MLC modulation that starts at 24°.

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Figure 5. Isocenter placement in axial view along with isodose distribution of the brain VMAT –
SBRT plan with the 100% isodose line covering 99% of the PTV. The 100% isodose line is
represented by the red line.

Figure 6. Isocenter placement in sagittal view along with isodose distribution of the brain
VMAT – SBRT plan with the 100% isodose line covering 99% of the PTV. The 100% isodose
line is represented by the red line.

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Figure 7. Isocenter placement in coronal view along with isodose distribution of the brain
VMAT – SBRT plan with the 100% isodose line covering 99% of the PTV. The 100% isodose
line is represented by the red line.

Figure 8. A Dose Volume Histogram (DVH) demonstrates the dose related to the tissue volume
of the PTV and OARs.

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Organ at Risk (OAR) Planning Objectives Planning Outcomes

Optic Chiasm V15-20<0.2 cc 0 cc
Max dose < 25 Gy 686.5 cGy
Optic Nerve V15-20<0.2 cc 0 cc
Max dose < 25 Gy 567.8 cGy
Brainstem 0.5cc < 23 Gy 0 cc
1 cc < 20-26 Gy 0 cc
Max dose < 31Gy 552.7 cGy
Cochlea Mean < 15 Gy 767 cGy
Max dose < 25 Gy 1370 cGy
Figure 9. Planning objectives and planning outcomes.

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