Brittany Bird

March 12, 2017

Case Study Outline
Simultaneous Integrated Boost for Liver Lesions
I. History of Recent Illness
a. Patient is an 82-year-old female with a history of high-grade ovarian serous
carcinoma that was diagnosed in June 2012. She underwent a hysterectomy with
debulking.
b. Pathology revealed a 6.5 x 4.5 x 2.3 cm tumor positive for high grade ovarian serous
carcinoma with multifocal transcapsular extension. 3/3 nodes were negative for
metastatic disease.
c. Chemotherapy was recommended, however the patient declined therapy. Medical
oncology was consulted in February 2013 for an elevated CA-125 level. The patient
remained asymptomatic and was still reluctant to pursue chemotherapy. Her CA-125
levels continuously fluctuated and then finally significantly elevated.
d. She was placed on Tamoxifen for which she tolerated well and her CA-125 levels
improved and the liver mass decreased in size. After CT imaging, she was referred to
radiation oncology.
II. Past Medical History
a. Arthritis, asthma, and cancer (ovarian cancer with liver mets)
b. Past surgical history includes a hysterectomy with debulking in June 2012 and a right
breast biopsy.
III. Social History
a. States that she has never smoked and doesnt drink alcohol.
b. Looking more into the patients family history.
IV. Medications
a. The patient uses the following medications: Albuterol, Aleve, Biotin, DHEA, Fish oil
capsule, Loratadine, Naproxen, Nasonex, Probiotic, Reclast, Sertraline, Singulair,
Symbicort, Vitamin D, and a Xopenex Nebulization solution.
V. Diagnostic Imaging
a. A CT scan was performed in August 2014 which revealed a subcapsular right hepatic
mass. She declined a biopsy. After her CA-125 levels improved for an extended
period, the levels started rising once again.
b. Another CT scan was performed in April 2015 showing an increase in the
subdiaphragnmatic dome of the liver. After finalizing her treatment of SBRT to the
liver region in August 2015, the patients follow-up displayed three new lesions to the
liver.
c. The patient still declined chemo at this point, but was willing to do more radiation
treatments.
VI. Radiation Oncologist Recommendations
a. The patient has been successfully treated with SBRT to the liver. She now has
symptomatic progression of her disease in the liver. The physician doesnt think
 SBRT is a treatment option for her given the multiple lesions. She also refuses
chemotherapy.
b. The radiation oncologist recommends whole liver radiation with IMRT. He would
prefer simultaneous integrated boost (SIB) to the gross disease.
VII. The Plan (Prescription)
a. The patient will be receiving 2160 cGy to the whole liver at 180 cGy per fraction for
a total of 12 fractions. The boost will entail a dose of 3600 cGy liver at 300 cGy per
fraction for a total of 12 fractions.
b. A VMAT technique will be applied using a 10 MV photon energy.
VIII. Patient Setup/Immobilization
a. The patient was scanned using a Siemens large bore CT scanner.
b. The patient was lying head-first supine on a wingboard, using a B clear Silverman
headrest with a custom vac-lok bag. Both poles were indexed to letter E on the
wingboard in order for the patient to comfortably bring their arms out of the treatment
region.
c. A knee bolster was placed under her legs for support and to alleviate back pressure.
Her feet were tied together with a band to replicate the same position for daily
treatment.
IX. Anatomical Contouring
a. The CT dataset was imported into Velocity, where specific avoidance
structures were contoured. The organs at risk (OR) included the
esophagus, external body, heart, kidneys, lung total, bowel, and
spinal cord.
b. It is vital to contour the critical structures in the treatment area to
see what constraints are met. If a structure is exceeding the dose
limit, then the plan must be modified by either adjusting the beam
arrangement, field size, or energy. If a patient needs to be re-
treated, dose constraints will be evaluated.
X. Beam Isocenter/Arrangement
a. A Varian TrueBeam linear accelerator was used for the treatment of this case.
b. A total of four arcs were used rotating from 181 CW 40 twice and 40 CCW 181
twice. The collimator for arc 1 is 95, arc 2 is 85, arc 3 is 10, and arc 4 is 350.
c. Objectives were met in the VMAT optimization per QUANTEC and Mobius
tolerances.
d. The plan was calculated using the Acuros algorithm in the Eclipse treatment planning
system.
XI. Treatment Planning
a. Used an Eclipse Treatment Planning System calculating with the Acuros algorithm.
b. A normal tissue objective was used and the isocenter depth was placed at 9 cm for all
arcs.
c. Dose constraints were met with the mean heart dose receiving 411.5 cGy, the spinal
cord receiving a maximum dose of 1780.4 cGy, and the PTV receiving the full
prescription dose set by the physician.
d. Plan normalization was set to 100% of the target receiving 95% of the dose.
XII. Quality Assurance/Physics Check
 a. Once the plan is initially approved by the physician, it will be exported to the Mobius
3D application.
b. Mobius at my clinical facility has embedded Quantec and RTOG protocols that will
alert the dosimetrist and physicist if a tolerance is not met, a stray pixel is located, if
there isnt adequate target coverage, and if the gantry angles wont clear the treatment
couch.
c. Portal dosimetry was also performed on the TrueBeam linear accelerator by the
physicist prior to the patients first treatment.
XIII. Conclusion
a. Once I have researched into more information for this assignment and had discussions
with the planning team and physician, I can mention the things I have learned from
this assignment and why this technique was used for this case.
b. Include a summary of the paper.