Savannah Coleman

I. History of Present Illness

a. 14 y.o. female
b. History of T cell myeloid mixed lineage leukemia/lymphoma
c. Allogeneic transplantation at Children’s Hospital of Atlanta in May of 2017
i. 7q post transplant
d. Admitted to hospital 11/23/18
i. 2 week history of headache, nausea, blurred vision
e. MRI 11/23/18
i. Demonstrated lesion in the right inferior cerebellum
1. 0.9 x 0.9 x 0.9 cm
2. Consistent with a chloroma
f. Started on high-dose Decadron 8 mg twice a day 11/23/18
g. Lumbar Puncture 11/24/18
i. Confirmed leukemic cells
h. Emergent radiation therapy consult requested on 11/25/18
i. Visual problems worsened despite steroids
i. CT 11/25/18
i. No acute intracranial process
j. Started emergent whole brain radiation Sat. 11/25
i. Hand calculated
k. CT Simulation for whole brain 11/27
i. CSF-inclusive whole brain fields
ii. Switched to TPS plan on 11/28
iii. 20 Gy total in 10 fractions
l. Final WB treatment 12/06/18
m. MRI 12/19/18
i. Tumor decreased to 3.5 mm
ii. Judged as a good but incomplete response to cranial irradiation and
intrathecal chemotherapy
n. Re-eval consult on 12/21/18
o. CT Simulation for Brain IMRT 12/27/18
p. Started Brain IMRT plan 01/03/18
i. Per COG Protocols AML2951 and AML1031 planned 2000 cGy in 10
fractions to the remaining chloroma GTV plus 1 cm margin
ii. Total 4000 with previous RX
q. MRI 01/09/18 (5-days into treatment)
i. Accumulation of plaqued leukemia cells creating a progressively enlarging
tumor burden in the L4 to S5 thecal sac
1. Contributor to her lower extremity weakness and discomfort
ii. Small-tumor studding in the upper lumbar and thoracic spine thecal sac
areas
iii. Potential disease in the lower cervical spine thecal sac
iv. Chloroma no longer present
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II. Past Medical History

a. Ongoing
i. AML
ii. Oppositional Defiant Disorder
iii. Issues related to past/present chemotherapy
1. Mucositis
2. Chest pain
3. Pulmonary artery stenosis
b. Historical
i. No major diseases or conditions
III. Social History
a. Recently released by Children’s Hospital of Atlanta
b. 9th grade
c. Lives at home with parents
d. No contributory family history
IV. Medications
a. Acetaminophen-hydrocodone
b. Cefdinir
c. Ciazepam (Valium)
d. Diphenhydramine/lidocaine/nystatin topical
e. Loratadine (Claritin)
f. Ondansetron (Zofran)
g. Pregabalin (Lyrica)
h. Promethazine
i. Sulfamethoxazole-trimethoprim (Septra DA)
V. Diagnostic Imaging
a. MRI 11/23/18
i. Lesion in the right inferior cerebellum consistent with a chloroma
b. Fluoroscopically Guided Lumbar Puncture
i. Confirmed Leukemic cells in CSF
c. CT 11/25/18
d. MRI 12/09/18
i. Tumor decreased to 5mm
e. MRI 12/19/18
i. Tumor decreased to 3.5mm but judged as incomplete response
f. MRI 01/09/18
i. Leukemia cell accumulation in the L4 to S5 thecal sac
ii. Small-tumor studding in the upper lumbar and thoracic spine thecal sac
areas
iii. Potential disease in the lower cervical spine thecal sac
iv. Chloroma no longer present
VI. Radiation Oncologist Recommendations
a. Stop the targeted IMRT small-volume field
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i. Chloroma target appears to have resolved

b. Recommended cranio-spinal axis irradiation (CSI)
i. Concern for meningeal studding and sanctuary sites
ii. 1800 cGy over 10 days
c. Boost the top of L5 to the bottom of the thecal space
i. Additional 800 cGy over 4 treatments
ii. Due to bulky disease in this region
VII. The Plan (prescription)
a. CSI
i. 1800 cGy in 10 fractions
ii. VMAT multi-isodose plan
b. Thecal space boost
i. 800 cGy in 4 fractions
ii. IMRT plan
c. CT Simulated 01/10/18
d. Thecal boost to start first 01/12/18, while CSI is being planned due to lower leg
weakness and symptoms
e. CSI started on 01/16/18; finished 01/29/18
VIII. Patient Setup/Immobilization
a. Full body scan
i. Above the head to mid-thigh
b. Supine on S-Board
i. Clear C HH
c. Aquaplast mask
i. Full head and shoulder
d. Arms by side
i. Strap used as a reminder to keep still
e. Vac-Lok for legs
f. Reference marks and BB’s placed
i. Subsequent marks placed for multiple isocenters on first day of treatment
after shifts were made from plan and imaging
IX. Anatomical Contouring
a. Eclipse treatment planning system
b. Dr. Structures
i. CTV Thecal L4-S5
ii. PTV Boost
iii. Lt/Rt Optic Disks
iv. Cribriform
c. Dosimetrist Contours
i. PTV Brain
ii. PTV Spine
iii. Brain
iv. Lt/Rt Eye
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v. Lt/Rt Lens
vi. Lt/Rt Optic Nerve
vii. Oral Cavity
viii. Lt/Rt Parotid
ix. Larynx
x. Esophagus
xi. Lt/Rt Lung
xii. Combined Lung
xiii. Heart
xiv. Spinal Canal
xv. Lt/Rt Kidney
xvi. Liver
X. Beam Isocenter/Arrangement
a. Varian 23IX Machine
i. Iso 1
1. 6 MV rapid arc (2 arcs)
ii. Iso 2
1. 6 MV rapid arc (single)
iii. Iso 3
1. (6 MV rapid arc (single)
iv. Boost
1. IMRT (9 field)
b. All 6 MV energy due to heavy modulation of VMAT and IMRT
i. Risk of neutron contamination with higher energies
c. Plan Isocenter 1
i. Isocenter placed in the posterior aspect of the brain
ii. 2 full 180 degree arcs
iii. 350 degree collimator rotation on CW, 10 on CCW
1. 10 degrees opposed used to help minimize MLC leakage
iv. Used a mirroring method
1. Max MLC leaves can travel is approximately 16cm
2. Can add a third arc to help the dose in the middle, or do mirroring
3. Explain mirroring technique
a. Leave X, change Y
b. Leave Y, change X
d. Plan Isocenter 2
i. Isocenter placed at approximately T5
ii. 1 full 180 CCW arc
iii. 10 degree collimator
iv. Avoidance sector 50-310
e. Plan Isocenter 3
i. Isocenter placed at the level of L3
ii. 1 full 180 CW arc
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iii. 350 degree collimator

iv. Avoidance sector 310-50
f. Plan IMRT Thecal Boost
i. 9-field
ii. None entering anteriorly
XI. Treatment Planning
a. Varian Eclipse
b. Radiation Oncologist entered prescription for boost and CSI, and requested that
the boost be planned first
c. Dosimetrist chose IMRT for boost
i. Ended up with 9 fields
1. PA and 4 angles to either side
2. No angles entering anteriorly
a. 80 and 280 are most anterior angles
3. Ring to constrict dose
4. Objectives put on PTV’s and rings
d. Dosimetrist used process for CSI adapted from published study
i. Explain planning
1. 3 isocenter
a. All ran in the optimizer together so that overlapping dose
would be optimized, then separated for treatment machine
2. Avoidance sectors anteriorly
3. Ring to constrict dose
4. Objectives put on PTV’s and rings
e. Separated isocenters out and then insert a plan sum
f. Plan sum created for all CSI plans plus the boost
g. Evaluated DVH
i. Include objectives
1. Most taken from the published article
ii. Special attention placed on all organs due to youth
1. ALARA
h. The new plans were summed with previous brain treatments for doctor reference
i. Brain max did not exceed Quantec values
XII. Quality Assurance/Physics Check
a. All plans exported to RadCalc
i. MU second check
b. Boost QA
i. QA sheet printed for physicists
ii. Portal dosimetry QA
1. EPID diode array
iii. Second check MU and IMRT QA approved by physics
c. CSI QA
i. QA sheet printed for each isocenter for physicists
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ii. Portal Dosimetry QA for each of the isocenters

1. EPID diode array
iii. Second check MU’s and VMAT QA for all isocenters approved by
physics
XIII. Conclusion
a. Technique for total CSI irradiation involving 3 isocenter VMAT
i. Technique provides a much more conformal technique than traditional
photon CSI, and reduces exit dose
1. Try to find article corroborating
2. Include figures of exit cloud versus exit cloud of traditional
b. Struggled with
i. Complexity of the planning process
1. Saw planning only 2 weeks into clinical rotation
c. Thing I learned
i. New technique
1. Previously only seen CSI plans with traditional CSI photon setups
and with proton planning
ii. Mention the need to be willing to read the latest published information, be
willing to be flexible in your planning technique, not stay stagnant
1. Better for your patients