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Clinical Oncology Assignment

Kelli Braith
University of Wisconsin- La Crosse
Clinical Oncology DOS 531-501
April 25, 2024
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Introduction
Squamous cell carcinoma (SCC) is the second most common type of non-small cell lung
cancer and accounts for about thirty percent of all lung cancer cases.1 Squamous cell carcinoma
of the lung often occurs in the central part of the lung or airway, such as left or right bronchus.
The main cause of squamous cell carcinoma of the lung is tobacco smoke. SCC is most strongly
associated with smoking more than any other non-small cell lung cancer (NSCLC). Other risk
factors are age, family history, second-hand smoke, mineral and metal particles, and asbestos.2
The patient presented to the emergency department with right upper quadrant pain and
right chest pain. A CT scan was completed and displayed a soft tissue mass in the right hilar and
subcarinal lymph regions. The patient had a history of tobacco use of eighteen packs per year. A
bronchoscopy was performed. The initial diagnosis was malignant neoplasm of bronchus and
multiple right lung sites. A biopsy was performed that confirmed positive for malignancy of
squamous cell carcinoma. An MRI of the brain showed no intracranial metastatic disease. The
PET CT revealed a central right hilar mass with mass effect on the adjacent right hilar vascular
and airway structures that were both highly metabolic. These results were consistent with the
SCC diagnosis. Chemotherapy was also implemented with the drugs Carboplatin AUC and
Paclitaxel 50 mg along with radiation.
Positioning
Patients are positioned at the time of CT simulation in the position that they are to be
treated in for daily treatments. The patient was positioned at CT simulation in the headfirst
supine position. His arms were positioned up over his head in an upper vaclok conforming to the
shape of the arms and elbows, encouraging reproducibility. The upper vaclok was fixated by a
plate with two bubbles, to ensure that the vaclok was indexed. The patient’s chin was in the
neutral position for comfort and reproducibility. Comfort was also considered when
implementing a cushion under the knees. Figure 1 demonstrates the patient’s set up position. The
patient’s toes were also strapped. This is done to ensure that the patient doesn’t move the feet and
to limit the crossing of the feet at the ankles. Crossing of the feet at the ankles can rotate the
patient and make three-point set up more difficult. Figure 2 provides information that a toe strap
was used. It is important to have all set up information in the set-up note, sometimes patients
have blankets on, and all set up devices are unseen. The patient was tattooed to ensure that the
set-up marks remain daily. The tattoos assist with straightness and roll of the patient prior to the
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CBCT daily. A 4-DCT scan was obtained to assess motion of the target due to breathing
amplitude and cardiac motion. A 4DCT is used for target delineation for tumors that are mobile.
The process involves describing the target volume on individual phases, on the maximum
intensity projection (MIP), and on the average intensity projection data sets.2
Target Dose and Fractionation
The target dose prescribed for this patient was 6000 cGy over 30 fractions. 200 cGy
delivered per fraction. The physician requested target coverage of D95% >= 100% (60.0 Gy) and
D99% > 93% (55.8 Gy). This plan was able to achieve these requested values. This fractionation
was delivered daily, Monday through Friday. A treatment course of definitive radiotherapy given
concurrently with chemotherapy was recommended. The chemotherapy regimen prescribed was
Carboplatin AUC 2, Paclitaxel 50 mg per m2 weekly with concurrent radiation. The regimen was
chosen according to the National Comprehensive Cancer Network Non-Small Cell Lung Cancer
guidelines. According to the guidelines for squamous cell non-small cell lung cancer, treatment
involves Paclitaxel weekly and carboplatin AUC 2 concurrent thoracic RT.3
According to RTOG 0617, survival was increased for patients that received standard-
dose (60.0 Gy) chemoradiotherapy. It was shown that 60.0 Gy along with concurrent
chemotherapy for patients with stage III non-small-cell lung cancer is safer than 74.0 Gy in two
fractions.4 This is important to consider when deciding on which fractionation of treatment to
prescribe. Physicians consider side effects and quality of life when choosing treatment regimens.
Avoidance Structures
The organs at risk (OAR) for this patient included cord, cord PRV (planning organ at
risk), esophagus, heart, right lung, left lung, and liver. The PRV is developed to include
geometric uncertainties of OAR in treatment planning.5 The PRV for the cord is the cord contour
plus a 0.5 mm expansion. The cord structure had a constraint of the max (Gy) to be less than 50.0
Gy and the cord PRV max (Gy)[cc] needed to be less than 55.0 Gy. Both constraints were met
without having to add an avoidance structure.
The esophagus constraints were priority three due to the esophagus being included in the
PTV. The esophagus constraints are implemented to avoid esophagitis. It is recommended to
keep the mean dose less than 34.0 Gy.6 An avoidance structure was created to limit hot spots in
the esophagus. This was done by creating a structure that included esophagus within the PTV.
This structure was used when optimizing to limit more than prescription dose within that
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structure. A structure was also created to avoid over prescription of the heart to avoid
pericarditis. Figure 3 illustrates the avoidance structures in the axial view. Figure 4 shows the
avoidance structures in transverse view.
The table below indicates the dose constraints that the physician requested and the
QUANTEC dose constraints. Also included are the contradictions if the tolerances are not met.
All the requested constraints were met for this plan, except for the heart max (Gy) less than 62.0
Gy and esophagus V60.0 Gy [%] < 5%.
Lymph Node Region Involvement
This patient had right hilar and subcarinal lymph node involvement. The hilar lymph
nodes are station ten. These nodes are found on the right and left side of the mainstem bronchi.
The subcarinal lymph nodes are station seven. These lymph nodes are directly behind the carina
and between the mainstem bronchi.7 The patient had a PET CT in mid-March that revealed
indications of a central right hilar mass effect on the nearby right hilar vascular and airway
structures. The anatomy was hypermetabolic and consistent with previously biopsy proven
squamous cell carcinoma. The PET CT images were fused with the planning CT at the point of
nodal involvement are shown in Figure 5.
Treatment Field Borders
The anatomical borders were defined by the physician. The physical treatment boundaries
included the right hilar and subcarinal areas of the soft tissue. The right interlobar, middle lobe
and lower bronchi were also involved. Figure 6 depicts the treatment target volumes defined by
the physician in the axial view. The transverse view is indicated in Figure 7 and the sagittal view
is demonstrated in Figure 8. A gross tumor volume (GTV) is created to encompass the tumor
seen on CT scan, PET, or other imaging modalities.8 A volume is created to assess motion of the
tumor obtained from the 4DCT. This volume is the internal target volume (ITV). A clinical
treatment volume (CTV) is created to encompass the GTV plus margin for sub-clinical disease
spread.8 The planning treatment volume (PTV) is lastly created. This volume allows for
uncertainties in planning or treatment delivery.8 The physician used these methods to create the
volume to be treated. A visual of the GTV, CTV, and PTV is provided in Figure 9.8
Treatment Technique
The technique type ordered by the physician for the patient was intensity modulated
radiation therapy (IMRT) with volumetric modulated arc therapy (VMAT). This type of plan was
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to be treated on a Varian TrueBeam. The isocenter was placed near the middle of the PTV, 4 cm
to the right of midline, due to laterality of the volume. The vertical and superior and inferior
shifts assisted with placing the isocenter as central as possible. The two half arcs that were used
were clockwise 181.0-0.0 and counterclockwise 0.0-181.0. Figure 11 indicates the treatment
field that included two half arcs. Two half arcs were sufficient for this plan as it is a circular
shape, and the two beams were able to conform to the target effectively while limiting dose to
critical structures.
Collimator angles of 15° and 90° were used. It is important to not use the same collimator
angle for both fields. Leakage from the multi-leaf collimators (MLC) will be in the same location
if the collimator is kept the same. The energy that was used for both arcs was 6x. The MLC was
fit to the PTV structure with a 0.5 cm margin around the PTV, Figure 10 demonstrates the field
margins around the PTV. This plan did not require couch kicks, wedges, or split fields.
Before starting to plan the patient in the optimizer, many structures were created to assist
with dose distribution and control. The structures are created to ensure that dose is deposited in
the correct places and limited in others. The “in” structures of the organ are where dose is
desired, but not more than 105%. The “out” structures of the organ were created to reduce dose
to that organ as much as possible. The principle of ALARA (as low as reasonably achievable)
was practiced on these organs. A dose limiting annulus (DLA) is also created by adding a 3.0 cm
margin to the PTV and cropping the DLA away from the PTV by 0.2 mm. This is to allow
prescription dose to be achieved in the PTV but to control lower dose and integral dose. The
DLA was set up so that zero percent of the prescription dose is allowed.
After completing all the desired structures in contouring, optimization occurred. This plan
was optimized three times. The first optimization was to achieve the requested dose to the PTV
and to limit dose to OAR. The second optimization done was to push on the esophagus and the
heart to get lower dose. The second optimization was also done to try to achieve more
prescription dose in spots that were cold. After the second optimization a cold structure was
created to assist with distributing dose to those cold regions. The third optimization was to
deposit dose to the cold structure to obtain prescription dose.
After desired dose was met to the PTV and OAR and were limited by the thought of as
low as reasonably achievable (ALARA), the plan was finished. The global hot spot was 110.4%
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and inside the PTV. The global maximum hot spot is depicted in Figure 12. The coverage
requested by the physician was achieved, D95% >= 100%, totaling 100.47%.
Conclusion
The final dose volume histogram (DVH), shown in Figure 13, displays the achievements
of this plan. The physician requested the highest priority of this plan to be the coverage of the
PTV. The request was D95% >= 100%, was met with 100.47%. Most of the OAR were met as
well. The cord, cord PRV, lung total, left lung, right lung, and liver were achieved. The
esophagus was mostly achieved except for the V60.0 Gy < 5%, a priority 3. The value achieved
was 20.47%. This was difficult to meet as part of the esophagus was contoured into the PTV. The
heart was also all met except for the heart max < 62.0 Gy, a priority 3. The achieved value was
63.22 Gy, this was pushed on to try to lower the max dose, but consequently coverage to the PTV
was lost. The final achieved values of the plan are shown in Figure 14. The physician was
pleased with this plan and the plan was used to treat the patient.
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References

1. What is squamous cell carcinoma? Moffitt Cancer Center.

https://www.moffitt.org/cancers/lung-cancer/faqs/what-is-squamous-cell-carcinoma/
#:~:text=Squamous%20cell%20carcinoma%20of%20the,of%20all%20lung%20cancer
%20cases . Accessed April 19, 2024.
2. Bhanusivakumar R. Sabbula, David P. Gasalberti, Fatima Anjum. Squamous cell lung cancer.
StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK564510/#:~:text=Squamous%20cell
%20carcinoma%20%28SCC%29%20of%20the%20lung%2C%20also,causative%20agent%20of
%20cellular%20transformation%20is%20tobacco%20smoke . Updated September 4, 2023.
Accessed April 15, 2024.
3. Tryyggestad, E, Li, H, Rong, Y. 4DCT is long overdue for improvement. J Appl Clin Med
Phys. 2023; 24(4). https://doi.org/10.1002/acm2.13933
4. NCCN guideline for patients: early and locally advanced non- small cell lung cancer. NCCN.
https://www.nccn.org/patients/guidelines/content/PDF/lung-early-stage-patient.pdf. 2023.
Accessed Arpil 15, 2024.
5. Bradley, J, Paulus, R, Komaki, R, et al. Standard-dose versus high-dose conformal
radiotherapy with concurrent and consolidation carboplatin plus paclitaxel with or without
cetuximab for patients with stage IIIA or IIIB non-small-cell lung cancer (RTOG 0617): a
randomised, two-by-two factorial phase 3 study. The Lancet Onc. 2015; 16(2): 187-199.
http://doi.org/10.1016/S1470-2045(14)71207-0
6. Stroom, J, Heijmen, B. Limitations of the planning organ at risk volume (PRV) concept. Int. J
of Radiat Oncol Biol Phys.2006. 66(1): 279-286. https://doi.org/10.1016/j.ijrobp.2006.05.009
7. Emami, B. Tolerance of normal tissue to therapeutic radiation. Rep of Radiot and Oncol. 2013;
1(1).
8. Burlew, J, Weber, C, Banks, K. Anatomy, thorax, mediastinal lymph nodes. StatPearls.
https://www.ncbi.nlm.nih.gov/books/NBK532863/ . Updated July 24. 2023. Accessed April 16,
2024.
9. Burnet, N, Thomas, S, Burton, K, Jefferies, S. Defining the tumour and target volumes for
radiotherapy. Cancer Imaging. 2004; 4(2): 153-161. https://doi.org/10.1102/1470-
7330.2004.0054
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Figures

Figure 1: Positioning: upper vaclok, arms up, head in neutral position, and knee cushion.

Figure 2: Simulation set up note: h3 (bubble board), sup (supine), vac (vaclok), lg kn (large knee
cushion), t.s. (toe strap).

Figure 3: Axial view avoidance structures.

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Figure 4: Transverse view avoidance structures.

Figure 5: Hilar nodal and subcarinal nodal involvement on PET CT.

Figure 6: Axial of treatment target volumes.

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Figure 7: Transverse of treatment target volumes.

Figure 8: Sagittal of treatment target volumes.

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Figure 9: GTV, CTV, PTV.

Figure 10: Field margins around PTV.

Figure 11: Field with arcs.

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Figure 12: Global maximum hot spot.

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Figure 13: Final DVH.

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Figure 14: Final achieved values.

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Table

Table 1: Dose constraints requested by the physician and the QUANTEC dose constraints.
Avoidance Physician Tolerance QUANTEC Achieved Contradictions
Structure Tolerance
Cord Max [Gy] < 50 Gy Max [Gy] < 50 Gy 35.37 Gy Myelopathy
Cord PRV Max [Gy] < 55 Gy 40.6 Gy
V55 Gy [cc] < 0.1 cc 0 cc
Esophagus Mean [Gy] < 34 Gy 21.62 Gy
V60 Gy [%] < 5% V60 Gy [%] < 30% 20.47% Esophagitis
V55 Gy [%] <= 40% 24.3%
V50 Gy [%] < 45% V50 Gy [%] < 40% 26.55%
V35 Gy [%] < 50% V35 Gy [%] < 50% 31.62% Esophagitis
Lung Total Mean [Gy] < 20 Gy 15.2 Gy
V10 Gy [%] < 42% 41.89%
V20 Gy [%] < 35% 29.46%
Left Lung Mean [Gy]: Report
DC 1000cc [Gy]: Report
DC 500cc [Gy]: Report
V10 Gy [%]: Report
V20 Gy [%]: Report

Volume [cc]: Report V20 < 31% Symptomatic

V20 < 40 % Pneumonitis
Right Lung Mean [Gy]: Report
DC 1000cc [Gy]: Report
DC 500cc [Gy]: Report
V10 Gy [%]: Report
V20 Gy [%]: Report

Volume [cc]: Report V20 < 31% Symptomatic

V20 < 40 % Pneumonitis
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Heart Max [Gy] < 62 Gy 63.22 Gy

Mean [Gy] < 20 Gy 12.72 Gy
V40 Gy [%] < 33% 7.42%
V30 Gy [%] < 46% V30 Gy < 46% 11.88% Pericarditis
V25 Gy < 10% Long-term
cardiac
mortality
Liver Mean [Gy] <= 30 Gy Mean <= 30 Gy .62 Gy