Case Study

Thanh Bui
Argosy University Twin Cities
Clinical Training Radiation Therapy: RTH290
Jessica Donahue
4/29/15

Introduction
Within the previous weeks, I was able to have the opportunity to be a part of a
very tough and hard journey a brave woman had to deal with. She was kind enough to let
me follow her whole radiation therapy treatment from her initial consult to her finishing
of treatment. In this case study I will discuss her consultation, describe how the patient
was simulated and discuss treatment-planning aspects involved. I will also talk about the
daily treatments as well as how the patients tolerated treatment. To conclude the case
study I will talk about inflammatory breast cancer with brain metastases and options
available to treat this disease.
Consultation

The patient is a 51-year old female who was diagnosed with poorly differentiated
inflammatory breast cancer. She first noticed swelling in her left breast in July of 2012.
Her left breast was then biopsied on 9/7/12 to give the pathology of the mass. Estrogen
and progesterone receptors were positive. HER-2 was also positive. She was first treated
with Adriamycin and Cytoxan followed by Taxol and Herceptin, these were all completed
by 1/25/13. On 2/1/15 she started using Tamoxifen and Herceptin. On 2/25/13 she
underwent bilateral mastectomies and left axillary lymph node dissection. Pathology of
the axillary lymph nodes showed extensive residual tumor and 7 out of 8 lymph nodes
were involved with the tumor. She underwent radiation therapy to the left chest wall,
axilla and supraclavicular area for a total of 5940cgy which she completed on 5/17/13.
She completed her Herceptin in November 2013. Also in November she went to New
Orleans for a TRAM flap reconstruction. After that procedure she developed deep venous
thrombosis. Tamoxifen was discontinued because of the deep venous thrombosis. In
February 2014, CT scan showed abdominal edema, small amount of ascites and masses in
the pancreas. She was evaluated at the University of Minnesota where an endoscopic
ultrasound also showed masses in the pancreas. A biopsy was performed but during that
procedure the pancreas was lacerated she was hospitalized for 5 days after. In April of
2014 she developed a left lower extremity deep venous thrombosis and was started on an
anticoagulant. On 5/19/14 she underwent an exploratory laparotomy, total abdominal
hysterectomy, removal of both ovaries, omentectomy, appendectomy and partial tumor
debulking. Surgical finding revealed extensive carcinomatosis with a 15cm left ovarian
mass. Pathology confirmed metastatic breast cancer because of the deep venous
thrombosis. Tamoxifen was discontinued and an inferior vena cava filter was placed.

On 6/14/14 she was admitted to Abbott Northwestern hospital where she received
Docetaxel but that was quickly discontinued because she developed acute respiratory
distress. On 11/27/14 she had an unexplained fall. The next day she went in for brain
MRI that revealed diffused intraparenchymal and leptomeningeal metastases with the
largest mass measuring up to 3cm in the right cerebellum. She was then referred to our
department for radiation therapy. This will be the second time she has been referred to
our department.
The patient had an unexplained fall that recently happened. She also developed,
headaches, dizziness and blurred vision which she reported to our nurse. The doctor came
into the exam room with heaviness in the air because of the patients past medical
problems. He wanted to show her the MRI of her brain that was done previous days
before. The patient, doctor and I all looked over the MRI. The doctor first pointed out the
3cm mass in the right cerebellum and then showed many other small masses throughout
the brain. The patient then started to break down because of the hard news. The doctor
told the patient about either going into hospice care right away or to continue with
treatment for a palliative purpose. The patient chose to continue with the option of
radiation therapy. The patients primary diagnosis was IBC but she is in to be treated for
her brain metastases.
The patients family and social history is as follows: father is deceased at the age
of 70 because of heart failure. Mother is alive with diabetes. Both maternal grandparents
are deceased. Never was a smoker and drink occasionally. She is a retired marketing
agent for Disney and is wheel chair bound since 11/26/15.
Simulation
The patient had just one simulation. The patient was simulated on the same day as
the consult. At our clinic we have a conventional simulator. We brought the patient in and

assisted her from her wheel chair to the sim table. We initially set the table up with an
independent head holder with two shims and a clear B head holder. We explained to the
patient that this was a simulation for a whole brain treatment. We laid the patients head
on the head holder and used the tip of tragus to line up the patient. Once the lasers were
lined up on the tip of tragus we then placed an aquaplastic mask into a hot water bath to
make the mask more malleable. We then stretched the mask over the face of the patient
and locked the mask into place with the independent head frame. We then looked under
fluoroscopy to make sure the patient head is lined up straight. Once straight, a mark is
made on the mask to indicate the left/right on midline. When then went to our first angle
which was RAO at 275 degrees. The boarders for a whole brain are set with the inferior
boarder splitting C1-C2 and 2cm flash with the other boarders. The doctor will then come
in and approve the film. We then place a film into the image intensifier with a RAO
mark and took a film. SSDs are also gathered at this angle. We then rotated to our other
angle of LAO at 85 degrees. Once at this angle a film was taken and the SSDs were also
gathered. We then moved back to the angle of 0 degrees and used the lasers to make our
lateral marks on the mask. The mask was removed from the patient and their last name
and B head holder was written on her mask. Then patient also was able to set up their
appointment times since she was to start her treatment the next day.
Treatment Planning
The patients treatment plan was to use a whole brain technique. This type of
treatment was chosen because of the wide spread of the brain mets. With the films taken
from the simulation the doctor draws the necessary blocks for the eye and face. Blocking
was done with the use of MLC. The beam angles are just two angles RAO-275 and LAO
85 degrees. A total of ten treatments of 300cgy per fraction were given to a total dose of

3000cgy using 10x photons. The main thing with the planning of this treatment is the
blocking of the eye and making sure no dose gets to the eyes.
Daily Administration of Treatments
The patient was brought in for their first treatment the day after their simulation.
We set the patient up according to the simulation notes. The procedure was explained to
the patient and it was stated that we would be starting with a few x-rays to verify the set
up. Once the patient was lined up we moved to our first angle to record the SSD and
check the eye for blocking. If the there was not enough blocking for the eye the table is
shifted either in or out to give the eye enough blocking. We then did the same thing for
the other angel. The day one port films were compared to the initial sim x-ray photos to
make sure set ups look the same. Every day for treatment we would record SSDs and
checked the eye for proper blocking. Port films were recorded every five days.
Assessment of Patient During Treatment and Prognosis
Over the course of the radiation treatment, the patient did not respond well to the
radiation. On the patients 5th day we got her on the table and had to get her down
immediately because of the pain and distress the patient was in. She did not show signs of
improving symptoms with treatment. On her 6th day of treatment the doctor discontinued
her treatment and she was referred to hospice care. She died shortly after on 12/22/14.
Inflammatory Breast Cancers
Inflammatory breast cancer (IBC) is a rare and aggressive disease in which cancer cells
block the lymph vessels in the skin of the breast. This type of breast cancer is called
inflammatory because the breast often looks swollen and red. Inflammatory breast
cancer accounts for 1-5% of all breast cancer diagnosed each year in the United States.
Most IBC cancer are invasive ductal carcinomas, which means they develop from cells
that line the milk ducts of the breast and then spread beyond the ducts. IBC grows

rapidly, usually in a matter of weeks or months. IBC is usually staged at 3 or 4,

depending on whether cancer cells have spread to nearby lymph nodes or to other tissues
as well. Common routes of spread for lymph are internal mammary and axillary nodes.
Common sites for mets are brain, bone, liver and lung.
Some general risk factors for breast cancer are: Being a woman, women are 100
times more likely to develop breast cancer than men, Having a family history of breast
cancer, Having denser breast tissue.
Some common diagnostic methods include: mammogram of the breast, breast ultrasound
and clinical breast exams. The most common symptom for breast cancer is a lump or
mass on the breast. With a case of IBC a MRI or bone scan is usually done to see if the
disease has spread anywhere else because of the disease rapid growth. Treatment of IBC
is treated first with chemotherapy to help shrink the tumor, then surgery to remove as
much tumor as possible and then radiation therapy. Treatment techniques are almost
always with an breast tang. and supraclavicular set up.
Other Treatment Options
Neoadjuvant chemotherapy: This type of chemotherapy is given before surgery
with at least 6 cycles of chemotherapy for 4-6 months, Unless the disease is growing at a
very rapid pace where the doctor does not want to delay surgery anymore.
Targeted therapy: This therapy is used if a womans biopsy shows that her cancer
cells have a tumor marker that can be targeted with a specific drug. For example, IBC
tend to produce greater than normal amounts of HER2 proteins, which means they
respond positively to drugs such as Herceptin.
Hormone Therapy: If a womans biopsy samples show that her cancer cells contain
hormone receptors, hormone therapy is another option. For example, breast cancer cells
that have estrogen receptors tend to respond well to tomaxifen.
Surgery: The standard surgery for inflammatory breast cancer is a modified
radical mastectomy. This surgery involves the removal of the entire breast and most or all

of the lymph nodes under the adjacent arm. Often the underlying muscles of the chest is
also removed but the chest muscles are preserved.
Adjuvant therapy: This may be given after surgery to reduce the chance of the
cancer reoccurring. This therapy may include additional chemotherapy, antihormonal
therapy, targeted therapy or a combination of these.
Supportive/palliative care: The goals of this care is to improve the quality of life
of patients who have serious or life threatening disease, such as cancer or to provide
support to their loved ones.
In conclusion, I feel very honored to be able to follow and observed this womans
treatment every day. It was honestly a hard and very sad journey that only the bravest
people can take on. The patient chose to do radiation therapy to help with her side effects
of her brain metastases which would improve her overall quality of life but the rapid
spread of her cancer ended her long fought battle with her disease. She was a very nice
woman who was so humble and nice even though she was in so much pain. I will never
forget this inspiring person.

Referrences
Inflammatory Breast Cancer (IBC) :: The National Breast Cancer Foundation. (n.d.).
Retrieved May 2, 2015, from http://www.nationalbreastcancer.org/inflammatory-breastcancer/?gclid=CLTnvOWro8UCFZY0aQodeGAApg
Inflammatory Breast Cancer. (n.d.). Retrieved May 2, 2015, from
http://www.cancer.gov/cancertopics/types/breast/ibc-fact-sheet

Inflammatory breast cancer. (n.d.). Retrieved May 2, 2015, from

http://www.mayoclinic.org/diseases-conditions/inflammatory-breastcancer/basics/definition/con-20035052