Glenda Longoria

April Case Study

April 1, 2016

Palliative IMRT of Maxillary Sinus

History of Present Illness: In February 2016, the patient in this case study, SH, was referred to
our radiation oncology department for palliative treatment of a solitary maxillary sinus mass. SH,
is a 60-year-old Hispanic female with a history of metastatic inflammatory breast cancer,
previously treated in 2014. She was referred to radiation oncology following confirmation of
metastatic disease involving the right maxillary antrum, extending to the floor of the orbit, and
also involving bone and liver metastasis. She presented to us at this time with symptoms of facial
pressure and pain in her sinus region, as well as difficulty breathing. She was referred by her
medical oncologist for evaluation of radiation therapy to the maxillary tumor.
Past Medical History: Patient has a history of diabetes mellitus, arthritis, and hypertension. Past
surgical history consists of modified radical mastectomy, 4 cesareans, hysterectomy, and surgery
of the right foot.
In 2013, SH presented to her family physician in Mexico with a palpable right breast mass that she
noticed 6 months prior. The mass was evaluated first with ultrasound, and later a biopsy was
performed at our radiology facility. The findings of the mass were conclusive to be stage 2
inflammatory breast cancer (IBC) characteristic of infiltrating ductal carcinoma.
IBC is an aggressive form of breast cancer, accounting for 1%-2% of all breast cancer cases, and
typically associated with poor overall prognosis.1 Patients diagnosed with inflammatory breast
cancer have seen optimal results when treated with systemic chemotherapy, hormonal therapy,
radiation therapy, and surgery, although rates still remain low for long-term survival.2
Following the diagnosis, she was referred to a medical oncologist, and SH completed her course
of chemotherapy, followed by a modified radical mastectomy and a full course of radiation therapy
in 2014.
Upon completion of treatment for breast cancer, SH was asymptomatic for two years until most
recently when she presented with complications from boney metastasis, liver metastasis, as well
as a solitary lesion located in her maxillary sinus cavity that extended to nearby structures. A PET
CT was performed to confirm metastasis, as well as a liver biopsy. Concerning the maxillary
tumor, there was no biopsy performed, however, considering the patients history of extensive
metastatic disease and confirmed clinical pathology of metastatic hepatic lesions, the team of
physicians including her medical oncologist, radiation oncologist, and surgeon, consulted with one

Glenda Longoria
April Case Study
April 1, 2016

another and decided radiation therapy was the best option to treat her maxillary disease and
symptoms. Surgery was the second treatment option, however, radiation therapy was decided
upon as the physicians anticipated a better response and was more tolerable than invasive surgery.
Social History: Patient is married and lives at home with her spouse. She had 4 pregnancies, and
5 births with one set of twins. Patient denies smoking or alcohol abuse. According to the patient,
her father died of complications from cancer, however she could not recall what type it was. Her
mother died from complications of diabetes mellitus. There is no history of breast cancer in the
patients immediate family.
Medications: SH is currently taking the following medications: Compazine, Enalapril, Letrozole,
Metoprol Tart, Novolin Rand Humulinn, Vitamin B12, and Xanax.
Diagnostic Imaging: In February 2016, after a follow up with her medical oncologist, SH was
recommended a PET CT of the whole body to evaluate for metastatic disease. The results of the
PET CT showed significant uptake of the radioactive isotope in the patients liver, spine, and
maxilla region. Consequently, the patient was referred to have a needle biopsy of the liver to
determine the pathology of the liver lesions, and were soon after confirmed to be metastatic disease
from her original primary of inflammatory breast cancer. It was this PET CT, and the confirmation
of metastatic disease from the needle biopsy, that determined SH was a good candidate for
radiation therapy.
Radiation Oncologist Recommendations:

After initial consult for the maxillary tumor

recurrence, the physician reviewed the patients medical records and recommended to proceed
with palliative radiation therapy in an attempt to improve her symptoms of this large maxillary
mass. The radiation oncologist discussed treatment options with the patient and her family,
explained of the possible side effects, and the patient opted to proceed with simulation to start her
course of palliative radiation therapy.
A CT simulation of the head and neck was used to plan the radiation and to further evaluate the
extent of metastases at the time of treatment planning.
The Plan (prescription): The radiation oncologist prescribed 250 cGy per fraction over a course
of 15 fractions. Total dose would not exceed 3750 cGy, and there was no boost planned for this
palliative course of treatment. The treatment was delivered with an IMRT technique due to the
extent of the tumor and the critical structures in and near the GTV.

Glenda Longoria
April Case Study
April 1, 2016

Patient Setup/Immobilization: SH was taken to the simulator on the day of consult with
anticipation that her treatment would start as soon as possible. The CT simulator used at our
facility is a GE Lightspeed CT scanner. LAP lasers were used to place reference points on the
patient and images were sent to the planning workstations in dosimetry once the simulation was
completed via a DICOM interface.
The process of her simulation was explained before it started and as it progressed. She was
positioned supine on the CT simulator table, head first, and her head was placed on a base plate
with the clear head rest B. An aquaplast mask was made to mold her face for immobilization
during her treatment. She was given a knee sponge for comfort under her knees, and her hands
were relaxed at her side. Scouts were taken of the treatment area to ensure it was straight, and
adjustments were made to correct any misalignments. The simulation was completed using metal
point markers on her aquaplast mask as reference points for her treatment.
Anatomical Contouring: Contoured structures in this plan are the GTV, GTV with 1.5 cm
margin, brain, right eye, left eye, right optic nerve, left optic nerve, optic chiasm, right lens, left
lens, brainstem, spinal cord, mandible, oral cavity, right parotid gland, and left parotid gland.
The physician drew in the initial GTV, and the structure labeled ptv1gtv 1.5 mar was added for
planning purposes to assure that the dose would target the GTV plus a 1.5 cm margin around it.
Beam Isocenter Arrangement: The course of treatment for SH was completed on a Varian
Trilogy linear accelerator using 6 MV and 7 IMRT fields with MLCs. The physician placed the
isocenter as close to the middle of the irregularly-shaped GTV and requested an IMRT plan with
a 1.5 cm margin around the GTV, for a total dose of 3750 cGy.
The main priority in planning this treatment was to avoid any organs at risk in this very delicate
region. Since the tumor was located in such a position in the middle of her facial bones, it made
treatment planning very difficult. Radiation dose can sometimes be limited due to critical
structures that lie near the treatment area, therefore it is extremely vital during the treatment
planning process to properly identify and contour these structures to deliver the maximum dose to
the PTV, while sparing the radiosensitive tissues nearby.3
Treatment Planning: Our senior dosimetrist planned this treatment as I was very eager to watch
the planning process. Once the radiation oncologist placed his GTV in the treatment planning
system, the medical dosimetrist immediately started contouring all of the critical organs in and

Glenda Longoria
April Case Study
April 1, 2016

near the treatment area in order to get the patients treatment started as soon as possible. The
organs at risk in the treatment area were identified by the doctor as he wanted to track the dose to
the nearby structures, and after nearly a day and a half of working diligently to spare the normal
tissue and deliver the maximum dose to the GTV with the margin, she was able to get an acceptable
plan for SH with a maximum dose of 111.2%, normalized to 99%. Prior to the approval of this
treatment plan, the physician had to reject two plans due to inadequate dose around the PTV. The
plan consisted of 7 IMRT fields with 6 MV energy, and MLCs all weighted equally to deliver the
radiation therapy. The angles used for SHs IMRT treatment were planned with the gantry set at
205, 235, 265, 295, 350, 10, all with 0 collimator and couch rotation, and one angle set at 0
gantry with a 90 couch rotation. The field with the couch rotation was initially planned to be a
vertex field, however due to a dose distribution advantage of rotating the gantry back to 0, the
doctor changed the field parameters, leaving the couch rotated.
Ultimately, the patient started her treatment 3 days after her initial consult, finished her course of
treatments in 15 fractions, and will continue to follow up with her medical oncologist. She suffered
little side effects from the radiation therapy during this course of treatment.
All fields were calculated for and delivered on the Varian Trilogy linear accelerator. Varian
Eclipse was the planning software used to plan the course of treatment for SH and her treatment
plan is displayed at the conclusion of this case study in figures 1 through 7.
Quality Assurance: MU Check was used to verify monitor units prior to starting the patients
treatment. Also in place for quality assurance is the dose distribution check that occurs prior to
treatment. Our physicist performs this QA on the treatment machine using solid water phantoms,
a farmer ion chamber, and Map Check 2 software to verify the doses for all IMRT treatments prior
to the patients first day of treatment.
Our physicist is very pleased with the accuracy of the treatment delivery, stating that his readings
have never differed from the treatment plan by more than 2%, where the acceptable deviation is
actually 5%.
Conclusion: This case was very unique to me with regard to conventional palliative radiation
therapy. In most palliative cases we see bone or brain metastasis and typically treat with simple
fields. This patients case was distinctive as it involved metastatic disease in her sinus cavity
requiring IMRT treatment and special considerations. It was interesting to see the treatment

Glenda Longoria
April Case Study
April 1, 2016

planning process as the physician tried to still spare normal tissue around the tumor, while planning
a very detailed course of radiation therapy.
I was able to witness the struggles the dosimetrist faced while planning around so many different
critical structures. It took a lot of time and patience to plan this course of treatment, going through
several different plans before finding the best one.
SH had a very unfortunate prognosis to start, being that she came back to us with extensive
metastatic disease. I admire the radiation oncologist for agreeing treat this patient given the
obstacles he knew we would face in treatment planning.
Figure 1: Lateral view of the isocenter

Figure 2: AP view of the isocenter

Glenda Longoria
April Case Study
April 1, 2016

Figure 3: Dose coverage of the GTV (seen in red segment contour) showing the 100% isodose
line in yellow segment contour

Glenda Longoria
April Case Study
April 1, 2016

Figure 4: Transverse view of the isocenter with isodose lines, GTV in red

Figure 5: Frontal View of the isocenter with isodose lines (refer to Figure 4 for isodose line
values), GTV in red

Glenda Longoria
April Case Study
April 1, 2016

Figure 6: Sagittal view of isocenter with isodose lines (refer to Figure 4 for isodose line values),
GTV in red

Figure 7: Dose volume histogram for this treatment plan

Glenda Longoria
April Case Study
April 1, 2016

References:
1. Rehman S, Reddy CA, Tendulkar RD. Modern outcomes of inflammatory breast cancer.
Int J Radiat Oncol Biol Phys. 2012; 84(3): 619-624.
2. Rubin P. Clinical Oncology: A Multidisciplinary Approach for Physicians and Students.
8th ed. Philadelphia, PA: W.B. Saunders Company; 2001.
3. Washington, CM, Leaver, D. Principles and Practice of Radiation Therapy. 4th ed. St.
Louis, MO: Mosby Elsevier; 2010.