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Alecia Eliason
Case Study
March 30, 2017
3D Treatment of Merkel Cell Carcinoma of the Left Arm
History of Present Illness: RD is a 93-year-old man who presented to his primary care provider
with a rapidly enlarging, mobile, and painless mass of his left forearm in late June of 2016. The
PCP initially believed this mass to be a small hematoma or sebaceous cyst. However, an attempt
to drain the lesion was unsuccessful. Concerned about the possibility of a neoplastic process, the
PCP referred RD to general surgery.
RD was consulted in early July of 2016 by a general surgeon, who measured a 4 x 3.5 cm
well-rounded, soft tissue mass of the left mid-forearm which did not involve deeper structures of
the forearm. A wide local excision under local anesthesia was recommended. In late July of
2016, the general surgeon performed the aforementioned surgery using an 8 x 5 cm excision with
a 2-layer closure, with a full-thickness graft of 6 x 2 cm. No penetration into muscle was noted.
The removed mass was sent to pathology, where it was determined to be a 4.2 x 3.5 x 1.5 cm
Merkel cell carcinoma with negative margins. A relatively rare and aggressive skin cancer,
Merkel cell carcinoma has the following risk factors, all of which describe RD: individuals over
the age of 50, Caucasian ethnicity, and significant history of sun exposure.1
Weekly evaluations of the wound were performed by the general surgery clinic. Although
RD presented to the emergency department one week after the surgery due to minor trauma and
bleeding at the incision site, the general surgeon felt the graft was healing appropriately and was
100% viable. The surgeon presented RDs case at a multidisciplinary tumor board, receiving
recommendations to consider sentinel lymph node biopsy and postoperative radiation therapy.
RDs diagnosis at the time of radiation oncology consultation was stage II pT2cN0M0 Merkel
cell carcinoma of the left dorsal forearm.
Past Medical History: RD has type 2 diabetes with diabetic nephropathy, as well as chronic,
stage III kidney disease. He had a cerebral infarction in 2011 and was diagnosed with
cerebrovascular disease in 2013. RD has a number of diseases affecting both eyes, including
glaucoma, presbyopia, astigmatism, macular degeneration of the retina, nuclear sclerosis, and
pterygium. Gastrointestinal history includes umbilical hernia in 2008, esophageal ulcer in 2012,
GERD, and Barretts esophagus.
Social History: RD is married, living independently with his wife. They have 3 children, one of
whom lives locally and the others in different parts of the country. He has a brother who was
diagnosed with leukemia while in his 70s but has no other family history of malignancy in
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primary relatives. Most of RDs days are spent in his chair watching TV, keeping up with sports
and the news. His sole exercise most days is walking to the edge of his driveway while his wife
takes care of most household chores. RD does not drive or go out of the house often. He smokes
2-3 cigars daily but does not drink alcohol.
Medications: The following medications are taken daily by RD: omeprazole, pravastatin,
acetaminophen, enalapril/hydrochlorothiazide, ferrous sulfate, and potassium chloride. Daily
ophthalmic drops include Azopt, brimonidine, and Lumigan. RD has no known drug allergies.
Diagnostic Imaging: Extensive discussions with the radiation oncologist were had about the
possibility of sentinel lymph node mapping, because a positive result would warrant regional
nodal radiation. Strong consideration could be given to avoiding regional nodal radiation if the
patient had a negative sentinel lymph node biopsy. However, there is a high false negative rate
with this test. Due to RDs surgery to his left forearm and arm, a sentinel lymph node biopsys
sensitivity would be decreased, as well as increasing morbidity. The radiation oncologist
concluded that his treatment recommendations would not be altered with a positive or negative
sentinel lymph node biopsy, but the test may provide prognostic information. RDs family
decided not to pursue this test. No other diagnostic imaging was recommended.
Radiation Oncologist Recommendations: The radiation oncologist reviewed various
management recommendations with RD and his family. The least invasive step would be
observation with regular clinical surveillance. This was not an ideal treatment option for RD due
to the high risk of recurrence of Merkel cell carcinoma after surgery.1 Radiation therapy
delivered daily for 5-6 weeks to the resection bed, left axillary lymph nodes, and left
neurovascular bundle was the final recommendation of the radiation oncologist to reduce the
relapse rate and enhance control locally in the postoperative setting.2 Although this extensive
treatment may have a greater risk of morbidity than treating only the resection bed, the radiation
oncologist wanted to address in-transit metastases possibilities and provide the patient with the
best overall prognosis. Radiation would begin about 4 weeks after surgery or longer to ensure
proper healing of RDs graft.
Plan (prescription): After extensive conversations with his colleagues and with RDs family, the
radiation oncologist decided to treat RDs left forearm, epitrochlear nodes, neurovascular bundle,
and axilla. The radiation would be delivered in 25 fractions at 200 cGy per fraction to a dose of
5000 cGy. Additionally, the primary tumor bed would receive a boost of 3 fractions at 200 cGy
per fraction to a dose of 600 cGy, resulting in a total dose to the primary tumor bed of 5600 cGy.
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Specifically, the structure identified as PTV 5000 was to receive at least 95% of the prescribed
dose of 5000 cGy, and the structure identified as PTV 5600 was to receive at least 95% of the
prescribed dose of 5600 cGy. Weekly portal images to verify isocenter placement and
reproducibility were also deemed necessary by the physician.
Patient Setup/Immobilization: The patient was simulated on a CT simulator in the supine
position with his affected left arm slightly akimbo to decrease skin folds in the axillary region
and bring the arm treated away from the rest of the body. A vac fix device was created to
immobilize the patients head, trunk, and left arm. Although this mold successfully immobilized
the left arm, the radiation therapists made sure to mark on the mold the exact placement of the
left shoulder, left elbow, left wrist, and left hand/fingers to ensure accurate reproducibility. Due
to RDs age, a thin pad was used under his lower spine and butt for comfort. A knee cushion was
used for comfort as well. RDs head was turned towards his right, away from the area to be
treated, to eliminate the possibility of his head or chin interfering with the radiation beam or
potential beam angles to be decided upon in the treatment planning system. An AP tattoo was
given mid-sternum, a central and stable area, assuming all isocenter shifts to be from this point.
Lateral tattoos, along with paint marker lines drawn on the patients skin and vac fix, were given
to ensure setup reproducibility. The surgery scar on the patients left arm was highlighted on the
CT scan by wires placed by the radiation oncologist. 1 cm of bolus was draped from RDs left
elbow to his left wrist, encompassing the entirety of the tumor bed and excision site with a 4 cm
margin superiorly and inferiorly.
Anatomical Contouring: All anatomical contouring for RD was performed in MIM Maestro
version 5.4. The organs at risk contoured by the medical dosimetrist included the spinal cord,
lungs, esophagus, left humerus, and heart. The bolus placed at the time of CT simulation was
also contoured by the medical dosimetrist. The radiation oncologist identified and contoured the
planned treatment volumes of 5000 cGy and 5600 cGy, along with the left axillary nodes and left
neurovascular bundle. The radiation oncologist considered discussion had with the general
surgeon, the general surgeons operative notes, and his knowledge of lymph node anatomy to
define the PTV volumes. At this time, the radiation oncologist also completed a wish list as
shown in Table 1, identifying the prescription and the OR dose constraints sought after for this
treatment plan.
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Table 1. Physician-ordered wish list. PTV structures and corresponding desired dose
objectives, as well as organs at risk and corresponding constraints.

Structure Desired Dose Objective Constraints

V (5600 cGy) 95% in 25 fx @
PTV 5600
200 cGy/fx + 3 fx@ 200 cGy/fx
PTV 5000 V (5000 cGy) 95% in 25 fx @
Left axillary lymph nodes
Left neurovascular bundle 200 cGy/fx
V (3500 cGy) 50%
Esophagus V (5000 cGy) 40%
Dmean 3400 cGy
V (2500 cGy) 5%
Heart
Dmean 200 cGy
V (500 cGy) 60%
Left lung V (2000 cGy) 30%
Dmean 2000 cGy
Spinal cord Dmax 4500 cGy
Left humerus V (5000 cGy) 50%

Beam Isocenter/Arrangement: Understanding that the area to be treated exceeded the field size
limitations of the linear accelerator, the radiation oncologist and medical dosimetrist decided to
split the treatment into upper (superior) and lower (inferior) sections. The upper section consisted
of the left axilla, left humerus, and left neurovascular bundle, and the lower section encompassed
the left forearm and excision site. The upper isocenter was placed by the medical dosimetrist in
the center of the left humerus, representing the center of the upper field. The lower isocenter was
placed just inferior to the left elbow joint with the intention of using a half-beam blocking
technique (blocked superiorly) to reduce overlap of the upper and lower fields. Junction changes
were to take place every 5 fractions (after every 1000 cGy was delivered) to reduce the hot spots
between the overlap of the upper and lower fields.
A total of 5 fields were created for the upper treatment area. These consisted of 2 large
opposed oblique fields encompassing the PTV 5000 structure with a 1 cm margin. Due to the
very large area treated in these upper fields, MLC limitations led to areas receiving dose that
were wished to be blocked. To compensate for the inability to block these small open areas, a
field-in-field technique was employed, allowing blocking where needed. The upper AP oblique
had 2 FIFs and the upper PA had one FIF. A small strip of skin was blocked intentionally to
prevent lymphedema post-radiation. 6 MV photons were employed for all fields except the 2
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treating the left axillary nodes, due to the relatively thin separation to be treated and the lesser
penetration of lower energy beams.3 18 MV photons were used to treated the FIFs targeting the
left axillary nodes due to the thickness of the patient in this area and the desire for greater beam
penetration.
3 fields were created for the lower treatment area. Like the upper fields, 2 large opposed
oblique fields encompassed the areas to be treated (PTV 5000 structure), and one FIF was used
posteriorly, all beams delivered with 6 MV photons. However, the reasoning for creating the
lower FIF differed from the upper due to treatment machine limitations in regards to using a
wedge. The linear accelerator used for treatment (Elekta Infinity) possesses a dynamic wedge;
this wedge can only cover a treatment field up to 15 cm away from the CAX in any direction.
Due to the lower fields beginning at CAX with a length of 20 cm, the wedge needed for the
lower PA field was unable to cover this distance. Consequently, a FIF was created to shorten the
lower PA field and use a wedge to provide the proper coverage and dose distribution. A small
strip of skin again was intentionally blocked for lymphedema prevention.
Treatment Planning: The physicians wish list was reviewed, and the patients CT scan with
contoured structures was loaded into Xio, the treatment planning system used for 3D treatment
plans. The medical dosimetrist understood the complexity of this planning process immediately
due to the large treatment area and the necessity for abutting or overlapping fields in order to
provide proper coverage of dose. It was decided to begin with creation of the lower fields,
placing isocenter for those fields at CAX utilizing a half-beam blocking technique to superiorly
shield the patients upper arm. Doing so eliminated beam divergence from the lower fields,
effectively lowering dose overlap between upper and lower fields and keeping the hot spots as
low as possible. The upper fields were then created as discussed earlier. The inferior field borders
for the upper fields were calculated to leave a gap of 0.2-0.3 cm on the patients skin surface
between the upper and lower fields, changing slightly for each junction change. The hot spot
where the upper and lower fields overlapped was 111% of the prescribed dose, but because this
point would move 1 cm inferiorly with each junction change (every 5 fractions), the physician
approved this higher dose.
Due to the complex nature of this case and the desire to decrease the chance of setup
inconsistencies or errors, the medical dosimetrist decided to keep the isocenters for each site
(upper and lower) the same throughout the course of treatment and simply change the field
borders for each junction change. The superior border of the lower arm fields ended exactly at
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CAX for Junction C, the 3rd junction. Junction A increased this superior border to 2 cm superior
of CAX and was decreased by 1 cm for each junction change, ending with the superior border 2
cm inferior of CAX for Junction E. This decision was again based on the desire to decrease beam
divergence by as much as possible. The beam diverges only minimally near the CAX,3 so by
keeping the superior border for the lower fields within 2 cm of the CAX, beam divergence was
kept as low as possible. The inferior borders of the upper arm fields increased inferiorly by the
same increment of 1 cm with each junction change, effectively increasing the field size by 1 cm
with each new junction.
1 cm of bolus covered the entire lower left arm for all treatments, including the boost.
RDs primary Merkel cell carcinoma was excised from this area, so it was important for the skin
surface at the excision site to receive adequate dose coverage. The bolus effectively increased
coverage at the skin surface because 6 MV photons were used for the plan, with a dmax of 1.5
cm.3 Since the dose had to travel 1 cm through the bolus, higher isodose lines reached the skin
surface, adequately encompassing the excision site. The lower AP fields were weighted more
heavily than the PA field, so more dose was delivered at the excision site. The boost fields were
simple opposed obliques, delivering an extra 600 cGy to the primary tumor bed.
The medical dosimetrist worked closely with the radiation oncologist to develop an
acceptable plan. This process took longer than the normal amount of time allotted for creation of
most treatment plans, so a lapse of 3 weeks was between the patients CT simulation and
verification simulation. The physician requested a delay in the start of treatment delivery due to
the need for RDs graft to heal before receiving high doses of radiation, so the 3 week planning
process worked in the physicians favor. All dose objectives and constraints for organs at risk
were met, as shown in Table 2.

Table 2. Dose Volume Histogram Summary showing dose delivered to areas of interest specified
in the physicians wish list. Delta is the difference between the achieved and wished values.
Dose Min
Structure Volume Mean (cGy) Max (cGy)
(cGy) (cGy)
Name cc %/cc Delta Dose Delta Dose Delta
100.00
PTV 5600 54.76 5600 5.00 5622 5904 6073
%
PTV 5000 189.49 5000 96.21% 1.21 3741 5599 6073
Left axillary
243.64 5000 95.25% 0.25 4752 5278 5569
lymph nodes
Left 261.12 5000 97.72% 2.72 3168 5259 5584
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neurovascula
r bundle
3500 0.00% 50.00 66 99 3301 167
Esophagus 118.46
5000 0.00% 40.00
Heart 977.61 2500 0.00% 5.00 39 120 80 385
1670.4 500 31.22% 28.78 83 749 1251 5087
Left lung
2 2000 11.77% 18.23
Spinal cord 67.15 14 91 182 4318
Left humerus 257.12 5000 30.40% 19.60 137 2732 5349

Quality Assurance/Physics Check: RadCalc was used as a second check for MU calculations,
with a discrepancy of 5% from the treatment planning system deemed acceptable. Each field
for each junction was entered into RadCalc, and the MU calculations from RadCalc agreed with
those of Xio within 5%. Due to the use of bolus on the lower arm, Mosfet in vivo measurements
were performed on the first day of treatment delivery. 5 leads were placed along the patients
scar under 1 cm of bolus to measure the dose delivered to the skin surface at the excision site.
The readings were as expected: less than 3% difference resulted between the in vivo
measurements and the planning systems dose estimate along the scar.
An additional quality assurance check was performed in the treatment room prior to the
treatment plan approval. Due to the very large treatment fields created, couch limitations were an
area of concern of the medical dosimetrist. A radiation therapist and a physicist used the patients
mold (without the patient present) to identify the ideal placement of the mold on the treatment
couch. All treatment fields, including junction changes and boost fields, with corresponding
gantry and collimator angles were simulated to ensure delivery would be possible. Ideal table
coordinates were noted at this time to ensure efficiency of the verification simulation.
Conclusion: The treatment planning process for RD was incredibly complex due to the rarity of
Merkel cell carcinoma with limited treatment data available, along with the large areas requiring
treatment, necessitating the use of gaps between adjoining fields and treatment couch limitations.
I had the privilege and challenge of working with this case via 2 roles: one as a treating therapist,
and the other as a medical dosimetry student. Great value was placed on the initial CT simulation
and positioning of RD, drawing opinions from the entire radiation oncology team to create a
reproducible setup while ensuring obtainability of proper coverage of dose. As one of the
therapists performing the CT simulation, I realized how invaluable a strong and experienced
medical dosimetrist is to the radiation oncology team. In my experience, rarely is the opinion of a
dosimetrist needed during CT simulation; however, had we not reached out to our dosimetrist,
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the initial positioning we had decided upon would have made it impossible to create a feasible
treatment plan.
Once ready to begin treatment planning, I was surprised with the MLC limitations
presented. Before studying as a dosimetry student, I had the notion that with MLCs, any
treatment field, with the exception of a positive block, was possible. I discovered how using a
FIF technique can help to overcome these limitations. Proper isocenter placement was crucial to
success of this plan, as well. Understanding beam divergence, and lack thereof at CAX, aided the
dosimetrist with treatment planning and helped to lower hot spots within the plan. The
dosimetrist I worked with on this plan had extensive experience as a radiation therapist, which
led her to make decisions regarding the number of treatment fields, isocenter shifts, and junction
changes with reproducibility and real-life feasibility always at the top of mind. Although patient
age was thought to be a possible hindrance with daily setup and perseverance, RD did
exceedingly well with this extremely complex course of treatment and is disease free 5 months
post-radiation.
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Figure 1. Patient positioning as determined during CT simulation.

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Figure 2. Patient positioning as determined during CT simulation with 1 cm bolus placement on

left lower arm.
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Figure 3. Close-up image of left lower arm scar from excision and skin graft.

Figure 4. DRR of left upper arm field 1-1 for junction A.

Figure 5. DRR of left upper arm field 1-2 for junction A, a FIF of 1-1.
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Figure 6. DRR of left upper arm field 1-3 for junction A, a FIF of 1-1.

Figure 7. DRR of left upper arm field 1-4 for junction A.

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Figure 8. DRR of left upper arm field 1-5 for junction A, a FIF of 1-4.

Figure 9. DRR of left lower arm field 1-6 for junction A.

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Figure 10. DRR of left lower arm field 1-7 for junction A, a FIF of 1-6.

Figure 11. DRR of left lower arm field 1-8 for junction A.
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Figure 12. DRR of left arm boost field 1-41, an AP oblique.

Figure 13. DRR of left arm boost field 1-42, a PA oblique.

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Figure 14. Single-plane axial slice at left upper arm isocenter.

Figure 15. Single-plane coronal slice of left upper arm showing axillary nodal and neurovascular
bundle contours.
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Figure 16. Single-plane axial slice of left lower arm showing PTV 56 contour.

Figure 17. Single-plane coronal slice of left lower arm showing PTV 50 and PTV 56 contours.
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Figure 18. Single-plane sagittal slice of left lower arm showing PTV 50 and PTV 56 contours.

Figure 19. DVH of target objectives set by the physician as a function of volume and dose,
summarizing the dose distribution of each structure.
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Figure 20. DVH of constraint objectives set by the physician as a function of volume and dose,
summarizing the dose distribution of each structure.

References:
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1. Bahtia S, Storer BE, Iyer JG, et al. Adjuvant radiation therapy and
chemotherapy in merkel cell carcinoma: Survival analyses of 6908
cases from the national cancer data base. J Natl Cancer Inst.
2016;108(9). http://dx.doi.org/10.1093/jnci/djw098

2. Chao KSC, Perez CA, Brady LW. Radiation Oncology Management Decisions.
Philadelphia, PA: Lippincott Williams & Wilkins; 2011:125-126.
3. Khan FM, Gibbons JP. Khans The Physics of Radiation Therapy. 5th ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2014.