Teri Burrier

SBRT Planning for Treatment of the Right Lung

I. History of Present Illness

a. 82 y.o. male
b. May 2017, symptoms began
i. Experienced low-volume hemoptysis in the mornings
ii. Dyspnea on exertion
iii. Difficulty walking long distances
c. PET/CT on 6/28/17
i. Showed 2 cm hypermetabolic RML lung lesion
d. Bronchoscopy with biopsy on 10/24/17
i. Most of the cells were benign respiratory epithelial cells
ii. No malignant cells were identified
iii. Diagnosis could not be made
e. CT-guided core needle biopsy on 11/17/17
i. Pathology positive for adenocarcinoma
f. Repeat PET/CT done for restaging on 12/8/17
i. Lesion measured 5.2 cm
ii. No evidence of distant metastatic disease
g. Met with surgeon at the University of Iowa 12/12/17
i. Determined to be a very high-risk surgical candidate
1. Medical comorbidities
2. Lung function
ii. Recommended radiation therapy
1. Referred on 12/14/17
h. Met with Radiation Oncology 12/21/17
i. Recommended SBRT
1. RTOG 0813
2. 50Gy/5fx
II. Past Medical History
a. Esophageal cancer
i. Surgically removed via laparotomy
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ii. Unknown date 20 years ago

b. Aortic stenosis
i. Saw cardiac surgeon 10/4/2017
1. Candidate for TAVR procedure
2. recommended diagnosis of known lung mass prior to TAVR
c. COPD
i. Multiple inhalers
d. Reflux
e. Hypertension
III. Social History
a. Married
i. One son
1. History of lung cancer
b. Retired from the army
i. Previous helicopter pilot (1973)
c. Cigarette Smoker
i. Smokes 1 pack a day
ii. 65 pack year history
d. Previous heavy drinker
i. Quite 20 years ago
e. Brother with history of lung cancer
f. Sister with history of brain cancer
IV. Medications
a. Albuterol Q6H
i. PRN
b. Aspirin
c. Lipitor
d. Lisinopril
e. Lopressor
f. Omeprazole
g. Singulair
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h. Spiriva
V. Diagnostic Imaging
a. PET/CT 6/28/27
i. Right middle lobe lung lesion seen
ii. 2cm in size
iii. Highly suspicious of malignancy
b. CT angio of abdomen and pelvis 9/25/17
i. For TAVR planning
ii. No abdominal metastasis was noted
c. Bronchoscopy with fluoroscopic guidance 10/24/17
i. For biopsy of right lung
ii. Results were inconclusive
d. Chest x-ray 10/24/17
i. Post Bronchoscopy
ii. Right lung mass seen
iii. No post-procedure pneumothorax noted
e. CT-guided Biopsy 11/17/17
i. Local anesthesia
ii. Results showed adenocarcinoma
f. Chest x-ray 11/17/17
i. Post CT-guided biopsy
ii. No pneumothorax noted post biopsy
g. PET/CT 12/8/17 for restaging
i. Part of RTOG protocol
1. Scan needs to be within 8 weeks prior to beginning protocol
ii. Mass increased in size to 5.2 cm
iii. No metastatic disease noted
iv. T2 N0 M0
VI. Radiation Oncologist Recommendations
a. Recommended SBRT
i. Better chance of local control
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ii. Surgery tx of choice

1. Lobectomy results in 5-year survival rates of 60-70%
a. Not a surgical candidate
2. Conventional radiation has inferior results 10-30%
b. RTOG 0813 Protocol
i. 50Gy in 5 fractions
ii. Requirements met
VII. The Plan (prescription)
a. 50Gy in 5 fractions
b. Treatment every other day
c. IMRT plan
d. Daily CBCT
e. Simulated 12/22/17
f. Started course 1/3/18 and ended 1/12/18
VIII. Patient Setup/Immobilization
a. Civco Body Pro-Lok
i. Respiratory Belt for compression
ii. Knee cushion with Clam Lok cushion over knees
b. Wingboard with arms up
c. 4D CT scan used for planning CT
i. Evaluate tumor movement with breathing
d. External marks placed on patient’s skin
i. Fiducials placed over drawn marks for visualization on CT
IX. Anatomical Contouring
a. Eclipse treatment planning system
b. Physician drew PTV volume
i. Used MIP from 4D CT
ii. Image Fusion
1. PET/CT from 12/8/17
c. Dosimetrist contours
i. Normal structures
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1. Rt lung, lt lung, total lung, descending aorta, esophagus, heart,

bronchial tree, chest wall
ii. Optimization structures
1. 2cm, external sub PTV, external sub 2 cm, R lung sub PTV, ring
1.4mm and 7mm, total lung sub PTV, heart sub rings, bronchial
tree opti
X. Beam Isocenter/Arrangement
a. Varian Trilogy machine
i. 6MV Rapid Arc plan
ii. VMAT planning
1. 2 half-beam rotations
a. Patients right side only to spare opposite lung
b. Gantry angles of 0 to 181
b. Isocenter placed in center of PTV
XI. Treatment Planning
a. Varian Eclipse
i. Heterogeneity correction
1. Used to account for lower density of lung tissue
b. Dose tolerances
i. Smaller volume being irradiated
1. Conventional dose-volume limits are not as useful (ex. V20)
a. NCCN guidelines Maximum dose constraints
i. Cord is 30 Gy (6Gy/fx)
ii. Esophagus 105% of PTV prescription
iii. Heart 105% of PTV prescription
ii. Considerably lower for SBRT than conventional fractionation
1. Due to high fraction dose
c. Area of greatest concern
i. Lung toxicity due to preexisting lung problems
1. Protocol allows for dose adjustment if necessary
d. Discuss ability to meet constraints
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i. Use of rings
e. Final plan outcome
XII. Quality Assurance/Physics Check
a. Plan sent to IMSure
i. MU second check
b. Rapid Arc QA
i. Map CHECK 2 (1/2/2018)
ii. Approved by physics
XIII. Conclusion
a. SBRT offers higher dose to tumor volume
i. Greater chance of local control compared to conventional therapy
b. Planning obstacles
c. Things I learned