My Cases Log

Treatment Planning

Nasopharynx
T1N2B
McKenna Jeannette
Volumes:

GTV70? Tumour + Gross Nodes Visible

CTV70? GTV70( tumor + nodes ) +margin; Also ? Ptrygoid plates, 2 slices base of skull, 1/3 ant clivus, whole nasopharynx, and upper oropharynx
** If bulky node ? still just add SOME margin ( not necessarily uniformal ? cover muscles close and recesses) for CTV70, we don’t need to cover the whole adjacent nodal level to 70Gy.
CTV56? GTV+0.5cm margin;Ptrygoind muscles, + Base of skull-wider than CTV70; ? lower sphenoidal sinus; 1/3 ant clivus; 1/3 post nasal cavity; 1/3 post ethmoid sinus; whole Nasopharynx; upper oropharynx

Nodes? Bilat Ib-V; + ipsi lower SupraClav + RP
Tonsil
T2N2B
Villneuve Ronald
GTV70? Tumour + Gross Nodes
For nodes? any enlarged nodes + any 1cm LN adjacent to >1cm nodes
CTV? ipsi Base of tongue; ant and post tonsillar pillar; post wall of oropharynx; ipsi soft palate
Nodes? ipsi Ib-IV ( lower IV )
Contra II-IV
Floor of Mouth
Post-op T2N0 ( ipsi LN dissection ? pN0
Nodes ? bilat I-III
Surgical Bed? full dose ( 60Gy )
Melanoma in-transit recurrence
Skin is CTV
50/25
Melanoma recurrent in LN
Intraparotid
( Head and Neck )
LN dissection ( II, III, IV )
CTV? Ipsilateral intraparotid/ periauricular/ II-V
50Gy to CTV? 70/35 ? Surgical Bed + intraparotid + II ( where LN + existed )
Buccal Mucosa
T2(3cm)N1(Facial node ) no ECE Node 1.4cm
Post-op ? High dose to tumor bed
Low dose to ipsi Ia-IV
Laryngeal T4; post induction chemo
Lopes, Luis Raul
For PTV70? Add 0.5cm to CTV70
CTV70 ?
1- GTV
2- GTV+margin? 0.7mm or when reaches a barrier
3- Larynx
4- Thyroid Cartilage ( whole ipsi – half contra )
CTV56?
1- Bilat LN
a. Ipsi II-V
i. II ipsi from jugular foramen
ii. II contra from C1 transverse process
b. Contra II-IV
c. VI ( as pre-chemo tumour / residual tumor present in Level VI )

Prostate High risk
Sutcliffe, Norman
Simulation
• Supine
• Full Bladder ? less small bowel in the field
• Empty rectum ( only during simulation not treatment ) ? how ???
o That will be the worse case scenario for rectum
o Difficult to do and no need during the treatment
Nodes, start at distal common iliac L5
7mm around vessels ? trim for normal tissue( bone, bowel )
Pre-sacral nodes from S1-S3
Obturator LN? stop as soon as you see Seminal Vesicles
RTOG ? symphysis pubis
Prostate + SV proximal? If SV + ( SV will be included in higher dose volume )

Direct post field for bone Mets/ cord compression

Dr Eapen ? width of field 10cm for lumbar area; 8cm for Thorax;
Dr MacRae ? Check the bone and give a margin

Know attenuation (fall off) ? 6MV: 3-4% /cm
Know Penumbra for different energies ? 6MV :
Know build up for different energies

POP ? Nausea
Direct Post ? less homogeneity

If cervical vertebrae ? Face Mask/Shell for immobilization
If possible two lateral ( if shoulders are not in the way )
Otherwise ? POP
Side effects ? hoarseness, dysphagia

Durocher, Robert
Extensive Small Cell
Post chemo ? good response to chemo; brain mets resolved after chemo
XRT to Brain? WBRT ? 25Gy/10
XRT consolidation to peri-hilar mass
GTV post-chemo
Dose ? 30/10

Small Cell limited stage usually concurrent CRT except
• Frail patient
• Volume is too big ? V20 > ~40
• Wonder if the patient is extensive? Questionable mets?
• Pleural Effusion
Pelvic Ewing Sarcoma ? post-op ( operation post chemo )
We know these patients (pelvic) have worse prognosis
Close margins ? 2.5 & 3.5 mm
CTV volume for post op ? PRE-OP chemo
OAR ? Femur Head
Uterus
Overies? 2Gy for fertility
? 12Gy for menaopause
Bladder
Rectum
Michie, Alicia
Melko, Paul J
T3N1 Rectal Ca
10-11cm from anal verge
Simulation
• Prone
• Bellyboard
• Full bladder ? how ???
• Oral Contrast ? how ???
Need to cover internal iliac and presacral nodes and ????
RTOG guideline.
CTV 45 ? Post border ? a bit ( 1mm ) of sacrum included
Ant border
Superior ? Sacral Promontery
Inf ? ??? Pelvic floor
CTV50 ? margin around visible tumor
Include the rectum wall at the level or only margin
Sup and inf ?
Radial margin ?
Dose and Fractionation
• In two volumes
o 45Gy/25fractions
o 5.4Gy/3fractions

Khakhria, Mangaldes
Abdomen Sarcoma, Pre-Op Tomo

Adams, James
T3N0
Supraglottic
Ph/E ? No Vallecula involvement
CT ? Vallecula involvement
Base of Tongue ? biopsy negative
GTV70 ? Tumor
CTV70 ? Epiglottis; Vallecula; Aryepiglottic folds;
CTV56? Bilat Ib-V + Larynx; Arytenoids; Piriform Sinus; True Vocal Cord

? Spread anteriorly and circumferentially
? Through base of epiglottis into :
• pre-epiglottic space
• lingual epiglottis ? VALLECULA
• pharyngeoepiglottic folds
? Through aryepiglottic fold/ or even originating from aryepi
• ( if thourgh ) Usually bilat ? producing horse shoe appearance
• ( if originating ) may grow through any direction
• Anteromedially
o Epiglottis
• Posteriorly
o Arytenoids
• Laterally
o Piriform sinus
• Inferiorly
o True vocal cord
** for suspicious node ? contour them and add 0.5cm margin for CTV63
(1.1cm SupraClav LN + Mediastinal)

Christian, Carmen
Breast Ca Left

NASOPHARYNX

Luu, Phuong ?

T2 N1 M0 Nasopharynx Right side

N1 in NPH is unilateral
Even if it is multiple
N2 is bilateral
Nodal staging in nasopharynx is different in NPH

GTV? Tumour + Gross Nodes Visible
CTV70? GTV + 0.5mm margin+ ptrygoid plates + total nasoph.
CTV56? GTV+0.5cm margin; + Base of skull; cavernous sinus; ? lower sphenoidal sinus; 1/3 ant clivus; 1/3 post nasal cavity; 1/3 post ethmoid sinus; whole Nasopharynx; upper oropharynx; Ptrygoid muscle ; ptrygoid plate

Nodes? Bilat Ib-V; + RetroPharyngeal N.
NPH
N1 - unilateral nodes, 6 cm or less, above the supraclavicular fossa, and/or retropharyngeal lymph nodes 6 cm or less (unilateral or bilateral)
N2 - bilateral nodes, 6 cm or less, above the supraclav fossa
N3a - lymph node greater than 6 cm
N3b - extension to the supraclav fossa (defined as the triangular region described by Ho, bounded by the superior margin of the sternal head of the clavicle, the superior margin of the lateral end of the clavicle, and the point where the neck meets the shoulder. This includes some of level IV as well as V.)

Son, Kyungok 36508109
Post mastex ? neoasj chemo; Pre chemo ? MRI ? suspicious LN but bx neg; Tumor triple positive in biopsy + high nuc grade ; 3cm
Complete response to chemo

KNOW indications of post-mastectomy chest wall/ nodal XRT
KNOW the issue of neoadjuvant chemo for adjuvant post mastx
Know the constrictions for heart and lung in breast XRT

PTC chest wall
1- include ribs? very close to lungs
2- Muscles ? yes
3- 5mm from skin
4- Contour Heart

Hurlbert, Richard
Mental Retard, Soft Palate necrotic tumor with extension to nasopharynx and oropharyng

Treated with 55Gy/25
GTV + 0.5cm ? CTV + Bilat Ib; II and III

Brunoni, Vittorio

87Male,
Recurrent SCC forehead, mets to pre-parotid LN, not a surgical candidate
Treated with 70Gy radiacal dose to GTV + 0.5cm to get CTV
And 56Gy to ipsilateral parotid + Ib –III LN
Skin in between not treated.

Macdonald, Eva
66Gy/33
T1N3M0 NSCLC
Esophageal Obstruction

GTV= tumor + nodes
CTV=0.5cm
PTV=0.5cm

Coderre, Ghislaine

T1aN0M0 NSCLC refused surgery
60Gy/5
GTV= tumor
GTVmip? 4DCT
ITV = GTV + GTVmip
PTV= 0.5cm margin

Draw trachea, and proximal airway separately…

Kamara W
16m child with neoplastic ependymoma ? post-op; complete resection
54Gy
CTV ? surgical bed.
PTV ? CTV + 0.5mm
Draw organs at risk ?
1- whole brain
2- brainstem
3- cochlea
4- chiasm
5- pituitary gland
a. Chiasm is sup/inf and ant/post to pituitary gland ???
6- Eyes and lens
7- Optic nerves

Fabian , Garry
Metastatic colorectal for SBRT for single mets in Left lobe lung
Previous lobectomy for right upper lobe lung
Lesion is within central zone ? 60Gy/8
GTV + GTVmip ? ITV

Kern, Kevin
50ish young man, Locally advanced rectal ca,
CTV45?
CTV Boost ( 5.4Gy/3)
Need to cover internal iliac and presacral nodes and ????
RTOG guideline.
CTV 45 ? Post border ? a bit ( 1mm ) of sacrum included
Ant border ? Denonvillier fascia
? men : posterior wall of prostate/bladder
? women : post wall of uterus/vagina
Superior ? Sacral Promontery
Or where Iternal mesenteric a. divided into sigmoid a. and sup rectal a.
Inf ? Levator ani muscle
- Pelvic floor
CTV50 ? margin around visible tumor
Include the rectum wall at the level or only margin
Sup and inf ? 1cm
Radial margin ? 1cm
Dose and Fractionation
• In two volumes
o 45Gy/25fractions
o 5.4Gy/3fractions

Pre-Op Rectum
Functioning ileostomy
Gervais, Rachel

Be careful with GTV ? in CT Rectal tumor is a solid thickness of the wall.
CTV ? POSTRIOR BORDER OF BLADDER
You can constraint CTV as you reach levator ani muscle. ? You can exclude ischiorectal fossa

Contour small bowel
Contour Femoral Head

Irving, Stuart Adams
Palliative 30Gy/10
For bladder Ca ? metastatic to lungs, LN + Left internal iliac
PTV ? whole bladder + 0.5cm.
Don’t miss gross tumor… may even include whole prostate in there

Davies , Maurice Owen

77 yr male with diffuse large B cell NHL
prior confluent disease from left mastoid to left clavicular and left axilla
now residual in low left neck and left axilla
for involved field XRT
use minimantle
treat right neck, left neck, both supraclavicular regions, left axilla
treat from line along lower mandible: chin to mastoid
place pt with neck hyper extended so superior field line run along the above line
Hands on hips with arms akimbo to treat left axilla

use 6 MV photons
AP/PA POP
95% of PTV to get 35 Gy/20

Wayne Kendal

Pre chemotherapy volume vs post-chemotherapy volume?

Pre-Chemo

For indolent Lymphoma ( stage 1,2 Follicular lymphoma )
What are the options?
IFRT* 30-35 Gy
• Expect ~ 40% long term FFR
• Alternate:
• Chemotherapy
• Observation. Treat when symptomatic
PRE-CHEMO:

POST-CHEMO:

Indications for RT:
• Residual disease
• Bulky Disease
• Extranodal Disease
• MALT lymphoma
• Early stage follicular

What did I do?
GTV ? gross residula disease
Involved field Radiation Therapy
I contoured adjacent level to GTV ? Level II and I ipsilateral as well as :
Level III and IV + Upper axilla

Contra lat neck ? II and III and I?????????

St Louis , Ronald Gordon

Janu 18 2011
66 yr old man with resected CA esophagus
post op leak into mediastinum ICU stay
MRSA postitive by OGH records
now enlarging subcarinal nodes
thickening of wall of neo-esophagus at that level

propose XRT
6 MV photons…AP/PA POP
PTV to be drawn by me
dose 95% of PTV to get 30 Gy/10

Wayne Kendal

St Jean, Denis Leopold
Wayne Kendal wrote:
Nov 17 2010
64 yr old man with T2B Gl 7 PSA 6.41
for 6 months hormones, XRT to start in 3rd of 4th month of hormones
He has an ANAL FISSURE…contour anus to monitor dose

Get Planning CT
NO TRUS NO SEEDS
Place anal marker please for CT

Kendal to mark PTVs
follow care plan otherwise

Wayne Kendal

Fleet Enema before CT sim
Bladder full

Intermediate Prostate Ca

CTV1 ? Prostate + proximal 1cm seminal vesicles only
CTV2? Prostate only

53.2Gy/28 to at least 98% PTV1; 1.9 Gy/fr
19Gy/10 to at least 98% PTV2; 1.9Gy daily

OARs ? Bladder, Rectum ( entire length ? from ischial tuberosity to rectosigmoid flexure; femurs, small bowels )

No more than 30% of rectum > 70Gy

Daily Cone Beam,

Why do we prescribe the dose this way?
Previously we used to prescribe 56Gy + 20 to isocentre. It was not a volumetric plan.
The 95% isodose used to encompass the whole PTV.

That’s why in order to avoid quite hot dose on rectum and femoral head. 53.20 is the 95% of 56Gy with which we would like to cover almost all of our OTV ( 98% )

Ogilvie, Douglas
64Male
AdenoCa Lower Rectum ? Extension into anal canal ? 8mm from anal verge

biopsy proven inguinal LN

Pre-Op ChemoRT
Curative intent
Tomotherapy IMRT technique
Organs at risk :
• Small Bowel
• Bladder
• Testicles
• Femoral Heads
GTV : tumor + abnormal LN
CTV50 : GTV + 0.5cm margin
CTV45 : External Iliac + inguinal bilat + entire mesorectum ? Cephalad limit ? 2cm proximal to most superior part of gross tumor
Caudad level? any skin coverage necessary? Not in this case as adenoCa

Jones, Arthur Frank
T2A Gl 8 PSA 6.27 high risk CA

To treat nodes.

Prostate High risk
(See above : Sutcliffe, Norman)
Simulation
• Supine
• Full Bladder ? less small bowel in the field
• Empty rectum ( only during simulation not treatment ) ? how ???
o That will be the worse case scenario for rectum
o Difficult to do and no need during the treatment
Nodes, start at distal common iliac L5
7mm around vessels ? trim for normal tissue( bone, bowel )
Pre-sacral nodes from S1-S3
Obturator LN? stop as soon as you see Seminal Vesicles
Dr Kendal ? When see proximal SV. Should be connected.
RTOG ? symphysis pubis
Anterior margin of external iliacs ? Not further ant to symph. Pubis.
Prostate + SV proximal? If SV + ( SV will be included in higher dose volume )

Cleroux, Raye
Feb 2 2011

70 yr old man with T3a Gleason 8 PSA 15.6 high risk ca prostate
for 3 yrs Zoladex and XRT to start now
to treat prostate and seminal vesicles, no nodes

This man has LFT abnormalities, he will have his LFTs done in several weeks for us

Get planning CT
NO TRUS, NO SEEDS

Kendal to define PTV
follow care plan for dose

Wayne Kendal

Why no nodes?
Role of neoadjuvant Hormones in high risk?
3months of neoadjuvant hormones before intermediate risk ? Bola Trial

Udell, Daniel Spencer

Intermediate Prostate Ca

De Guire

Palliative Prostate + L5

Blank, Diane

3 level cord compression

Apr 26th 2011
49 Breast Ca, L2 Cord Compression—> MRI —> maybe plasmacytoma! Hx of crohns!