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Stephanie Olson
DOS 771 Case Study
February 23, 2015
Treatment for Hodgkin lymphoma using SSD technique
History of Present Illness: Patient KR is a 64 year-old male who was seen in our department to
discuss oncologic management for his recently diagnosed nodular sclerosing Hodgkin
lymphoma. KR initially present in December 2013 with right neck adenopathy. He noted since
that time, there was a gradual increase in adenopathy and it became painful starting in August of
2014. KR was then seen at a local clinic and on August 29, 2014, he underwent core needle
biopsy of the right neck lymph nodes. The surgical pathology from this biopsy demonstrated
classical Hodgkin lymphoma of the nodular sclerosing subtype. Approximately 60 to 80% of
Hodgkin lymphomas are of the nodular sclerosing subtype and most commonly present in the
mediastinum and supradiaphragmatic regions.1 For staging purposes, KR underwent a CT of the
neck, chest, abdomen and pelvis regions on September 16, 2014. Results from the neck CT scan
showed right level II region matted lymph nodes with a measurement of 3.8 x 1.9 cm. In the
level III region, there was a 1.6 x 1.3 cm lesion and in the level IV region, there was a 1.5 x 1.0
cm lesion. The remainder of the chest, abdomen and pelvis CT scans were without evidence of
lymphomatous involvement. The following day, a PET/CT scan was performed which
demonstrated FDG uptake localized to the right side of the neck extending from the second
cervical vertebral body to just above the right clavicle. This scan showed involvement of the
anterior cervical lymph nodes and scattered right posterior cervical triangle lymph nodes. A
bone marrow biopsy was performed on September 19, 2014 and was negative for evidence of
lymphoma. At the time of consultation in our department, the patient was also seen by medical
oncology to discuss the possible role of standard Hodgkin lymphoma chemotherapy. He was
however not felt to be an appropriate candidate due to his co-morbidities of coronary artery
disease and severe chronic obstructive pulmonary disease (COPD). Thus, patient KR was
referred to one of our satellite radiation therapy centers closer to his hometown for radiation only
tomotherapy treatments. Prior to beginning radiation therapy, a recommended restaging PET/CT
scan was performed on November 12, 2014, which unfortunately showed significant increase in
disease compared to the previous scan from September 2014. There was increased FDG uptake
in the right cervical adenopathy as well as new left cervical adenopathy, right upper mediastinal

and left axillary adenopathy. A radiation treatment planning CT scan was performed and
tomotherapy plan developed but due to his left axillary adenopathy and mediastinal disease, his
pacemaker was in the middle of the radiation field and estimated to receive a dose in excess of
30 Gy. Given this and concern for pacemaker malfunction, he returned to our department for
consideration of alternative options. After returning to our department, discussions began with
Cardiology and it was decided his pacemaker would need to be removed. He underwent an
implantable cardioverter defibrillator (ICD) explant and fitted with a life vest which he would
wear through the course of his radiation therapy. Once his ICD was removed, the patient
returned to our department for radiation treatment planning.
Past Medical History: KR has a past medical history of coronary artery disease, peripheral
vascular disease, chronic kidney disease, COPD, anxiety, hypertension, gastro-esophageal reflux
disease (GERD), mitral valve repair in 2011, and a pacemaker. In addition, KR reported
allergies to Ketorolac Tromethamine, Moxifloxacin, Rosuvastatin calcium, Tizanidine,
Ibuprofen, Morphine, Nitrofurantoin, Oxycodone, Statins, and Sulfamethoxazole.
Social History: KR is single and lives with his son. He smoked approximately one pack per
day for approximately 40-pack-year smoking history. KR denied drinking more than one to two
alcoholic drinks per day. KR reported that his brother was diagnosed with lung cancer and one
of his sisters was diagnosed with premenopausal breast cancer. He has no other family history of
malignancy.
Medications: KR uses the following medications: Albuterol, Alprazolam as needed, Aspirin,
Baclofen, Plavix, Truvada, Etravirine, Famotidine, Fluoxetine, Advair, Hydrochlorothiazide,
Norco as needed, Ipratropium, Prevacid, Lisinopril, Metoprolol, Raltegravir, and Trazodone.
Diagnostic Imaging: On August 29, 2014, KR underwent a core needle biopsy of the right neck
lymph nodes after presenting with neck adenopathy and pain. After surgical pathology from this
biopsy demonstrated classical Hodgkin lymphoma of the nodular sclerosing subtype, he
underwent a CT of the neck, chest, abdomen and pelvis regions on September 16, 2014 for
staging purposes. Results from the neck CT scan showed right level II, level III, and level IV
regional involvement however the remainder of the chest, abdomen and pelvis CT scans were
without evidence of lymphomatous involvement. On September 17, 2014, a PET/CT scan was
performed which demonstrated FDG uptake on the right side of the neck extending from the
second cervical vertebral body to just above the right clavicle. This scan showed involvement of

the anterior cervical lymph nodes and scattered right posterior cervical triangle lymph nodes.
Due to some delays with transferring his care closer to his hometown, a recommended restaging
PET/CT scan was performed on November 12, 2014, which unfortunately showed significant
interval increase in disease compared to the previous scan from September 2014. There was
increased FDG uptake in the right cervical adenopathy as well as new left cervical adenopathy,
right upper mediastinal and left axillary adenopathy. KR was staged as IA initially but changed
to stage IIB after restaging PET/CT was performed.
Radiation Oncologist Recommendations: After reviewing pathologic, radiologic and clinical
data with KR and his son, the radiation oncologist discussed the utilization of radiation therapy
to treat his nodular sclerosing Hodgkin lymphoma. Given that chemotherapy was not a feasible
option for KR due to his arterial disease and severe COPD co-morbidities, a radiation only
treatment regimen was recommended. While previous trials of radiotherapy alone demonstrate
an excellent overall survival, the radiation fields in those trials were much larger than what is
typically used today. The radiotherapy fields utilized were those of extended field using a mantle
plus upper abdominal treatment fields.2 Given KRs co-morbidities and his pacemaker, the
radiation oncologist explained to KR that his radiation fields would be limited to the areas
involved with disease; right and left neck, right upper mediastinum and left axilla; without
extending the fields to include imaging negative areas.
The Plan (prescription): The radiation oncologists treatment recommendation to KR was a
radiation only approach that consisted of anterior-posterior (AP) and posterior-anterior (PA)
fields to the areas of imaging positive disease. The prescription recommended for this plan was a
dose of 36 Gy at 2 Gy per fraction for 18 fractions. No additional boost was planned for this
patient.
Patient Setup/Immobilization: On December 4, 2014, KR underwent a CT simulation scan for
radiation therapy treatment planning. The patient was placed in the supine position using a
Civco head and shoulder Aquaplast mask with a standard clear head sponge plus an Elekta
immobilization vac-loc mold under his thoracic region. The patients arms were down and
slightly akimbo (Figures 1 and 2). A sponge was placed under his knees for support. Planning
CT images were acquired using 2.5 mm slices. The scanning parameters included from the
vertex of the head and extended to include the entire thoracic cavity. The patient was marked
using two sets of 3-point markings; one set of fiducials on his head and one set on his chest.

After completion of the CT scan, permanent tattoos were placed on the patients skin in the chest
region at the points of fiducial placement. The 3-point markings on the patients head were
documented using tape and a Sharpie marker which were placed on his mask.
Anatomical Contouring: After completion of the CT simulation scan, the CT data set was
transferred into the Philips Pinnacle3 treatment planning system (TPS) for contouring. The
radiation oncologist contoured the nodal gross tumor volume (GTV). The location and size of
the involved disease was verified from the PET/CT scan performed November 2014 which was
fused to KRs treatment planning CT scan. Additionally, the cerebellum, larynx, oral cavity, and
parotid glands were also contoured by the radiation oncologist. The medical dosimetrist
contoured organs at risk (OR) that included the spinal cord, heart, right and left lung, a total lung
volume, carina, right and left eye and mandible. The radiation oncologist completed a treatment
planning order which identified the prescription, dose constraints and other pertinent treatment
planning information. These instructions were given to the medical dosimetrist to begin
treatment planning.
Beam Isocenter/Arrangement: Once all contours were finalized, the radiation oncologist
placed an isocenter approximately at the level of the suprasternal notch (Figure 3). Due to the
extent of disease that needed to be covered, a source-to-skin distance (SSD) technique was used
for both the anterior and posterior fields. The anterior field isocenter is set to 100 SSD to the
skin and the posterior field isocenter is set to 100 SSD to the table top (Figures 4-6). The
anterior and posterior fields had a gantry angle of 180o and 0o respectively using a Varian Trilogy
linear accelerator. The field sizes for each field were created based on the custom blocking used
for these fields which were similar to a traditional mantle field. The superior field border is at
the inferior portion of the orbits, and the inferior field border is at the level of the tenth thoracic
vertebral body. Laterally, the axillary lymph nodes are included. Due to the multi-leaf
collimators (MLC) being unable to reach all areas needing to be blocked, custom Cerro bend
blocks were created (Figure 7 and 8). The AP and PA beams utilized an energy of 10
Megavoltage (MV) to get proper dose coverage of the gross positive disease. A forward
planning technique was used to reduce the hot spots and to even out the dose distribution. In
forward planning, beam factors such as shapes and intensities are adjusted in a process of manual
iterations to create a desired plan.3 A collimator angle of 270o was used for both fields in order
for the MLC to match the field shape desired by the radiation oncologist.

Treatment Planning: The radiation oncologist instructed the dose prescription and objectives,
which were to cover 95% of the GTV with 95% of the dose. A dose of less than 54 Gy would be
accepted for the cerebellum and a dose of less than 60 Gy would be accepted for the oral cavity.
The combined lung volume mean dose of less than 18 Gy was desired but the volume receiving
20 Gy would be accepted at 35% or less. The mean heart dose of 40 Gy or less was also desired.
Due to the SSD planning technique, a calculation point was placed mid-plane within the patient.
The calculation point was placed at approximately 2 cm superior to the anterior isocenter (Figure
9). Placing the calculation point slightly superior also helped to create a better dose distribution
in the superior portion of the field as there was difficulty delivering dose to the superior aspect of
the GTV. Approximately 58% of the dose delivered was from the anterior field and the other
42% was delivered from the posterior. Three control points were used for each field (Figure 10
and 11). Beam weights for the AP control points were 95%, 3% and 2% while the PA control
points were weighted 93.2%, 2% and 4.8% respectively. Once adequate coverage was
established, the medical dosimetrist reviewed the dose volume histogram (DVH), isodose lines
and OR with the radiation oncologist. The DVH (Figure 12) reflects that approximately 93% of
the GTV was covered by the 95% isodose line. Due to the large positive margin which needed to
be covered, complexity of the field blocking needed, and many different anatomical contours and
tissues, the radiation oncologists desire to cover 95% of the gross tumor volume with 95% of
dose was not achievable. The cerebellum received a maximum dose of 34 Gy. The oral cavity
received a maximum dose of 40 Gy. The mean total lung dose was equal to 8.875 Gy and the
volume receiving 20 Gy was 18%. Heart mean dose was kept to only 19.5 Gy. After reviewing
the plan, the radiation oncologist gave approval for treatment.
Quality Assurance/Physics Check: The monitor units (MU) for the plan were double checked
using the RadCalc program. The departmental allowed difference between the Philips Pinnacle3
TPS and RadCalc is 5% for each field. This plan met these criteria with a RadCalc of 0% for the
anterior field and -2.4% for the posterior field. This plan was done conventionally; therefore, no
quality assurance (QA) testing was necessary on the linear accelerator. In addition to the
RadCalc as a double check for this plan, the physicist also completed an initial chart check on
this plan. During the initial chart check, the physicist checked the following: patient name,
treatment site, radiation oncologists prescription signature, prescription matched the treatment
plan, plan entry into ARIA was correct, and the physicist also verified the Cerro bend blocks.

After completion of the physics initial chart check, the plan was then given to the radiation
therapist to complete a final QA check prior to the patient beginning treatment. The radiation
therapist QA check included verifying the radiation oncologists prescription matched the
treatment plan, the correct treatment machine was selected, the treatment site matched the
treatment plan, the field parameters were correct such as the MU, field size and energy, the
correct accessories were identified such as breath hold and bolus, and the control points were
verified.
Conclusion: Creating a plan that provided adequate dose coverage to a GTV that was so wide
spread and which had many different anatomical contours proved to be rather challenging for the
medical dosimetrist. There was difficulty achieving proper dose coverage to the superior aspects
of the GTV and there were hot spots in the axillary regions; therefore, the medical dosimetrist
moved the calculation point superiorly to push the dose in that direction. To help even out the
hot spots throughout the plan and create a more uniform dose distribution, the medical
dosimetrist used a forward planning step and shoot technique.

References
1. Green S. Lymphoreticular System Tumors. In: Washington CM, Leaver D, eds. Principles
and Practices of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby; 2010:610-627.
2. Gospodarowicz, MK, Sutcliffe, S.B., Clark, R.M. et al. Analysis of supradiaphragmatic
clinical stage I and II Hodgkins disease treated with radiation alone. Int J Radiat Oncol Biol
Phys. 1992;22(5):859-65.
3. Lozano RG. Intensity-Modulated Radiation Therapy. In: Washington CM, Leaver D, eds.
Principles and Practices of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby; 2010:328-346.

Figures

Figure 1 and 2. Patient position from CT simulation.

Figure 3. Isocenter placement: AP view.

Figure 4. Isocenter placement: Lateral view of the AP isocenter at 100 SSD to the anterior skin.

Figure 5. Isocenter placement: Lateral view of the PA isocenter at 100 SSD to the table top.

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Figure 6. AP and PA isocenter in the axial view.

Figure 7. Field shape on AP beam. Gross tumor volume in red. Custom Cerro bend blocking in
yellow.

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Figure 8. Field shape on PA beam. Gross tumor volume in red. Custom Cerro bend blocking in
yellow.

Figure 9. Calculation point in red. Isocenter in green.

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Figure 10. Controls points 1, 2, and 3 of AP field respectively.

Figure 11. Control points 1, 2, and 3 of PA field respectively.

Figure 12. Dose volume histogram (DVH).