Respiratory Case StudySL3, 12:36pm, 12/16/2009

Amber Strasburg

NSCLC: Bronchogenic mucinous adenocarcinoma 87 year old female Hospitalized for acute abdominal pain in

August 2009 Abdominal x-ray showed mass in left lung

PET/CT showed a 3cm mass in the lung SUV (standardized uptake value) of 21.6.

Needle core biopsy confirmed bronchogenic mucinous adenocarcinoma

Epidemiology Lung cancer is the leading cause of

cancer-related death in the U.S. Estimated new cases in 2014 is 224,210 Estimated deaths is 159,260 NSCLC accounts for about 85% of all lung

cancers. Adenocarcinoma is most common with

40% of all lung cancers Occurs most often in women

Etiology Most common cause is tobacco

exposure 87% of lung cancers are the result of

smoking Other risk factors include:

Occupational exposure Fumes from coal tar, nickel, chromium, and

arsenic as well as exposure to radioactive materials

RT to breast or chest

Histology 12 primary tumor types

Epidermoid carcinoma Small cell anaplastic carcinoma Adenocarcinoma Large cell carcinoma Combined epidermoid and adenocarcinoma Carcinoid tumors Bronchial gland tumors Papillary tumors of the surface epithelium Mixed tumors and carcinomas Sarcomas Unclassified Mesotheliomas

Presenting Symptoms Patient specific:

None Pt. denies any

change in respiratory status

Common: Hemoptysis Malaise Weight loss Dyspnea Hoarseness

Medical History History of bilateral breast cancer

Right breast DCIS and left breast invasive ductal carcinoma (T2 N0)

3 lumpectomies Whole breast irradiation to both breasts

60Gy to right side (1988), 50Gy to left side (2005) Bilateral mammogram in 2009 was negative for

malignancy History of endocarditis, TB, hyperlipidemia,

and hypertension

Family and Social History Family History:

2 sisters diagnosed with breast cancer at age 47 and 49 respectively

Social History: Pt. is retired No history of

tobacco, alcohol, or drug use

Very active ECOG (Eastern

Cooperative Oncology Group) score of 0

Lab/Imaging Studies PET/CT showed 3cm mass Needle core biopsy revealed invasive,

moderately differentiated mucinous adenocarcinoma

CBC showed abnormalities in MCHC (concentration of hemoglobin in RBC) and lymph. Immunophenotype of carcinoma confirms

pulmonary origin Not metastatic breast cancer

Stage TNM (Tumor, Node, Metastases) system is used Tumor size (T)

TX: Tumor cannot be assessed (not visible) T0: No evidence of tumor Tis: Carcinoma in situ T1a: Tumor ≤2cm, surrounded by lung of visceral pleura, without invasion of

main bronchus T2a: Tumor >3cm but ≤5cm or tumor involving main bronchus, ≥2cm distal

to carina; invading visceral pleura; associated with atelectasis or obstructive pneumonitis

T1b: Tumor >2cm but ≤3cm, surrounded by lung or visceral pleura, without invasion of main bronchus

T2b: Tumor >5cm but ≤7cm or tumor involving main bronchus, ≥2cm distal to carina; invading visceral pleura; associated with atelectasis or obstructive pneumonitis

T3: Tumor >7cm or tumor that invades parietal pleura, diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium or tumor in main bronchus or associated with atelectasis or obstructive pneumonitis of entire lung

T4: Tumor of any size that invades mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, or separate tumor nodule(s) in a different ipsilateral lobe

Stage Node Involvement (N)

N0: No regional lymph node metastasis N1: Mets in ipsilateral peribronchial and/or

ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension

N2: Mets is ipsilateral mediastinal and/or subcarinal lymph node(s)

N3: Mets in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s).

Stage Metastasis (M)

M0: No distant mets M1: Distant mets M1a: Separate tumor nodule(s) in a

contralateral lobe tumor with pleural nodules or malignant pleural (or pericardial) effusion

M1b: Distant mets (in extrathoracic organs)

Stage Grouping Occult carcinoma: TX, N0, M0 Stage 0: Tis, N0, M0 Stage IA: T1a, N0, M0 or T1b, N0, M0 Stage IB: T2a, N0, M0 Stage IIA: T2b, N0, M0; T1a, N1, M0; T1b, N1, M0; T2a,

N1, M0 Stage IIB: T2b, N1, M0; T3, N0, M0 Stage IIIA: T1a, N2, M0; T1b, N2, M0; T2a, N2, M0;

T2b, N2, M0; T3, N1, M0; T3, N2, M0; T4, N0, M0; T4, N1, M0

Stage IIIB: T1a, N3, M0; T1b, N3, M0; T2a, N3, M0; T2b, N3, M0; T3, N3, M0; T4, N2, M0; T4, N3, M0

Stage IV: Any T, Any N, M1a, OR Any T, Any M, M1b

Grade GX: Grade not assessable G1: Well differentiated G2: Moderately differentiated G3: Poorly differentiated G4: Undifferentiated

Pt. Stage and Grade Clinical stage 1 (T1, N0, M0) Grade 2- Moderately differentiated

Tx. Summary stated mass was >3cm, so T2a, N0, M0

Typical Routes of Spread 3 spread patterns:

Direct When the mass itself grows into surrounding

structures (lung, ribs, heart, esophagus, vertebral column, chest wall, diaphragm, pleura, and pericardium.

Lymphatic Cells can be trapped in nodes when lymph fluid is

filtered and pass through the nodes Cells can grow through the node and gain access to

the circulatory system Hematogenous

Lymph drainage has access to the whole body through the circulatory system

Metastasis Common:

Cervical lymph nodes Liver Brain Bones Adrenal glands Kidneys Contralateral lung

Patient: No metastasis

Treatment Options Surgery

First step Only 20% of lung cancer patients considered candidates

for surgery Chemotherapy

Alone or with RT Most effective single agent drug is cisplatin

Radiation Therapy Standard therapy generally includes concurrent,

sequential, or alternating chemo and radiation May be done before surgery to shrink tumor or after

surgery Can be used with curative intent or for palliation

Radiotherapy Considerations Standard fractionated IMRT Hypofractionated SRS

Increased dose allowing for better local control

Pt. not a candidate for surgery because of poor pulmonary function tests and lung damage caused by TB

SRS recommended, but pt. declined Tx with standard fractionation

Pre-Sim Ask the pt 5 identifiers (name, date of birth, address, phone

number, and area being tx) Take face photo Let pt. know that you will be making an alpha cradle for

immobilization and that it will be warm Instruct pt. not to use any creams or lotions as they may

contain metals that could interact with radiation Discuss side effects with them:

Dermatitis, erythema, esophagitis, dysphagia, coughing, dry throat, excessive mucous secretions

Tell them that they will be seeing the physician and the nurse once a week

Discuss diet: Soft, moist, and non-spicy foods and liquids at room temp. or

slightly chilled

Simulation Procedure Setup:

Alpha cradle, knee fix, rubber band Pt. will be asked to lie down on table, supine, arms

up, and she will be aligned visually using the sagittal laser

Alpha cradle will be made for immobilization A 4D CT will be done for planning

Tracks motion of tumor with breathing After CT, levels will be given, chin measurement will

be recorded, and photos will be taken of setup and levels

Pt. will be told to come back for verify sim to place the isocenter once planning is complete

Verify Sim Therapists will look at skin rendering

and DRR’s to ballpark isocenter, then a CBCT is done to confirm isocenter placement.

Tattoo will be given to mark c/a and 3-point will be recorded

Photo of c/a tattoo and any additional photos needed for setup will be taken

SSD’s will be taken and recorded

Setup photos

Prescription Site: Lt. lower lung Technique: 7 field

IMRT Modality: 6x

Fractions: 40tx @ 200cGy daily

Total Dose: 8,000cGy

Dose Spec: Volume

Beam arrangement

GTV, CTV, PTV GTV is the 3cm tumor CTV is 0.5cm margin around tumor PTV is 0.5cm margin around CTV

Isodose

Ortho Pair

Skin Rendering

DRR

Critical Structures

Critical Structures/Tolerance Doses Lung

TD 5/5: 2000cGy Dose given:

Lt- 1857cGy Rt- 699cGy

Heart TD 5/5: 4300cGy Dose given: 1605cGy

Spinal Cord TD 5/5: 4500cGy Dose given: 846cGy

Esophagus TD 5/5: 5000cGy Dose given: 1291cGy

Complications No complications Pt. tolerated tx well and did not develop

any significant shortness of breath, chest pain, dysphagia, odynophagia, or skin erythema

PrognosisStage5-year Survival Rate  IA49%IB45%IIA 30%IIB 31%IIIA 14%IIIB 5%IV1%

Lessons To Be Learned 87 year old woman had to come in

everyday for 8 weeks Takes time out of her day Many other places she’d rather be

Already went through RT for both breasts Probably feels like her life is being

controlled by cancer

References Washington CM, Leaver D. Principles and

Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010.

National Cancer Institute. Non-Small Cell Lung Cancer Treatment(PDQ). Available at: http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/healthprofessional/page1. Accessibility verified May 16, 2014.