Ashley Pyfferoen, MS, CMD Gundersen Health Systems La Crosse, WI
3 Radiation Oncologists 3 Physicists 2 Dosimetrists 9 Radiation Therapists
o o o o o o o o o Brachial Plexus Anatomy Brachial Plexopathy and Dose Restrictions NSCLC Characteristics Patient Selection Target Delineation Treatment Planning Plan Analysis & Evaluation Follow-up Research
Motor and Sensory Functions Origination Formation of 3 Trunks, 6 divisions, 3 cords 1 Figure 1. Divisions of the brachial plexus. 2
Figure 2. Divisions of brachial plexus.3
1. Identify and contour C5, T1, and T2. 2. Identify and contour the subclavian and axillary neurovascular bundle. 3. Identify and contour anterior and middle scalene muscles from C5 to insertion onto the first rib. 4. To contour the brachial plexus OAR use a 5-mm diameter paint tool. 5. Start at the neural foramina from C5 to T1; this should extend from the lateral aspect of the spinal canal to the small space between the anterior and middle scalene muscles. 6. For CT slices, where no neural foramen is present, contour only the space between the anterior and middle scalene muscles. 7. Continue to contour the space between the anterior and middle scalene muscles; eventually the middle scalene will end in the region of the subclavian neurovascular bundle 8. Contour the brachial plexus as the posterior aspect of the neurovascular bundle inferiorly and laterally to one to two CT slices below the clavicular head. 9. The first and second ribs serve as the medial limit of the OAR contour.
Figure 3. Step-by-step contouring process of superior brachial plexus for H & N patient. 4 Figure 4. Step-by-step contouring process for inferior brachial plexus on H & N patient. 4
Figure 5. DRR view of brachial plexus contour on planning CT. 4
RIBP Damage to nerves at high doses Side Effects 5 Pain and weakness Paresthesia Paralysis Dose limitations
Common Histology 6 Squamous Cell Carcinoma Adenocarcinoma Stages 6 0-4 Stage IIIA Stage IIIB Current Standard of Care Treatment 6 Surgery, Chemotherapy, Radiation Therapy
Figure 6. Current NCCN Guidelines for Standard of Care for Stage III NSCLC with N0 or N1. 7
Figure 7. Current NCCN Guidelines for Standard of Care for Stage III NSCLC with N2 or N3. 7
Cases diagnosed in US in 2014 Standard Doses 8 Local Control 8 Figure 8. Estimated new cases per disease site in 2014. 9
Characteristics NSCLC Lung Apex Brachial plexus involvement Dose Simulation GE CT Vaclok immobilization ExacTrac imaging Figure 9. GE CT Scanner similar to the one used at Gundersen Health Systems. 10
Treatment Planning System Fusion and Expansion Organs at Risk Brachial Plexus L and R Lungs Heart Spinal Cord Esophagus
74 year old female Presented with hemoptysis PET/CT confirmed 5 cm mass invading chest wall Stage IIIA (T4, N0, M0) Current Problem List Kidney Disease Anxiety Bipolar Disorder Hyperlipidemia Osteoporosis Tobacco Abuse Figure 10. Diagnostic PET/CT for patient 1.
Figure 11. PTV and brachial plexus overlap for patient 1.
Table 1. Planning objectives for patient 1. Structure Priority Instructions PTV 2 200cGy x 33fx V 6600 95% Will accept it cold to achieve brachial plexus constraint Brachial Plexus 1 Max 66 Gy Cord 1 Max 45 Gy
Table 2. Plan parameters for the treatment of patient 1. Prescription and Treatment Planning Parameters Site Beam Energy Prescription Dose Beam Arrangment Prescription Treatment Planning Parameters Right lung apex and chest wall invasion 6 MV 66 Gy in 33 fx (7) Co-planar beams Gantry Angles 212, 279, 318, 0, 48, 77, 150 Collimator Angles (Respective to gantry angles above) Planning Technique 0 IMRT * Treatment with concurrent chemotherapy
Figure 12. Axial view 1 of dose coverage for patient 1.
Figure 13. Axial view 2 of dose coverage for patient 1.
Figure 14. Axial view 3 of dose coverage for patient 1.
Figure 15. Axial view 4 of dose coverage for patient 1.
Figure 16. Axial view 5 of dose coverage for patient 1.
Table 3. DVH criteria obtained Structure Cord 43.298 Brachial Plexus 65.995 Figure 17. DVH for patient 1. Maximum Dose (Gy)
54 year old Presentation: Work up for unrelated condition Chest X-ray revealed mass Stage IIIB T4 N2 M0 Current Problem List Chronic Back Pain KPS=60
Figure 18. Diagnostic CT scan for patient 2 in axial view.
Figure 19. Diagnostic CT scan for patient 2 in coronal view.
Figure 20. PTV and expanded brachial plexus overlap.
Table 4. Planning objectives for patient 2. Structure Priority Instructions PTV 2 Best achievable dose Expanded Cord 1 Max 45 Gy Expanded Brachial Plexus 1 Max 60Gy
Table 5. Planning parameters for the treatment of patient 2. Prescription and Treatment Planning Parameters Site Beam Energy Prescription Dose Beam Arrangement Prescription Treatment Planning Parameters Right lung apex and mediastinal nodal involvement 6 MV 60 Gy in 30 Fx (7) Co-planar beams Gantry Angles 200, 250, 300, 0, 50, 100, 150 Collimator Angles 0 Planning Technique IMRT * Treatment with concurrent chemotherapy
Figure 21. Axial view 1 of dose coverage for patient 2.
Figure 22. Axial view 2 of dose coverage for patient 2.
Figure 23. Axial view 3 of dose coverage for patient 2.
Figure 24. Axial view 4 of dose coverage for patient 2.
Figure 25. Axial view 5 of dose coverage for patient 2.
ITV PTV Brachial Plexus Cord Cord 5mm Table 6. DVH criteria obtained Critical Structure Cord 39.57 Cord5mm 43.75 Brachial Plexus 60.01 Maximum Dose (Gy) Figure 26. DVH for patient 2.
66 year old female Undergoing workup for breast cancer Surgeon noticed hemoptysis upon review of systems CT scan revealed lung nodules Stage IIIB Current Problem List Breast cancer Diabetes Hypertension Hyperlipidemia Anemia Past Problem List Colon cancer
Figure 27. Superior axial slice taken from diagnostic PET/CT taken patient 3. Figure 28. Inferior axial slice taken from diagnostic PET/CT for patient 3.
Figure 29. PTV and expanded brachial plexus overlap for patient 3.
Table 7. Planning objectives for patient 3. Structure Priority Instructions PTV 2 Expanded Brachial Plexus Expanded Cord PTV with no BP overlap: V 60 95% Total PTV: V 57 100% 1 Max 60Gy 1 Max 45 Gy
Table 8. Planning parameters for patient 3. Prescription and Treatment Planning Parameters Site Beam Energy Prescription Dose Beam Arrangement Prescription Treatment Planning Parameters Left Lung apex and mediastinal nodal involvement 6 MV 60 Gy in 30 Fx (7) Co-planar beams Gantry Angles 204, 255, 306, 0, 51, 102,153 Collimator Angles 345, 335, 337, 0, 21, 20, 14 Planning Technique IMRT * Treatment with concurrent chemotherapy
Figure 30. Axial view 1 of dose coverage for patient 3.
Figure 31. Axial view 2 of dose coverage for patient 3.
Figure 32. Axial view 3 of dose coverage for patient 3.
Figure 33. Axial view 4 of dose coverage for patient 3.
Brachial Plexus PTV Cord5mm Table 9. DVH criteria. Figure 34. DVH for patient 3. Critical Structure Brachial Plexus 60.30 Cord5mm 44.55 Maximum Dose (Gy)
PTV Coverage Evaluation Table 10. PTV coverage for each patient. Patient 1 PTV Patient 2 PTV Patient 3 PTV Prescription Dose (Gy) PTV Evaluation Maximum Dose (Gy) Mean Dose (Gy) Percentage of PTV receiving 100% of Prescription Dose 66 70.28 66.19 73.6% 60 65.85 62 89.6% 60 69.76 61.23 75%
Treatment completion Side effects Status Staging RIBP Tumor control
Status: Deceased Staging: Formally unknown, no metastasis were noted RIBP: No Tumor Control: Local Failure
Status: Deceased Staging: Not restaged after treatment RIBP: No Tumor Control: Local failure
Figure 35. Post-radiation therapy PET/CT scan.
Figure 36. Diagnostic CT taken post-treatment suggesting local failure in the lung apex.
Status: Deceased Staging: Unknown RIBP: No Tumor Control: Local Failure
How do we change this outcome? Evidence of increasing dose for NSCLC Evidence of increasing dose to brachial plexus
History: 40 Gy to 60 Gy 11 Study demonstrated 102.9 Gy before lung toxicity 12 RTOG Guidelines: 60-66 Gy 13 Trials increasing dose to 74 Gy were successful14, 15,16 Escalated doses still controversial after RTOG 0617
Dose was compromised for brachial plexus in all 3 patients Retrospective Study analyzed 80 patients with variable treatment doses and brachial plexus maximum doses 17 Radiation Induced Brachial Plexopathy vs. Tumor-related Brachial Plexopathy 17 Maximum dose to brachial plexus vs. overall volume irradiated 17
Brachial Plexus Function and Anatomy NSCLC Characteristics Patient Characteristics Patient Follow-up Future endeavors to increase the prognosis of these patients
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