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Eyob Mathias February Case Study February 13, 2013 Stage I Classic Seminoma Case Study History of present illness: Mr. DS is a 41 year old white male recently diagnosed with Stage I, pT1 N0 M0 seminoma. On January 11, 2013 he presented to his primary care physician (PCP) with a symptom of left sided testicular pain radiating into the lower abdomen. His family physician ordered ultrasound screening and the result showed bilateral microlithiasis with multiple hypoechoic lesions in the left testicle. Subsequent to this screening, his lactate dehydrogenase (LDH), beta human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels were checked which were all normal. He underwent a left oriectomy on January 22, 2013. Final pathology result showed pT1 classic seminoma. pTNM is a cancer staging system where P determines if the stage is given by pathologic examination, T determines the tumor size, N determines nodal involvement and M determines if there are other organs involved or if the cancer has metastasized.1 Diagnostic imaging study: Postoperatively, he underwent computed tomography (CT) scan of the abdomen and pelvis which showed a left inguinal lymph node involvement measuring 1.5 X 1.2 cm. This involvement included small pelvic lymph nodes along with the left external iliac vessels and a portion of the lymph node right above left iliac lymph node at the bifurcation. After looking at the CT scan result, he was referred to Geisinger Wyoming Valley (GWV) hospital for adjuvant external beam radiation treatment. Family history: Mr. DS has a family history of throat cancer. Social history: Mr. DS is a nonsmoker and socially drinks alcohol. He works as an insurance adjuster in a local insurance company. Past medical history: Patient had a history of hypertension, hypercholesterolemia, fractured femur as a child and repair of an Achilles tendon rupture in 2004.

Current Medication: The patient is currently taking Simvastin 10 mg and Lisinopril 10 mg daily. Prescription: A total dose of 2340 centigray (cGy) is anticipated at 180 cGy per fraction to be delivered by 15Megavoltage (MV) per the generated dosimetric plan. The total treatment will be 13 fractions. Simulation: On February 18, 2013, he came to GWV oncology department for simulation procedure. He was placed in supine treatment position and radiation borders were obtained on the skin by the therapist. Reference point (BB) was placed and verified via CT scout films. CT scan was then performed of the target area without contrast. Measurements were taken and marks were placed. Treatment Planning: The CT images were downloaded to the treatment planning system. The target volumes, which included the tumor and immediately draining nodal areas, were outlined as well as adjacent critical normal organs at risk. Isocenter point was set in reference with the simulation BB marks. Anteroposterior (AP) and posteroanterior (PA) beams were created and the critical structures were blocked. The treatment field shape looks like a hockey stick and kidneys as well as the left testicle were blocked. No immobilization device was used for this treatment. Quality Assurance: The plan was finally approved by the doctor and it was sent to the physicist for quality assurance procedure. The quality assurance process consists of double checking measurements and calculation of monitor unit values. The difference in the calculated percent error should be 5% or less in order for the plan to be approved for treatment. In this particular case the percent error was 1.1%, so the medical physicist approved the plan and the patient was scheduled for treatment. Conclusion: Overall, this was simple, interesting and typical parallel-opposed treatment planning case. I learned about the different nodes that are involved in the treatment field when planning for seminoma cancer. According to the oncologist, stage I, pT1 N0 M0 classic seminoma has a 98% cure rate. But a recent research study states that adjuvant radiation therapy for stage I seminoma may cause secondary malignancy and is not recommended.2 In this case the

patient will complete his radiation treatment after 13 fractions. His treatment start date schedule is still pending, but it is expected that he will start his treatment within the week of February 25, 2013 and finish on the week of March 18, 2013.

Figure 1 Simulation AP Mark

Figure 1 Simulation Rt Lat Mark

Figure 2 Isodose distribution

Figure 3 Dose Volume Histogram (DVH)

Figure 4 Digitally Reconstructed Radiograph (DRR)

Figure 5 Rad Calc Data

8 Reference

1. Wikipedia, TNM Staging System. February 27, 2013. Available at: http://en.wikipedia.org/wiki/TNM_staging_system. Accessed February 27, 2013. 2. Chung P, Warde P. Stage I Seminoma: Adjuvant Treatment is Effective but is it necessary? JNCI J Natl Cancer Inst. 2011; 103(3): 194-196.