ROSE CASE-SOFT TISSUE SRCOMA

1. ROSE CASE
Extremity sarcoma
RADIATION ONCOLOGY
SIMULATION TO EXECUTION
DR KANHU CHARAN PATRO
MD,DNB[RADIATION ONCOLOGY]MBA,FAROI,PDCR,CEPC

2. HISTORY
• 27 year unmarried male
• Swelling on posterolateral aspect of thigh 2 month
• left side
• Wide local excision done outside

3. Imaging 04-06-2020
• Non contrast MRI pelvis
• T1,T2
• 5.3cm APx7.9cmMLx 8.9cm CC
• Mass arising from gluteus maximus
• Crossing the fascial plane to subcutaneous tissue
• Solid cystic lesion
• Fluid levels-hyper on T2
• Septate
• Adjacent edema
• s/o malignant etiology

4. Imaging 04-06-2020

5. Surgery by non oncologist
• Wide local excision
• PT- 6x5x4cm
• Malignant peripheral nerve sheath tumor
• No comment on margin
• No other comments

6. Immunohistochemistry

7. Immunohistochemistry
TLE1 POSITIVE
CD99/MIC2 POSITIVE
EMA POSITIVE
BCL2 POSITIVE
SATB2 POSITIVE
MIB1 INDEX/KI67 20-25%
Diagnostic gold standard for synovial sarcoma, TLE1
DIAGNOSIS- SYNOVIAL SARCOMA
Bharat Rekhi,/IJMR/2012

8. FINAL DIAGNOSIS
1. SYNOVIAL SRACOMA
2. LEFT LATERAL THIGH
3. pT2 cN0 cM0
4. Complete excision
DIAGNOSIS- SYNOVIAL SARCOMA

9. RE – EXPLORATION BY ONCOSURGEON
• WIDE EXCISON OF RESIDUAL TUMOR
• H/P- NO RESIDUAL TUMOR

10. Tumor board decision
• After group discussion with oncosurgeon,
radiation oncologist and patient, board
decided to plan for adjuvant radiotherapy
• Patient was explained about complications
and outcome of the procedure

11. Radiation consultation
• After discussion with radiation tumor board
Planned for adjuvant radiation
• 3DCRT/IMRT/ARC
• Phase-l-56Gy
• Phase-ll-10Gy

12. Patient discussion
• Gonadal dose
• Planned for sperm banking as unmarried
• Chances of recurrence
• Avascular necrosis femoral head
• Skin and sub cut fibrosis

13. Simulation
• Supine
• Hands up
• Vaclok
• Leg straight
• Gonads displaced
manually upward fixed
with tape

14. Imaging
• Contrast CT
• 5mm
• From umbilicus to knee joint
• Scar mark by copper wire rather than lead
wire
• Transferred to contouring station

15. Target delineation
• Image fusion CT and Pre OP MR
• Contour scar
• Contour surgical clips
• Contour surgical bed
• MRI GTV and edema
• Boolean clip, cavity, MRI GTV and edema
• CTV-4cm superior and inferior and 1.5cm radially
and 2cm for scar
• Edited from femoral head, uninvolved sub cut plane
• PTV- 1cm

16. THE GUIDELINES

17. MARGIN GUIDELINES

18. DESCRIPTION
Reconstructed
GTV
• Defined by MRI T1+C
• CT
• Fusion
• Post op bed
CTV1 • Proximal/distal: CTV = GTV + 4cm
• Radial: CTV = GTV + 1.5cm
• Cover T2 edema (per Wang et al JCO 2015), but confine CTV to muscle & compartment;
exclude skin, SQ tissue, and bone
• If 4 cm expansion of reconstructed surgical volume in longitudinal direction is shorter than
surgical scar, the elective CTV should be expanded to include the surgical scar
• Elective CTV should remain within the skin
• Surgically disturbed tissues and any scars, or drain sites are included with a 1 to 2 cm
margin expansion
PTV • CTV + 1cm
CTV Boost • In the longitudinal direction, the elective CTV66 is 2 cm longer on both sides than the
reconstructed GTV prior to surgery.
PTV boost • CTV boost + 1cm
• Cancer Biol Med 2016.
• doi: 10.20892/j.issn.2095-3941.2016.0028
Target delineation

19. Scar and scar marking

20. Leg and hand position

21. Marking the clips

22. Delineating the scar

23. Margin to scar

24. Post op cavity

25. CTV [outer]

26. Edited CTV-RED

27. PTV- Green

28. OAR- Femur head, Rectum, Gonads

29. Daily positioning of the gonads

30. 3DCRT PLAN VS IMRT

31. RECTUM DVH 3DCRT PLAN VS IMRT
3DCRT D50% VMAT-D50%
15Gy 29Gy

32. Gonads DVH 3DCRT PLAN VS IMRT
3DCRT DMEAN/MAX VMAT-DMEAN/MAX
2.65/6.4Gy 4.62/6.08Gy

33. LEFT FEMUR DVH 3DCRT PLAN VS IMRT
3DCRT D40% VMAT-D40%
64Gy 62Gy

34. Bladder DVH 3DCRT PLAN VS IMRT
3DCRT D50% VMAT-D50%
8.23Gy 16.57Gy

35. PTV56 DVH 3DCRT PLAN VS IMRT

36. PTV-BOOST DVH 3DCRT PLAN VS IMRT

37. LOW DOSE 70% SPILL 3DCRT PLAN VS IMRT
3DCRT
VMAT

38. 70% SPILL DVH 3DCRT PLAN VS IMRT
3DCRT VOLUME VMAT VOLUME
3651CC 3372CC

39. PARAMETER 3DCRT VMAT
PTV COVERAGE
D95% 93% 95%
D98 89% 93.5%
D2% 107% 105%
PTV56 COVERAGE

40. PARAMETER 3DCRT VMAT
PTV COVERAGE
D95% 93.4% 96.2%
D98 89.5% 93.9%
D2% 107.9% 103.4%
PTVBOOST[10Gy] COVERAGE

41. Plan acceptance
• 3DCRT plan is looking better with respect to
gonads
• With small variation with better dose profile
for FEMUR with VMAT
• VMAT plan has more spillage on organs like
rectum and bladder.
• 3DCRT PLAN ACCEPTED

42. CBCT MATCHING
• Picture missing

43. DOCTORS
• DR P S BHATTACHARYA
• DR C R KUNDU
• DR V K REDDY
PHYSICISTS
• MR A C PRABU
• MR A SRINU
• MR PRASAD
• DR ANIL KUMAR
TECHNOLOGIST TEAM
Acknowledgments