Week 3

I spent this week immersed in clinical practice. I saw numerous patients with Drs. Knisely, Sanfilippo, and Ng covering brain, lung, head and neck, breast, prostate, and GI cancers and saw patients with early staged, advanced, and metastatic disease. I was able to see patient consults, simulations, treatments, and follow-ups and developed a more comprehensive picture of the standards of care for each patient’s condition.

With Dr. Knisely, I saw a patient that had a moderately sized WHO II astrocytoma that had a partial MGMT mutation and was IDH1 negative (both prognostic indicators). He was 40 years old, which is important because patients with grade II’s who are 40 and over have a different prognosis than patients under 40, thus potentially changing the prescribed treatment. This patient presented at their ophthalmologist with migraine-like visual defects and was referred to a neurologist for an MRI brain scan after their eye exam was unremarkable. He reported no other neurological symptoms, but did recall one episode of “Alice in Wonderland” syndrome around 20 years prior. This syndrome causes the patient’s perception of their surroundings to change, causing everything around them to appear very big or very small relative to their body. This suggests that the mass may have been growing slowly over the last two decades. The mass was resected, and the question was whether to do chemo/radiotherapy (RT) or just watch the area, saving radiotherapy for a possible recurrence. In patients under 40, the recurrence average is 15 years.

The patient was told about two clinical trials which show that in patients with WHO II oligodendrogliomas, patients that receive adjuvant RT, then PCV chemo have the best outcomes in terms of survivability. Because this patient has an astrocytoma, the data are not clear about what will produce the best outcomes, so he must weigh what he hears from Medical Oncologist and Radiation Oncologist about treatment vs. close following and make a decision about possible lifestyle changes caused by upfront RT/chemo vs. the likelihood of recurrence and subsequent inability to retreat a previously irradiated area with RT.

With Dr. Ng, I saw a 4-dimensional, adaptive simulation and treatment of a patient with pancreatic cancer on the Viewray, an MR guided linear accelerator. The technicians and Dr. Ng spent approximately 45 minutes with the patient on the table and the MRI running while they contoured the patient in the MR images and synced that contour to the treatment plan. The patient was simulated during a breath-hold, so the machine only turned the beam on when they took a deep breath and held it, aligning the target area with the contoured plan. If they exhaled or the target area shifted outside the boundary, the beam shut off immediately.  This process is completely automated in the software. Such a high level of accuracy enables Radiation Oncologists to use higher dosages of radiation since they do not have to worry as much about toxicity to the surrounding tissue. This was truly amazing to see in real-time. Dr. Ng believes that higher dosage will be the key to seeing better results in pancreatic cancer, which is hard to treat without MR-guidance because the pancreas is surrounded by the radiation sensitive bowel and moves substantially as the patient breathes.