CASE STUDY


CASE STUDY ONE The patient (a 58 year old) routinely attended breast screening and was found to have a suspicious area on mammography. She underwent right wide local excision and sentinel node biopsy and the final pathology showed a 10mm G1 cancer with clear margins and 0/1 nodes ER8 and HER2 negative (T1N0M0). The multi-disciplinary team decision was therefore two field radiotherapy and Tamoxifen. She attended for CT scanning and at the clinical


mark-up it was noted that she had a diathermy burn on her breast which had been sustained accidentally at operation. The wound was still a little open and the plan was to check it prior to starting radiotherapy. Unfortunately, during the virtual simulation process to put on treatment fields, a suspicious lesion was noted in the upper lobe of her left lung. The medical records were checked to see if she had


a history of respiratory problems, however as this was negative and she was not a smoker, she had never undergone a chest x-ray. The patient was asymptomatic, with no shortness of breath or respiratory symptoms prior to surgery. The CT findings were discussed with the consultant oncologist and it was agreed to send an urgent referral to the respiratory physicians to investigate the lung lesion. Meanwhile, her breast radiotherapy treatment was put on hold until further notice. Her oncologist received notification several weeks later that the lung lesion had successfully been resected by left upper lobectomy via keyhole surgery. The pathology results showed a 42mm pT2a N0 moderately differentiated lung carcinoma and excision was complete. The lung multi-disciplinary team decided no further treatment


was required and re-referred her back for breast radiotherapy.


She subsequently re-attended for repeat CT scanning and on the planning CT scan there was obvious trauma and air gap where the surgeons had performed the excision through the chest wall and some distortion of the lung where the lobectomy had been performed. The patient commented how extremely grateful she


was that her primary lung cancer had been picked up by the radiographer during her CT planning as she was asymptomatic from it. This was a very interesting case with the patient


having two primary cancers at the same time, both of which were asymptomatic but fortunately also curable. This highlights the benefits of routine breast screening which picked up the first cancer, then as a result of her planning CT scan, identified a lung cancer.


Case study 1.


to rule out metastatic disease. Approximately 4% of all patients presenting with breast cancer will have metastatic disease at presentation4


metastases include the brain, lungs, liver, bones and skin5 Staging investigations usually involve haematology and


biochemistry blood tests for low risk cancers. Routine computed tomography (CT) staging for asymptomatic patients with early stage disease (T1/T2) is not recommended in early breast cancer6


. Once the staging


investigations are complete, the patient will then proceed to surgery followed by radiotherapy and some patients are also given chemotherapy to offer the best chance of cure. CT-based treatment planning for breast cancer is standard practice in radiotherapy centres, as it allows better visualisation of the breast tissue and underlying structures such as heart and lung. Studies have shown that radiotherapy fields designed with the aid of CT planning scans result in an increased detection of incidental pulmonary nodules7


recommendations (the Fleischner society)8


. There are evidence-based for evaluating


solid pulmonary nodules <8mm detected incidentally in patients >35 years on non-screening CT. However, Lee et al9


JUNE 2017 concluded that incidental nodules should not alter the


definitive therapy for breast cancer. Virtual simulation and field placement is routinely


. The most common sites for distant .


undertaken by advanced practice therapeutic radiographers for all breast cancer patients undergoing primary and adjuvant radiotherapy within the author’s cancer centre. The radiographers do not have any formal training in CT image interpretation, however years of experience working with CT imaging has proven useful in identifying abnormalities within the CT scans. All patients are scanned on a Philips wide bore CT scanner, using 3mm slices to enable adequate soft tissue definition and the CT scan is then exported to a Varian Eclipse planning station. The process for the virtual simulation is to identify the field borders, tumour bed cavity clips and tumour bed, then delineate these and apply treatment fields. During this process the radiographer must scroll through the CT slices and as a result the lungs, liver, vessels and lymph nodes are visible, and abnormalities are sometimes apparent. The detection of pulmonary nodules is common and in populations at high risk of lung cancer (such as smokers), nodules are detected in 20–50% of individuals10


.


According to the National Lung Screening Trial (NLST) effective treatment will result in a reduction in mortality11


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