A Novel Setup Technique for Radiation Treatment of a Severely Obese Patient With a Primary Brain Tumor.

Modern external beam radiation therapy (EBRT) techniques rely on the accurate positioning of the patient using the treatment couch. These motorized couches have weight limits that have decreased over time and are not able to support severely obese patients requiring EBRT. We aimed to develop a technique to support obese patients who are above their weight tolerance while accurately delivering radiation treatment to a brain tumor. This technique was used on a patient receiving adjuvant radiation for gliosarcoma, a variant of glioblastoma. The patient was CT scanned, and the 3D conformal radiation therapy plan was created. A custom treatment couch was created using a transport stretcher, Styrofoam, a CT couch-top, and an IMRT board, which allowed for a thermoplastic mask to be used for a reproducible setup. AP and lateral portal films were taken prior to each treatment to confirm the accuracy of the manual daily setup of the patient on the custom couch. The patient received 60 Gy in 30 daily fractions of 3DCRT in a reproducible fashion. The average deviation from the isocenter fell within the 10 mm and 8 mm planning margins applied to the clinical target volume (CTV) for the initial and boost fields, respectively. The average daily shifts in the anterior-posterior (AP) direction for the patient were 7.97 (-16.19 to 12.04) mm and 1.98 mm (-1.1 to 4.3) mm for the initial and boost treatments, respectively. The average daily shifts in the superior-inferior (SI) direction were 2.2 (-5.08 to 9.04) mm and 3.88 (-2.9 to 8.0) mm for the initial and boost treatments, respectively. This novel approach allowed treatment at 60 Gy for a gliosarcoma patient who had previously been denied treatment due to his weight. By utilizing readily available materials within the department, our team was able to create a reproducible setup technique to safely treat the patient.