Case study Epithelioid hemangioendothelioma of the spine treated with RapidArc volumetric-modulated radiotherapy Jean-Baptiste Guy, M.D.,* Jane-Chloé Trone, M.D.,* Cyrus Chargari, M.D., Ph.D., † Alexander Tuan Falk, M.D., ‡ Mustapha Khodri, Ph.D., § and Nicolas Magné, M.D., Ph.D.* * Department of Radiotherapy, Institut de Cancérologie de la Loire, St Priest en Jarez, France; † Department of Radiation Oncology, HIA du Val de Grâce, Paris, France; ‡ Department of Radiation Oncology, Centre Antoine Lacassagne, Nice, France; and § Department of Physics, Institut de Cancérologie de la Loire, St Priest en Jarez, France ARTICLE INFO Article history: Received 6 December 2013 Accepted 19 March 2014 Keywords: Epithelioid hemangioendothelioma Volumetric intensity-modulated arc therapy Conformational radiotherapy Radioembolization ABSTRACT Radiotherapy for epithelioid hemangioendothelioma (EHE) using volumetric intensity-modulated arc radiotherapy (VMAT). A 48-year-old woman was referred for curative irradiation of a vertebral EHE after failure of surgery. A comparison between VMAT and conventional conformal tridimensional (3D) dosimetry was performed and potential advantage of VMAT for sparing critical organs from irradiation's side effects was discussed. The total delivered dose on the planning target volume was 54 Gy in 27 fractions. The patient was finally treated with VMAT. The tolerance was excellent. There was no acute toxicity, including no increase in pain. With a follow-up of 18 months, no delayed toxicity was reported. The clinical response consisted of a decrease in the dorsal pain. The D max for the spinal cord was reduced from 55 Gy (3D-radiotherapy [RT]) (which would be an unacceptable dose to the spine because of the risk of myelopathy) to 42.8 Gy (VMAT), which remains below the recommended dose threshold (45 Gy). The dose delivered to 20% of organ volume (D 20 ) was reduced from 47 Gy (3D-RT) to 3 Gy (VMAT) for the spinal cord. The study shows that VMAT allows the delivery of curative treatment for vertebral EHEs because of critical organ sparing. & 2014 American Association of Medical Dosimetrists Introduction Epithelioid hemangioendothelioma (EHE) is a rare intermediate-grade vascular tumor deriving from the vascular endothelium with histological features between well- differentiated hemangioma and anaplastic hemangiosarcoma. 1,2 It is often located in soft tissues but also occurs in other organs such as the liver, lung, and bone. 2-4 Owing to the small number of cases, there is no strong consensus for the management of EHE treatment. For EHEs located in the spine, surgery, often preceded by a radiological embolization, remains the standard of treatment. Adjuvant or, when surgery is impossible, exclusive radiotherapy (RT) may also be performed. 5-8 Irradiation of the spine is challenging because the spinal cord is a dose-limiting organ. As the 5-year survival rate for patients undergoing total resection of their EHE may reach 80%, every effort should be made to preserve patients from RT-induced toxicities. 2 Volumetric intensity-modulated arc radiotherapy (VMAT) is a modern RT modality that allows high conformal dose distribu- tions, critical organ sparing, and rapid delivery. It is currently used for various tumor localizations. 9,10 Here, we evaluated this new high-tech RT modality for a patient with a lytic vertebral lesion. A comparison between VMAT and conventional conformal tridimen- sional (3D) dosimetry is performed, and the potential advantage of VMAT for sparing critical organs from irradiation's side effects is discussed. Patients and methods Case presentation A 48-year-old woman was referred for irradiation of a vertebral EHE in May 2011. The patient had a medical history of lung lymphangioleiomyomatosis since 1994 and hypertension. The patient was initially asymptomatic, and systematic journal homepage: www.meddos.org Medical Dosimetry http://dx.doi.org/10.1016/j.meddos.2014.03.002 0958-3947/Copyright Ó 2014 American Association of Medical Dosimetrists. Reprint requests to: Nicolas Magné, M.D., Ph.D., Department of Radiotherapy, Institut de Cancérologie Lucien Neuwirth, 108 bis, Avenue Albert Raimond—BP 60008, Saint-Priest en Jarez cedex 42271, France. Tel.: þ33 477 917 434; fax: þ33 477 917 197. E-mail: nicolas.magne@icloire.fr Medical Dosimetry ] (2014) ]]]–]]]