Savannah Coleman

Dos 531: Clinical Oncology for Med Dos

Clinical Oncology Assignment: Prostate Bed w/Nodes

The patient that I have chosen as the subject of this assignment, who will hereafter be referred to
as E.B., is a 60 year old male, diagnosed with a T3aN0 clinical stage IIIB adenocarcinoma of the
prostate. He underwent robot-assisted radical prostatectomy on November 28, 2016, which
revealed disease consistent with adenocarcinoma, Gleason score of 8. Surgery margin was
positive with a minute focus of invasive carcinoma at the left apex. Lymphovascular invasion
and perineural invasion was noted. A PSA taken in October 2017 was 0.3 NG per mL, consistent
with biochemical recurrence. E.B. has a paternal history of prostate cancer, has a 20 year pack
history of cigarette smoking, quitting in 1991, and is currently incarcerated. He was referred to
the radiation oncologist for salvage radiation to the pelvis and prosthetic bed.

How was this patient positioned for simulation? What positioning devices/accessories were
used, how and why?
Prior to simulation the patient was given prep instructions via nursing. These instructions
included to arrive with a comfortably full bladder and to begin taking Miralax to help regulate
his bowels and to help ensure a relatively empty rectum on simulation day. The patient was
positioned supine, with his head on a square cushion and his legs immobilized in a Vac-Lok
device. He was asked to hold a provided ring on his upper chest. The head cushion was used as a
comfort measure. The Vac-Lok device was used to provide a stable and reproducible position for
the daily patient setup. E.B.’s arms needed to be high and out of any potential radiation fields,
hence the need for placing them on his chest. The ring was used as a tool to make it easier for
E.B. to keep his hands in the required position. After scanning, marks were added to signify
origin. Permanent tattoos will be given to the patient after planned shifts are made on the first
day of treatment.

Figure 1: View of patient setup

 Figures 2 and 3: View of origin BB’s

Discuss the target dose as defined by your physician and the rationale behind the total dose
and fractionation regimen. Include any references or current research to help answer the
question.

The physician prescribed 4600 cGy to the PTV_Bed and PTVn (nodal volume) at 200 cGy/day.
She also prescribed a boost to the PTV_Bed for 2200 cGy at 200 cGy/day, to a total dose of 6800
cGy to the PTV_Bed. The prescribed energy was 10MV and the doctor requested a full bladder
and empty rectum for simulation and for daily treatments. Upon inquiry, the physician stated that
the NCCN guidelines recommend between 66 Gy and 70 Gy, so she split the difference for her
total dose, and that 46 Gy to the nodal volume is also a standard per NCCN. She mentioned that
she prefers a daily fractionation of 200 cGy versus 180 cGy. She stated that toxicity has not been
shown to be increased by increasing the daily dose 200 cGy, and that most sources include 180
cGy-200 cGy as conventional fractionation.1 She said it also allows the overall treatment time to
be decreased from approximately 38 to 34 treatments.

What specific avoidance structures were contoured? Include a screen shot of your
contoured target and organs at risk. Create and embed a table of OAR tolerance doses
based on your physician prescription and include any associated QUANTEC values. List
the contraindications if tolerance doses were to be exceeded.

After E.B. finished his simulation, I imported his CT scan into our Eclipse software, inserted the
desired structure set, and began contouring. The organs at risk that were contoured, planning
objectives, and the published QUANTEC2 tolerances are listed below. We used RTOG 05343
published constraints when evaluating our rectum and bladder, due to their specificity for
prostate bed treatments, but referenced departmental objectives for all other OAR’s and as a
second check for our rectum and bladder.

Organ at Risk Planning Objectives QUANTEC Values

Bladder Referenced QUANTEC, but V65 ≤ 50%
 ultimately only needed to meet V70 ≤ 35%
BladdermCTV constraints V75 ≤ 25%
V80 ≤ 15%
Bladder Minus CTV V65 ≤ 50% Not Applicable
V40 ≤ 70%
Rectum V65 ≤ 35% V50 ≤ 50%
V40 ≤ 55% V60 ≤ 35%
V65 ≤ 25%
V70 ≤ 20%
V75 ≤ 15%
Femoral Head (Left) V45 < 25% Not Listed
V40 < 40%
Femoral Head (Right) V45 < 25% Not Listed
V40 < 40%
Penile Bulb Max < 52.5 Gy Mean to 95% of gland < 50Gy
D 90 < 50 Gy
D60-70 < 70 Gy

Figure 4: PTV’s and OAR’s in sagittal plane Figure 5: Contouring Color Chart

Figure 6: PTV’s and OAR’s in axial plane

Figure 7: PTV’s and OAR’s in the coronal plane

Identify any involved lymph nodes in your treatment region. Embed a screen shot of the
nodal regions with corresponding labels.

The lymph node volume drawn included the obturator nodes, the internal iliac nodes to the body
of the sacrum, the medial external iliac nodes, and the common iliac nodes to the sacral
promontory below the L5-S1 interspace.

Figure 8:4 Lymph drainage diagram of the prostate

Figure 9: Axial view of upper nodal CTV

Figure 10: Axial view of nodal CTV

Figure 11: Axial view of nodal CTV

Figure 12: Axial view of lower nodal CTV

Use your IMAIOS Subscription: http://www.imaios.com/en and other anatomy references

to describe the anatomical “boundaries” (physical limits) of the area treated. Embed a
diagram and/or screen shot of your CT data to point out the boundaries.

The physician drew two areas prescribed to receive treatment. The prostate bed was drawn
bordered inferiorly by the GU diaphragm, superiorly to approximately the level of the previous
seminal vesicles and to include a section of the inferoposterior aspect of the bladder, laterally by
the obturator muscles, posteriorly by the anterior rectal wall, and anteriorly by the pubic
symphysis. The PTV_Bed consisted of the prostate bed plus an 8mm anterior and superiorly, a
6mm margin posteriorly and a 0 mm margin inferiorly.

Figure 13: PTV’s in the sagittal plane

Figure 14: PTV’s in the axial plane

The PTV for the nodal volume begins inferiorly at the level of the sacral endpoint. The volume is
drawn on both sides of the bladder and rectum. The two sections move posteriorly to meet and
combine along behind the posterior aspect of the rectum. The volume continues upward to end at
the level of the L5-S1 interface.

Figure 15: PTVn in the axial plane

Describe, in detail, the radiation treatment technique used to treat this anatomical region.

Volumetric modulated arc therapy (VMAT) was chosen as the intended technique for E.B.’s
plan. VMAT is a form of intensity modulated radiation therapy (IMRT), in which the gantry
rotates continuously as dose is delivered. It has the ability to provide highly conformal dose
delivery, and has improved efficiency as compared to IMRT prostate treatments.5 This technique
is often used at my clinical site to treat prostate cancer patients, both to minimize the time that
the patient has to keep a full bladder, and to improve machine efficiency. Below is the planning
process broken into steps, as observed on the day of planning.

Planning observations:

1. We combined the drawn PTVn and PTV_Bed to create a PTV sum for our “large” plan.
 Large is my clinic site’s way of saying the initial plan, or the plan in which all PTV’s go
to the same dose. After we completed our large plan, we created a boost plan that
delivered dose only to the PTV Bed_LN.
2. We inserted the plan using 10MV energy on our Edge machine, and set isocenter to the
superior aspect of the PTV_Bed in order to allow coverage of both the PTV_Bed and PTVn.
 If possible, my site likes to use the Edge to treat prostates because it is the only machine
that we have that has 10MV energy, which is the site preference for prostate planning.
3. We created a CW arc field starting at 210 and ending at 150. Collimator was assigned at
350.
 We allowed 30 on either side of 180 to try and increase rectal sparing.
 When doing VMAT planning, the arcs should have at least 10 of opposed collimator
rotation to reduce integral dose provided by MLC leakage.
 For the CW beam we tried both 350 and 10 and assessed that 350 suited the PTV
better.
4. We set the MLC to fit to our PTV Bed_LN with a margin of 0.3mm, and allowed for the
optimization of the collimator jaws. We then deleted the MLC.
 This process was done in order to set a field size that would encompass the entire PTV
as the arc completed its desired rotation.
5. We created a CCW arc field starting at 150 and ending at 210. Collimator was set on 100.
 We again allowed 30 on either side of 180, for the reasons listed above.
 We reversed the collimator on this field in order to have one arc in which the MLC
leaves traveled in the sup/inf direction, and one arc in which they traveled left/right.
 After bringing the collimator to 90, we then added 10 degrees in order to have rotation
that opposes our CW field.
Figure 16: Example of MLC direction Figure 17: Example of MLC direction
for the 350 arc direction for the 100 arc

6. We looked at our X and Y values. Our length limit for the Edge is 11, and we met that
criterion. Our width limit in order to allow proper MLC coverage is 15, and we did not meet that
criterion. Consequently, we decided to do a technique called mirroring.
 Mirroring is a technique that can only be used on machines with jaw tracking.
 On our CW field we kept the X1 value that we had gotten from fitting our MLC’s, and
adjusted our X2 value so that the total X value was 15.
o The original X value before mirroring was 18.5.
 On our CCW field we kept the Y2 value the same, and adjusted our Y1 value so that the
total Y value was 15.
7. We set our prescription to 200 cGy in 23 fraction (total of 4600 cGy) to our target of PTV
Bed_LN, with no plan normalization.
8. We accessed VMAT optimization.
 We chose to use normal tissue objectives and to use the automatic sparing of normal
tissue.
9. We set our original constraints.
Structure Upper Constraint Priority Lower Constraint Priority
Volume Dose Volume Dose
PTV_Bed 0% 4738 cGy 120 100% 4638 cGy 150
PTVn 0% 4738 cGy 120 100% 4638 cGy 150
Bladder 40% 4259 cGy 180
50% 3557 cGy 180
Rectum 60% 3557 cGy 180
45% 4259 cGy 180
20% 2855 cGy 180
10. After the plan optimized we set our plan focus to PTV Bed_LN, and normalized so that 95%
of the volume would be receiving 100% of the dose.
11. We evaluated the plan.
 We decided to put in avoidance structures to help further conform the dose.
o We put an avoidance in between the two PTV’s.
o We put an avoidance in the middle region of the nodal PTV to further conform
the 100.
o We put an avoidance on the superior portion of the bladder to try and reduce dose
to the bladder.

Figure 18: Original Plan Figures 19 & 20: Avoidance structures

12. We re-optimized the plan.

 Goals
o Make the 70% isodose lines conform around the individual PTV’s
o Pull the 60% isodose in on the bladder
o Pull the 50% in on the rectum
 Constraints
o New or edited constraints are highlighted
Structure Upper Constraint Priority Lower Constraint Priority
Volume Dose Volume Dose
PTV_Bed 0% 4738 cGy 120 100% 4638 cGy 150
PTVn 0% 4738 cGy 120 100% 4638 cGy 150
Bladder 40% 4259 cGy 180
 50% 3557 cGy 180
80% 2760 cGy 180
90% 2300 cGy 180
Rectum 80% 2300 cGy 180
60% 3557 cGy 180
45% 4259 cGy 180
20% 2855 cGy 180
Avoidance 0% 4600 cGy 180
(Nodal)
Avoidance 0% 3220 cGy 180
(Between
PTV’s)
Avoidance 80% 2000 180
(Bladder)
50% 2500 180
30% 3000 180

Figures 21, 22, & 23: Screenshots

from our final “large” plan in axial,
sagittal and coronal planes
13. We evaluated the plan and DVH and decided to move to planning the boost.

Planning Observations Boost:

1. Before planning we added a post rectum structure to help carve dose out of the rectum.
2. We copied our previous plan
 Deleted the dose calculation
 Deleted our calculated MLC’s
3. We adjusted our isocenter to the center of the PTV_Bed and re-fit our field size using the
method described in step 4 of the previous
4. We changed our prescription to 200 cGy in 34 fractions (total 2200 cGy) to our target
PTV_Bed, with no normalization
 We chose to do a full 34 fractions for this second plan so that we could use the published
constraints in our optimization.
o *(We changed the prescription to the correct fraction count of 11 before summing
the plans.)
5. We accessed VMAT optimization
6. We input constraints.

Structure Upper Constraint Priority Lower Constraint Priority

Volume Dose Volume Dose
PTV_Bed 0% 7004 cGy 120 100% 6904 cGy 150
Rectum 50% 4000 cGy 180
35% 5000 cGy 180
25% 6000 cGy 180
Post Rectum 0% 5200 cGy 180

7. After optimization we normalized so that 100% covered 95% of the target volume, and
evaluated the plan.

Figures 24, 25, & 26: Screenshots from our boost plan in axial, coronal and sagittal planes
8. After evaluation, we changed our boost fraction count to 11, summed our large and boost
plans, and then evaluated the summative plan and DVH.

Figures 27, 28, & 29: Screenshots from our

summative plan in axial, coronal and sagittal planes

Include a final DVH of your treatment plan with appropriate labels and discuss your
ability to meet the target and OAR tolerance guidelines.

We were able to meet all target and OAR tolerance objectives. The large and boost plans were
both normalized so that 100% of the dose covered 95% of the target volumes.
Bladder:
Plan Value Objective
V65 = 25% V65 ≤ 50%
V70 = 2.3% V70 ≤ 35%

Rectum:
Plan Value Objective

V65 = 15.9% V65 ≤ 35%

V40 = 54% V40 ≤ 55%

Femoral Head (Left):
Plan Value Objective

V45 = 0.3% V45 < 25%

V40 = 3.6% V40 < 40%

Femoral Head (Right):

Plan Value Objective

V45 = 1.9% V45 < 25%

V40 = 7.3% V40 < 40%

Penile Bulb:
Plan Value Objective

Max = 51.5 Gy Max < 52.5 Gy

Figure 30: DVH of the final Plan Sum

References
1. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 4th ed. St. Louis,
Missouri: Elsevier; 2016:83.
2. Bentzen SM, Constine LC, Deasy JO, et al. Quantitative analyses of normal tissue effects in
the clinic (QUANTEC): An introduction to the scientific issues. Int J Radiat Oncol Biol Phys.
2010;76(3):S3-S9. doi:10.1016/j.ijrobp.2009.09.040
3. Pollack A, Balogh A, Low D, et al. A phase III trial of short term androgen deprivation with
pelvic lymph node or prostate bed only radiotherapy (spport) in prostate cancer patients with a
rising psa after radical prostatectomy. Radiation Therapy Oncology Group (RTOG).
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0534. Published
2015. Accessed February 15, 2018.
4. Vann AM, Dasher BG, Wiggers NH, Chestnut, SK. Portal Design in Radiation Therapy. 3rd
ed. Augusta, GA: Pheonix Printing; 2013.
5. Teoh M, Clark CH, Wood K, Whitaker S, Nisbet A. Volumetric modulated arc therapy: A
review of current literature and clinical use in practice. Br J Radiol. 2011;84(1007):967-996.
http://dx.doi.org/10.1259/bjr/22373346