Lauren Brandl

Clinical Oncology Assignment

The patient I chose is a 66-year-old man with a recently discovered stage II T3N0M0

rectal adenocarcinoma. He is receiving curative radiation treatments to the rectum as well

as some surrounding nodes and is concurrently taking the chemotherapy drug, Xeloda. He

will later be undergoing surgery to remove the remaining disease upon completion of

radiation treatment.

The patient was positioned supine for his computed tomography (CT) simulation,

and was also scanned with a full bladder in order to increase reproducibility on a daily

basis and to push the bowel away from the volume to be treated. Underneath the patient

was a pad running the length of his body, which was used under the discretion of his

physician, Dr. Simpson. Upon speaking with Dr. Simpson he explained the use of the pad

was for comfort, and that the slight potential issue of setup reproducibility caused by its

use was preferable to the chance of the patient moving during treatment to alleviate pain.1

Also used during simulation was a small triangle under the knees and a rubber band

around the feet as a bind, both working to keep the legs in the same position daily. Finally,

the patient was instructed to keep his arms on his chest and to hold a small ring with both

hands, to ensure they were not included in the scan and would eventually be outside of the

treatment fields.

I also spoke to Dr. Simpson about the dose and fractionation regimen prescribed for

the patient’s radiation treatments. The prescription was for 4500 centigray (cGy) in 25

fractions to the planning target volume (PTV), followed by a 3 fraction, 540 cGy boost to a
new, more specific PTV. Each fraction would deliver 180 cGy. He explained that this dose

and fractionation were common amongst rectal treatments and there has been little

deviation since the release of the paper entitled “Preoperative versus Postoperative

Chemoradiotherapy for Rectal Cancer” published in 2004 in The New England Journal of

Medicine outlining the success and reduced toxicity to those undergoing preoperative

radiation in combination with chemotherapy.2

Upon creating the treatment, there were multiple surrounding structures that were

to be avoided in the distribution of dose. The list of organs at risk of receiving unwanted

dose included the bowel space, sigmoid colon, bladder, femoral heads, and external

genitalia. As the complete sparing of the organs at risk was impossible, tolerance doses

were referenced based on physician prescription and QUANTEC values, also following the

Radiation Therapy Oncology Group (RTOG) Protocol 0822.3,4

The contoured organs may be seen below with the first photo being the rectal plan

and the second being the boost. The photos are taken at isocenter, which was placed at the

volumetric center of each PTV.

 A table of QUANTEC organ tolerance doses for surrounding structures may be seen

below with the inclusion of the RTOG 0822 Protocol dose constraints.3,4

Organ at Risk Tolerance Dose

Small Bowel V35 < 230cc
V40 < 130cc
V45 < 90cc
 Bladder V40 < 55%
V45 < 30%
Dmax < 50 Gy
Right Femoral Head V40 < 65%
V45 < 40%
Dmax < 50 Gy
Left Femoral Head V40 < 65%
V45 < 40%
Dmax < 50 Gy
External Genitalia (Testis) V3 < 50%
*Note: Sigmoid not listed in either source

Though the patient had no involved lymph nodes at the time of diagnosis, it is

custom for the treated volume to include the internal and common iliac nodes as well as

the presacral nodes in the PTV, per the RTOG Protocol 0822.1,4

A photo with the treated nodes may be seen below, with the labels shown and best

displayed in the coronal view.

 Following the RTOG Protocol 0822, in order to find our PTV and boundaries of the

area treated, the gross tumor volume (GTV) including all gross disease found during

diagnostic imaging and exams must be defined. A clinical target volume (CTV) is then

outlined, including the GTV plus any areas at significant risk of microscopic disease. The

Protocol states, “The CTV for a T3 tumor should include all gross disease (rectal and nodal)

as well as the internal iliac lymph nodes and the mesorectum (perirectal fat and the

presacral space).”4 The PTV will then consist of a 5mm expansion of the CTV.4 Upon

looking at the PTV outlined on the patient’s scan, I would describe the borders of the

volume beginning inferiorly at the start of and encompassing the rectum. It then

widens as it runs superiorly, containing the rectum and mesorectum and extending

posteriorly to split the anterior edge of the sacrum. The PTV curves posteriorly

along the sacrum until it ends superiorly at approximately the vertebral space

beneath L5. Laterally, the volume rests within the ala of the sacrum and the body of

the ishium, slightly overlapping into the bony anatomy. At its most anterior point,

the vertebral space beneath L5, it extends over halfway across the body sagittally,

nearly 17 cm perpendicular from the posterior skin surface. The volume then tapers

posteriorly as it moves inferior and rests behind the bladder with a very small

margin of overlap of the structures at the level of the hip joint. Photos are displayed

below showing the outline of the PTV on the CT image.

 This patient was treated with two 3D conformal external beam plans. Each plan

consisted of three fields of 15 MV energy coming from the posterior to anterior (PA) with a

gantry rotation of 180 degrees, left lateral direction (LLAT) at 90 degrees, and right lateral

direction (RLAT) at 270 degrees. In the initial plan, the PA beam was weighted at 0.525 or
52.5%, while the LLAT and RLAT beams were weighted .239 or 23.9% and .236 or 23.6%,

respectively. This weighting was chosen because the majority of the PTV (PTV_45) fell

posteriorly, and was laterally in the center of the body. There was a slight variation in

lateral beam weightings due to some uneven anatomy, upon which weighting them

unequally provided a favorable dose distribution. On the LLAT and RLAT beams were two

45 degree enhanced dynamic wedges (EDW), both with their heels facing posterior and

toes anterior on the axial view. Because the wedges are on the Y jaws in Varian systems, the

collimator was required to be rotated 90 degrees for both beams, with an In wedge used on

the LLAT and an Out wedge used on the RLAT. The EDW’s worked to push dose towards

the toe and deeper into the anatomy to gain further coverage of the PTV. As stated earlier,

the isocenter was placed at the volumetric center of the PTV, and the PTV was deemed the

Target Volume in Eclipse, the treatment planning system (TPS). The plan was then

normalized so that 100% of the prescribed dose would cover 95% of this target volume.

This provided an acceptable dose distribution, coverage, and maximum dose, being

107.6%. Four setup fields at 0, 90, 180, 270 degrees were also used as well as a cone beam

CT (CBCT) for daily imaging to align the patient before treatment. Each setup field would

utilize the patient’s digitally reconstructed radiograph for anatomical matching. The plan

was then checked by a dosimetrist at my clinic and later approved by Dr. Simpson. A view

of the fields may be seen below. The view is at isocenter.

 The boost plan was then created to target the smaller and more specific PTV_50.4. It

was very similar to the original plan with a PA field and two lateral fields (LLAT and RLAT).

The isocenter of the boost plan was again placed at the volumetric center of the PTV, and

PTV_50.4 was then made the Target Volume in Eclipse. The PA field was again placed at a

gantry angle of 180 degrees, and the LLAT and RLAT were at 90 and 270 degrees once

more. The weighting was then adjusted for optimal dose distribution, with the PA beam

again heavily weighted at .490 or 49%, the LLAT beam at .256 or 25.6%, and the RLAT

being .254 or 25.4%. Similarly, the PTV fell posterior, resulting in a heavier AP weight, and

the target was in the center of the patient laterally, causing similar LLAT and RLAT

weighting. Also contributing to the heavier AP weight were two 45-degree EDW’s placed on

the LLAT and RLAT beams. The LLAT utilized an In wedge while the RLAT utilized an Out,

both with the heels facing posterior and toes pointing anterior in the axial view and a

collimator angle of 90 degrees for both. On the PA beam was a 10-degree out wedge, which
worked to drive dose further inferiorly. The heel of the wedge faced superiorly in the

sagittal view while the toe pointed inferiorly. The plan was then normalized to the 98.5%

isodose line to gain the desired coverage of the PTV, however, this normalization also

resulted in a maximum dose of 107.6%. The boost plan utilized the same four setup fields

and CBCT for daily imaging to align the patient. After being checked by a dosimetrist, the

plan was sent for review and later approved by Dr. Simpson. A view of the boost plan and

fields may be seen below. The view is at isocenter.

Upon evaluating the location of the prescribed volumes and later, the final dose

volume histogram of the plans, it was clear some of the organs at risk were inevitably going

to receive a greater dose than desired, but we did meet all of our constraints outside of the

maximum point dose of the bladder. Given the PTV was directly posterior to the bladder

and there even being some overlap of the margin into the volume of the bladder, it was
difficult to spare without sacrificing coverage. Dr. Simpson reviewed the situation and gave

his approval.

Organ at Risk Tolerance Dose Achieved Dose

Small Bowel V35 < 230cc V35 = 70.2 cc
V40 < 130cc V40 = 51.6 cc
V45 < 90cc V45 = 23.8 cc
Bladder V40 < 55% V40 = 15.8%
V45 < 30% V45 = 12.9%
Dmax < 50 Gy Dmax = 52.9 Gy
Right Femoral Head V40 < 65% V40 = 0%
V45 < 40% V45 = 0%
Dmax < 50 Gy Dmax = 35.77 Gy
Left Femoral Head V40 < 65% V40 = 0%
V45 < 40% V45 = 0%
Dmax < 50 Gy Dmax = 35.12 Gy
External Genitalia (Testis) V3 < 50% V3 = 0%

Photos of both the plan and boost DVH’s may be seen below.

Boost
Below is a view of the plan sum DVH with a key following.
 I chose this plan partially due to its qualification of assignment criteria, but also

because it was one of my first plans to be approved for treatment. I though it would be

interesting to analyze my work and see how far I’ve come in just the few short months I

have been in the clinical environment.

References

1. Simpson D. Physician Dose Rationale. February 2019.

2. Sauer R, Becker H, Hohenberger W, et al. Preoperative versus Postoperative

Chemoradiotherapy for Rectal Cancer. The New England Journal of Medicine.
2004;351(17):1731-1740.

3. Passmore, G. Normal Tissue Constraints. [PDF Copy]. La Crosse, WI: UW-L Medical
Dosimetry Program; 2019.

4. Garofalo MC, Berger AC, Hong T, Lerma F, Bendell J, Krishnan S. A Phase II

Evaluation of Preoperative Chemoradiotherapy Utilizing Intensity Modulated
Radiation Therapy (IMRT) in Combination with Capecitabine and Oxaliplatin for
Patients with Locally Advanced Rectal Cancer. Radiation Therapy Oncology Group
(RTOG) 0822. April 2008:6-7.
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0822.
Accessed February 27, 2019.