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Krzysztof Karteczka April Case Study April 21, 2012

Four Field Pelvis Present Illness: The patient is an 84 year old man who initially presented with an elevated screening of prostate-specific antigen (PSA) of 15.49. The patient underwent prostate biopsy that revealed adenocarcinoma, with a maximum Gleason grade of 4+5=9. It involved 6 out of 6 cores in the right lobe, and 3of 6 cores in the left lobe. There was Perineural Invasion (PNI) present. Computed Tomography (CT) of abdomen and pelvis showed a mildly enlarged prostate with hyperdensity of the right lobe of the prostate. There was no lymphadenopathy (LAN). There was mild chronic hydronephrosis and renal and liver cysts. Another PSA was 12.17. Bone scan showed degenerative changes in the cervical, thoracic, and lumbar spine with more marked uptake in the thoracic region (T7-T8). The patient received androgen deprivation therapy with lupron and casodex. Magnetic Resonance Imaging (MRI) of T-spine showed mild compression deformity of T7 without evidence of enhancement or metastatic disease. Another PSA was less than 10.0. Currently, the patient reports nocturia (urination at night) 4 to 5 times a night. He uses vesicare and flomax twice a day (bid) and notes a weak urine stream. He denies any urgency or incontinence but notes dribbling after urination. He denies any hematuria, diarrhea or bright red blood per rectum (BRBPR), however, he notes erectile dysfunction (ED) and tried Viagra in the past. He reported a few pounds of weight loss. Past Medical History: The patient has a medical history of diabetes mellitus (DM), hypertension (HTN), hypercholesterolemia, hemorrhoids, and benign prostatic hyperplasia (BPH). Past Surgical History: The patient has a surgical history status post (s/p) transurethral prostatectomy (TURP) in 2002, and hemorrhoid surgery. Allergies: The patient has no known allergies. Medications: The patient uses following medications: Flomax (bid), vesicare, glyburidemetformin, nifedipine, atenolol, and Lipitor.

Diagnostic Imaging Studies: The patients workup included prostate biopsy that revealed adenocarcinoma, CT of abdomen and pelvis showed a mildly enlarged prostate with hyperdensity of the right lobe of the prostate, bone scan, and MRI of T-spine. Family History: There is no family history of cancer. Social History: The patient denies any use of tobacco and alcohol, and denies drug abuse. He is married and has 3 children. He still works part-time as accountant. Review of Systems: The patient denies any significant symptoms referable to the respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, endocrine, hematological, head, ears, eyes, nose and throat (HEENT), skin, or neuropsychiatric systems. Assessment/Recommendations: The patient is an 84 year old man with a high risk T2cN0M0 stage IIB adenocarcinoma of the prostate with Gleason grade 4+5=9 disease, involvement of the bilateral lobes, PNI, and a PSA of 12.17. The patient has no evidence of metastatic disease. Currently, he is receiving androgen deprivation therapy and has an undetectable PSA. The doctor recommended treatment with radiation therapy. The rationale, risks, and benefits of therapy were discussed in detail with the patient and his wife. They discussed treatment of pelvic lymph nodes given the patient's high risk disease, as well as the potential acute and long-term side effects. They also discussed increased urinary side effects given the patient's baseline with BPH and urinary symptoms. The Plan (Prescription): The doctor reviewed the findings to date with the patient and his wife. He also reviewed the treatment options, risks, potential benefits and possible acute and chronic side-effects of radiation therapy. The plan is to deliver a dose of approximately 4500 centigray (cGy) conventionally to fields encompassing the pelvis in 25 fractions. He is to continue to receive androgen deprivation therapy for at least one year per medical oncology. Patient Setup/Immobilization: The patient was simulated in the supine position with both arms on the chest holding a blue ring and a Vac-Lok back to support his legs. A CT image of the pelvis was taken from the top of lumbar vertebrae four (L4) to the bottom of the ischial tuberosities. The slices from the CT scan were acquired at 3 millimeter (mm) intervals. The patient elected to not undergo fiducial marker placement in the prostate. The axial CT images were transferred to the Varian Eclipse treatment planning system.

Anatomical Contouring: The scan was imported from the CT scanner to the treatment planning computer. The external contour, prostate, seminal vesicles, bowel, bladder, rectum, right and left femoral heads, and planning tumor volume (PTV) were contoured. Beam Isocenter/Arrangement: The doctor assigned the isocenter during the CT simulation. It was placed in the superior portion of the PTV. This isocenter was used for treatment planning. I began by setting treatment fields. The caudal border included inferior aspect of the ischial tuberocities, cephalad margin was placed at L4-L5 interspace, and the lateral borders included bony pelvis with 1.5 centimeter (cm) margin. The anterior margins included the pubis symphysis and the posterior margins transected the rectum. According to the prescription, the physician wanted a four field arrangements: anteroposterior (AP), posteroanterior (PA), left lateral and right lateral, photon beam energy 10 megavolts (MV) used on Varian Clinax iX. I started on the anterior side of the patient with the AP beam placed at 0 degrees and continued around the patient with the remaining three beams, each 90 degrees apart to create four field box arrangements. Treatment Planning: The treatment planning system used was Eclipse 8.9. The objective of the treatment was to conform the dose distribution to the GTV, while minimizing the dose to surrounding tissues. I placed the calculation point superior from isocenter in the PTVs. To obtain proper dose distribution I created a Multi-Leaf Collimation and changed field weight factors, applying 0.26 to AP field, and 0.24 to PA field, and equally 0.25 to both lateral fields. The AP and PA beams were weighted more than the laterals to reduce the dose to femoral heads. The dose distribution in the PTVs was 102% and a hot spot 103.9%. Dose was calculated using the analytic anisotropic algorithm (AAA) of the treatment planning system. See Figures 1 and 2 below for graphic illustrations.

Figure 1: Axial, Sagittal, and Coronal slices of Isocenter location

Figure2: Dose Valume Histogram

Monitor Unit (MU) Check: After the plan was approved by the physician, the physicist performed a monitor unit check before the first day of treatment. A program called RadCalc was used to take the treatment parameter data from the treatment plan in Eclipse. For AP field monitor unit output value was 57, a 0 % difference from plan MU, MU for PA was 49 (1.9% difference), LT LAT 64 MU (0% difference) and RT LAT 64 MU (0 % difference). At NorthShore University Health Systems, percentages over +/- 5% are unacceptable for treatments. See Figure 3 for Photon Monitor Unit Calculation Sheet.

Figure 3: Photon Monitor Unit Calculation Sheet.

Quality Assurance Check: To verify that the dose produced on the accelerator was the same as what was planned in the Eclipse treatment planning system, diodes were used within the first three fractions. The mobile Mosfet Dose Verification System was used, with 1.5 cm bolus placed on the top of the dosimeter. The reading dose was within the acceptable limits. Conclusions: I chose this case study because it was a very interesting one and because it was the first pelvic treatment plan I completed on my own. Having studied this case, I have a better

understanding of the application of dose distribution, and complexity of treatment planning. I learned a lot from this patients plan and feel I am capable of creating treatment plans of similar cases in the future. Our department has a lot of patients with similar prostate cases and I look forward to applying the skills I learned from this case.