Katelyn Fernando 1

Clinical Oncology Assignment

Introduction

The patient used in this analysis was diagnosed with adenocarcinoma of the rectum, stage
T3N2M0. Colorectal cancer is the third most common cancer in men and women and is the
second leading cause of cancer death in the United States. 1 Thanks to early detection methods,
such as colonoscopies, death rates have been declining. 1 There are many different potential
causes for colorectal cancer including hereditary factors and a high fat, low fiber diet. 1
Colorectal cancer is staged using the American Joint Committee Staging system (TNM). This
patient can be categorized into Stage III based on their TNM score. They have a primary tumor
(T) score of 3 indicating that the tumor has invaded through the muscularis propria, regional
lymph node (N) score of 2 indicating that there has been involvement of 4 or more regional
lymph nodes, and a distant metastasis (M) score of 0 indicating that no distant metastasis was
found.1

Colorectal cancer is commonly treated with surgery, radiation therapy, and chemotherapy
depending on the stage of the tumor. 1 This patient received radiation therapy with concurrent
chemotherapy prior to surgery due to the size of the tumor and the lymph node status. The
chemotherapy used was Capecitabine, which is an oral agent commonly used to treat colorectal
cancer.2 By treating the patient with radiation and chemotherapy prior to surgery, the extent of
the surgery can be reduced, allowing sphincter preservation. 1

Methods

To begin the process of radiation therapy, the patient received a CT scan in the treatment
position which was then used for treatment planning. This patient was positioned prone on the
belly board with hands holding pegs above the patient’s head and an ankle sponge under their
legs (Figure 1). This positioning is used for a couple of reasons. First, it allows a posterior beam
to treat the rectum without interference from the treatment table. The rectum mostly lies
posterior in the patient, so this is an ideal beam arrangement. Second, the prone position with
the belly board allows the small bowel to pull away from the treatment field by permitting the
abdomen to fall forward into the hole in the belly board. Sparing small bowel dose is very
important when treating this area, due to the radiosensitivity of the small bowel. To reduce side
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Clinical Oncology Assignment

effects involving the small bowel, this area should be avoided as much as possible. Another was
to avoid small bowel dose, while also ensuring the internal anatomy of the patient is consistent,
is by giving the patient instructions to have a full bladder and empty rectum. The full bladder is
a useful tool in order to internally push the small bowel away from the treatment field. 1

The target dose prescribed by the physician was 4500 cGy in 25 fractions (180 cGy daily) with a
sequential boost of 540 cGy in 3 fractions (180 cGy daily) for a total dose of 5040 cGy. This is a
common dose regiment prescribed to colorectal cancer. 1 Exceeding doses of 5000 cGy is not
advised unless the small bowel can be avoided.1 This dose constraint causes the plan to
commonly be broken up into two parts, nodal volume and tumor bed volume. The nodal
volume is usually closer to the small bowel, restricting the dose. It is also more important to
prescribe a higher dose to the tumor bed volume, leading to a sequential boost to this area. It is
essential to ensure that the prescription is high enough to successfully treat the malignant cells
while sparing function of any nearby organs.

Different organs at risk (OAR) were contoured for this patient (Figure 2) to monitor dose to
each of those structures. For a rectum treatment, the OAR contoured are bladder, small bowel,
large bowel, femoral heads, and genitals. 3 Tolerance dose to these structures depends on the
potential short term and long-term side effects after a dose of radiation is received. For
example, the small bowel is a radiosensitive organ where 195 cc of the volume shouldn’t
exceed 4500 cGy 4 to avoid side effects such as radiation enteritis which causes diarrhea and
vomiting from inflammation of the intestines. The tolerance dose of OAR determines the
prescription dose of the patient’s treatment. It is important to protect OAR to ensure quality of
life after radiation. An OAR tolerance table can be found in Table 1.

The physician also contoured the clinical treatment volume (CTV) and the planning treatment
volume (PTV) for the primary prescription and the boost (Figure 2). This volume was based on
traditional field borders for radiotherapy to the rectum (Figure 3). The traditional superior
border is to the bottom of L5, inferior border is at least 5 cm below the tumor, lateral border is
1-2 cm beyond the pelvic inlet, posterior border is posterior to the sacrum, and anterior border
is anterior to or mid-acetabulum.3 These borders are set to treat the rectum and corresponding
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Clinical Oncology Assignment

lymph nodes. The lymph nodes that are involved in rectal carcinoma are the rectal, inferior
mesenteric, internal iliac, presacral, and inguinal nodes (Figure 4). 3 The lymph nodes that are
treated depends on the location of the tumor in the rectum.

Discussion

A conventional 3D conformal approach was taken for this case. A three-field arrangement was
made with a PA field and two lateral fields for both the primary and boost plan (Figure 5,6) to
give a homogenous dose distribution while sparing anterior structures. 1 The energy for both
prescriptions was 15MV due to the large separation of the patient’s pelvis. Higher energies
penetrate more deeply in the patient and can be useful as long as the patient doesn’t have
metallic devices which could produce neutron contamination. The weighting of the fields was
roughly 50% from the PA and 25% from the two lateral fields. Due to the three-field
arrangement, wedges were used on the lateral beams to push dose anteriorly. For the dynamic
conformal wedge to push anteriorly, the collimators were turned to 85/80 for the left lateral
fields and 275/280 for the right lateral fields. These fields are slightly off of 90 and 270 in order
to block as much OAR as possible with the jaws. A small wedge was also used on the posterior
field of the boost plan to push dose inferiorly. For this patient, the physician was very
concerned about the small bowel dose. To ensure small bowel sparing, a lightly weighted
reduced field was used on the left lateral field.

Image guidance radiation therapy was used to ensure the patient was treated in the same
position every day. Orthogonal pairs (MV/kV) were taken daily, while a cone beam was taken
weekly. The benefit of the weekly cone beam is that soft tissue is distinguished, allowing the
radiation therapists to ensure the patient is still following bladder and rectum preparation
instructions.

The Dose Volume Histogram (DVH) of this treatment (Figure 7) shows the dose given to the
treatment volumes as well as the OAR. This can be used to determine if this treatment met
dose constraint goals. All of the OAR constraints established by my clinical site, as well as any
QUANTEC values, were met with margin (Table 1).

Conclusion
Katelyn Fernando 4
Clinical Oncology Assignment

Colorectal cancer is a common cancer diagnosis in the United States which is regularly treated
with a combination of treatment modalities. Radiation therapy with chemotherapy and surgery
offers better tumor control in patients with larger tumors and/or positive lymph node
involvement than surgery alone.1 A three-field technique is commonly used to treat the patient
in the prone position. This technique, along with a full bladder, spares the radiosensitive small
bowel. Ensuring all OAR constraints are met will allow the patient to experience reduced side
effects from radiation treatment to protect the patient’s quality of life after treatment.
Katelyn Fernando 5
Clinical Oncology Assignment

Tables and Figures

Figure 1. Patient Positioning

The patient was positioned prone, on a belly board, with hands holding pegs above head. An
ankle sponge was used to support the legs.

Figure 2. Contoured Treatment Volumes and OAR

The Treatment volumes for the two prescribed doses are shown in orange (45 Gy) and red (50.4
Gy). The various OAR are represented by different colors as shown in the color key.
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Clinical Oncology Assignment

Table 1. OAR Tolerance Table

Organ at Desired Planning Objective Planning Objective Outcome

Risk (OAR)
Small  V30 <200 cc  57 cc 
Bowel  V35 <150 cc  45 cc 
 V45 <100 cc , QUANTEC V45 <195 cc4  31 cc 
 No point doses above 54 Gy  0 cc 
Femurs  No more than 50% is to exceed 30 Gy  R 20 % , L 22% 
 No more than 40% is to exceed 40 Gy  R 0.8% , L 0.3% 
 None to exceed 50 Gy  R 0 cc , L 0 cc 
Bladder  Mean dose < 40 Gy  35 Gy 
 QUANTEC V65 <50%4  0%
Genitals  Mean dose < 40 Gy  5 Gy 
Planning objective given for rectal cancer per Ohio State University rectum dose constraints. 5

Figure 3. Treatment Borders for Rectal Radiation

The orange contour represents the dose 45 Gy plan which includes nodal volumes. The red
contour represents the dose 50.4 Gy plan which is used as a boost. These contours reflect
traditional treatment borders for rectal radiation.
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Clinical Oncology Assignment

Figure 4. Lymph Nodes Involved in Rectal Carcinoma

The lymphatics treated in this case study are shown above. Inguinal and inferior mesenteric
nodes were excluded from the treatment field due to the location of the tumor.

Figure 5. Nodal Treatment Plan

The nodal volume (4500 Gy) was treated with a three-field arrangement, 15 MV, lateral
wedges, and a reduced field to spare OAR. The fields were roughly weighted 50% to the
posterior field and 25% to the lateral fields.
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Clinical Oncology Assignment

Figure 6. Sequential Boost Treatment Plan

The tumor bed volume (5040 Gy) was treated with a three-field arrangement, 15 MV, lateral
wedges, a posterior wedge, and a reduced field to spare OAR. The fields were roughly weighted
50% to the posterior field and 25% to the lateral fields.
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Clinical Oncology Assignment

Figure 7. Dose Volume Histogram

The dose to the OAR and treatment planning volumes for the total plan summary are shown. When compared to the dose
constraints (Table 1), each OAR dose is within tolerance.
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Clinical Oncology Assignment

References

1. Washington CM, Leaver DT. Principles and Practice of Radiation Therapy. 4th ed. St.
Louis, MO: Elsevier Inc.; 2016.
2. Bedi M, Das P, Skibber JM, et al. Capecitabine and timing of radiotherapy during
preoperative chemoradiation for rectal cancer. Gastrointest Cancer Res. 2007;1(2):44-
48.

3. Vann, A.M. GI Cancers. [Softchalk]. La Crosse, WI: UW-L Medical Dosimetry

Program;2021
4. Bentzen SM, Constine LS, 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 Suppl):S3–S9
5. Arthur G. James Cancer Hospital Ohio State University. Planning Objectives Rectum.
2017