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Anal Carcinoma Case Study

Simran Rai
Dos 531
April 13, 2022
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Introduction
The patient is an 80-year-old female presenting with squamous cell carcinoma of the

anus. This evolved from a high-grade intraepithelial neoplasia first found in 2018. The patient’s

latest exam revealed a one-centimeter anal ulcer. A 1.2-centimeter excision was made and

returned negative margins. The patient was later present for consult to discuss the role radiation

therapy in the management of possible remaining disease. PET scan showed no suspicious lymph

nodes of the tumor. Despite the negative margins and lack of suspicious lymph node activity the

the patient was deemed to still be at risk for further spread due to the intraepithelial neoplasia.

Additionally, the patient was in overall good health and was deemed able to tolerate treatment to

the lymph node region as well. The decision was made to continue with radiation treatment. The

patient was simulated to ensure optimal reproducibility. CT scans were acquired of the pelvis

headfirst in the supine position with the legs slightly abducted. A small radiopaque marker was

placed in the perianal verge to further help delineate the canal. The simulation included the

positioning aids of an indexed vac lock bag to immobilize the legs along with a wedged pillow,

and black cushion pad to maintain some level of comfort to facilitate immobilization. For

positioning the patient’s hands were placed on their chest to avoid the photon beam during

treatment. This position was deemed optimal for treating inguinal lymph nodes in conjunction

with the anal canal.

Target Dose and Delineation

The physician prescribed a 28-fraction treatment course in which 5040 centigray (cGy)

would be delivered to the anal canal in 180 cGy fractions. This included a simultaneous

integrated boost (SIB) that would deliver a total of 4200 cGy to lymph node volumes in the

inguinal and pelvic regions. The lymph node targets would in turn receive 150 cGy each fraction
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for a total of 28 treatments. PET CT fusion was utilized to help define the target volumes. A 2.5-

centimeter expansion was utilized in order to yield the high dose planning target volume

receiving 5040 cGy. Furthermore, a 0.8 centimeter expansion was used for the inguinal and

pelvic lymph node to produce the lower dose planning target volume that would receive 4200

cGy. The pelvic lymph nodes included the mesorectal, presacral, internal and external iliac

nodes. The inguinal nodes were included as well. When establishing the dose to the primary

target and nodes along with the expansion the national comprehensive cancer network (NCCN)

guidelines were used.1 5040 cGy is the recommended dose for T1-2 N0 disease (Table 1.) The

expansions for anal canal as highlighted in the NCCN guidelines was 2.5 centimeters and 1

centimeter for the nodal volumes. The only deviation from the guidelines was that a 0.8

centimeter nodal expansion was utilized due to the low risk of spread as stated by the physician.

Table 1. NCCN Guidelines by TNM stage for Anal Carcinoma

Organs at Risk

Given the generous expansion stated by the NCCN guidelines and multiple nodal chains

in the treatment field, the overall target volume encompassed a relatively large area. Due to this

fact several organs at risk were present in the vicinity of the target volumes. These included the

bladder, rectum, sigmoid colon, bowel space, right and left femoral heads, and genitalia.
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Figure 1. OARs Near Superior Treatment Volume of Anus

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Figure 2. OARs Near Inguinal Treatment Volume of Anus

Figure 3. OARs Near Inferior Treatment Volume of Anus

Organ TD5/5.2 RTOG 0529.2 (anus) Morbidity outcome

Bladder V65 < 50% V50 < 35 Gy Bladder spasms,

dysuria, incontinence

Rectum V50 < 50% V50 <50% Proctitis, bleeding

diarrhea

Sigmoid Colon Mean< 55Gy V50 < 50% perforation

Bowel Space V45 < 195cc V30 <200cc perforation

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Femoral Heads 52 Gy < Whole V30 < 50% Sclerosis/necrosis

Genitalia Max < 90Gy V30 < 50% Stenosis/necrosis

Table 2. OAR Tolerance Doses and Constraints

Target and Treatment Borders

The targets in this case included the anal canal, and lymph node chains that included the

inguinal, mesorectal, presacral, internal iliac and external iliac nodal chains.3 Throughout the

diagnostic work up process there was found to be no suspicious lymph nodes found in the PET

CT or any other examinations. Despite this, the patient was still prescribed a dose of 4200 cGy to

the nodal areas stated previously. The approximate anatomical borders of the treatment volume

fell 0.5 cm lateral of the pelvic brim, 1 cm anterior to the femoral and external iliac veins, 0.8 cm

posterior of the anterior aspect of the sacrum, inferiorly reaching the end of the anal canal, and

superiorly ending at the top of the S1 vertebral body as seen in figures 4-6.

Figure 4. Approximate Lateral Borders of Treatment Volume

0.5 cm lateral of Pelvic Brim

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1 cm Anterior of External Iliac Vein

0.8 cm Posterior Sacrum

Figure 5. Approximate Anterior and Posterior Borders of Treatment Volume

Top of S1

Inferior end of Anal Canal

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Figure 6. Approximate Superior and Inferior borders of Treatment Volume

Figure 7. Lymph Node PTVs 3D view

Plan Optimization

Six optimization structures were created in order to allow the inverse planning system to

distribute dose in favorable areas. These included structures representing the overlap of the

lymph node PTVs with the bowel space and sigmoid colon. These structures were labeled

PTV4200bowelOL and PTV4200sigmoidOL respectively. The anal canal PTV had an

optimization structure that excluded parts of the expansion that were outside the body.

Furthermore, the lymph node PTV had a structure that excluded its overlap with the anal canal
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PTV with an additional 0.5 cm margin. These structures were labeled PTV5040opti and

PTV4200opti respectively. Next, a 0.5 cm ring was drawn surrounding the peripheral region of

the lymph node PTV labeled LNring. Finally, the same 0.5 cm ring was created on the outside of

the anal canal PTV labeled anal ring. Each of these structures played a role in optimizing the

plan to reduce OAR dose or ensuring adequate coverage of all target volumes.

Each optimization structure had a unique role in the process. The two overlap structures

PTV4200bowelOL and PTV4200sigmoidOL were created so that the inverse planning system

would diminish areas of excessive dose in those areas. The goal was to not allow dose any

greater than the prescribed amount to fall in either of the overlap structures. The PTV5040opti

structure played the role of giving the planning system a volume to distribute the high dose

region too. The original PTV volume prescribed 5040 cGy could not be used for optimization as

a portion of it was outside the body. Similarly, the PTV prescribed 4200 could not be used for

optimization either, the PTV4200opti was used instead so that the planning system would not

view areas of the body where two doses were prescribed. This was because the both PTVs had an

area of overlap where the anal canal met the rectum since the mesorectal nodes were part of the

lymph node volume. Finally, the two ring structures labeled LNring and Anal ring were created

so that the planning system would not distribute areas of lower dose with in the peripheral region

of each PTV.

Treatment Parameters

The patient was treated with volumetric modulated arc therapy (VMAT) planned on rapid

arc with eclipse treatment planning system. This included four arcs two clockwise and two

counterclockwise. The first ranging from 181 to 179 degrees in a clockwise direction with a 15-

degree collimator. The second arc went the opposite direction, 179 to 181 degrees
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counterclockwise with a 345-degree collimator rotation. The third arc again went from 181 to

179 degrees clockwise with a 85 degree collimator rotation. Finally, the last arc traveled from

179 to 181 degrees counterclockwise with a 95-degree collimator rotation. The first pair of arcs

targeted more dose towards the anal canal ptv and inguinal lymph nodes while the second pair of

arcs provided more dose to the superior lymph node volumes near the sacrum. The treatment was

planned in an SIB fashion.

Figure 8. Field Parameters for all Arcs

Figure 9. Arc 1 at 0 Degrees

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Figure 10. Arc 2 at 0 Degrees

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Figure 11. Arc 3 at 0 Degrees

Figure 12. Arc 4 at 0 Degrees

Planning Objectives

The coverage on both PTVs was acceptable with 100 percent of each respective

prescription dose covering at least 95 percent of both volumes. The minimum dose for each

structure was acceptable as well. The minimum dose to the anal PTV was 93.9 percent of its

prescription dose and 92.4 percent for the nodal PTV. The maximum dose in the plan was 106.8

percent of the prescription dose which fell within the anal PTV.
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All OAR constraints were met comfortably. This included the bladder with the volume

receiving 65 Gy at 0 percent and volume receiving 35 Gy at 35.1 percent. The rectum and

sigmoid colon had a volume receiving 50 Gy of 37 and 0 percent respectively. The mean dose in

the sigmoid colon was 3276 cGy. The volume receiving 45 and 30 Gy in the bowel space was 0

cc and 75 cc respectively. Lastly, The femoral heads and genitalia had a volume receiving 30 Gy

of 5 and 3.2 percent respectively.

The bowel space was the OAR with the highest level of concern within the plan with a

maximum dose reaching 4400 cGy. The overlap structures allowed the maximum dose seen in

the bowel and sigmoid to stay at a reasonable level. Fortunately the dose to the nodal PTV was

4200 cGy, so this facilitated the process of minimizing OAR dose. The most difficult objectives

of the planning process was the coverage to the nodal PTVs. This was since there was a large

volume targeted. Additionally, there was a portion of the Nodal PTV that overlapped with the

sigmoid colon and bowel space. For these reasons it would not have been reasonable to create

the plan with a minimum dose closer to 100 percent while meeting OAR constraints as easily.
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Figure 13. Dose Volume Histogram

Conclusion

The use of SIB treatment techniques has been greatly facilitated by VMAT especially

when large volumes are included. In cases such as this it is often necessary to utilize two or more

pairs of arcs to distribute different gradients of dose within the patient volume. Fortunately, the

nature of the prescription allowed all OAR dose constraints to be met without great difficulty.

The RTOG protocols for the anus are generally stricter than for other pelvic treatments due to the

relatively low prescription dose, despite this no problems were encountered. Optimization

structures greatly increased the ease of the planning process. Ring structures inside the edges of

the PTVs and overlap structures are essential in cases like these as well as many VMAT plans

for the optimization process. Overall, VMAT was an excellent modality of choice for the the

planning process of this patient.

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References
1.National comprehensive Cancer Network. Anal Carcinoma. (Version1. 2022)
https://www.nccn.org/professionals/physician_gls/pdf/anal.pdf. Accessed April 14, 2022
2. Mitra D, Hong TS, Horick N, et al. Long-term outcomes and toxicities of a large cohort of
anal cancer patients treated with dose-painted IMRT per RTOG 0529. J Adv Radiat Oncol.
2017;2(2):110-117. doi:10.1016/j.adro.2017.01.009
3.  Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 4th ed. St.Louis,
MO: Mosby-Elsevier; 2016.