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Clinical Oncology Assignment

Melissa Piercey
April 19, 2023
Introduction:

The patient chosen for this assignment is a 64-year-old man with unfavorable-intermediate risk,
stage IIB (cT2b, cN0, cM0) adenocarcinoma of the prostate. His Gleason score is 3 + 4=7 with
6/12 cores positive. He presented with an elevated PSA score of 11.7 during routine screening
and was sent for a TRUS (trans-rectal ultrasound) biopsy. The patient has a family history of
prostate cancer including his father and brother. He denies any incontinence, voiding difficulties,
painful urination, urine retention, incomplete emptying, urinary frequency, or blood in the urine.

Planning:

This patient was positioned for simulation in the supine position. He was given a pillow and knee
rest to provide comfort on the treatment table. His feet were banded as reminder not to adjust his
legs or feet during treatment. The patient was instructed to have a full bladder for the simulation
and was given an oral contrast of 20 ml of Isovue 300 with Breeza®. A full bladder is necessary
for simulation and treatment each day as it ensures the prostate is in the same position daily and
moves small bowel out of the treatment field, decreasing side effects and toxicity. The patient
was prescribed 46 Gy, 2 Gy per day, for 23 fractions. He was also given interstitial
brachytherapy of high dose rate Iridium – 192 for 2 fractions, 10.5 Gy per fraction, to a dose of
21 Gy. Total cumulative dose to the patient is 67 Gy. This regimen was chosen because “...very
high radiation doses for intermediate- and high-risk prostate cancer patients...” has proven to
improve local-regional control and decrease the chance of treatment failure or distant metastasis.1

Avoidance Structures:

Avoidance structures that were contoured for this treatment include the bladder, left and right
femoral heads, penile bulb, rectum, small bowel and large bowel. Corewell East/Beaumont
radiation oncology clinic has a specific dose objective worksheet for each anatomical site with
values that are based on QUANTEC recommended dose limits. Below is a re-creation of the
worksheet for this patient.
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Organs at Risk (OAR) Desired Planning Planning Objective Contradictions if Dose

Objective2 Outcome Exceeded3

Bladder V45 <25% V 45 = 20% Grade 3+ toxicity:

Increased frequency and
V40 < 40% V40 = 33.8% urgency, nocturia hourly
or more frequent,
V30 <70% V30 = 55.4% dysuria, pelvis pain,
bladder spasms,
hematuria

Left and Right Femoral D 1% < 45 Gy 26Gy Fracture

Heads
V30< 50% 0.1% Joint inflammation

Penile Bulb D mean <30 Gy 22.8Gy Severe erectile

dysfunction

Rectum V45 <15% V45 = 10.5% Grade 3+ Toxicity:

Diarrhea requiring
V40 <40% V40 =31.4% parenteral support,
severe mucus, bloody
V30 <70% V30 =54 discharge, abdominal
distention

Small Bowel D1cc <50 Gy 48.1 Gy Grade 3+ Toxicity:

Diarrhea requiring
parenteral support,
severe mucus, bloody
discharge, abdominal
distention

Large Bowel D1cc <50 Gy 47.9 Gy Grade 3+ Toxicity:

Diarrhea requiring
parenteral support,
severe mucus, bloody
discharge, abdominal
distention
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Figure 1: Axial, Sagittal and Coronal view of contoured target and OAR

Lymph Node Regions:

There were several factors that justified the inclusion of pelvic lymph node in the external beam
treatment volume. The patient had a staging of T2b, Gleason score of 3+4+7 (moderately
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differentiated), and 6/12 cores positive on biopsy. These factors classified the cancer as
unfavorable intermediate risk.4 RTOG 0924 protocol and NCCN (National Comprehensive
Cancer Network) guidelines recommend treating pelvic lymph nodes including the sacral nodes,
external nodes, internal iliac nodes, common iliac nodes and obturator nodes.5,6

Figure 2: Axial view of external iliac node, internal iliac node and sacral node.7

Figure 3: Axial view of common iliac node.7

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Figure 4: Axial view of obturator node.7

Treatment Borders:

The PTV for this prostate plan (outlined in red) has a superior border between L4 and L5. The
lateral borders extend approximately 3 cm from the pelvic brim. The inferior border is 1 cm
inferior to the pubic symphysis. The anterior border extends 1 cm beyond the pubic symphysis
and posterior border splits the rectum at S1.
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Figure 5: Superior, inferior, and lateral treatment borders.

Figure 6: Anterior and posterior treatment borders.

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Treatment Technique:

The treatment technique used for this prostate treatment was Volumetric Modulated Arc
Therapy (VMAT). Two 356 degree arcs with 6MV energy were used for the treatment plan.
The clockwise beam started at a gantry angle of 183 and ended at 179 with a collimator angle
of 45 degrees. The counter clockwise beam started at a gantry angle of 177 and ended at 181
with a collimator angle of 315 degrees. Physicists at Corewell East/Beaumont prefer the
beam angles to be staggered at 4 degree intervals to allow more control points for dose to be
calculated and delivered. Opposing collimator rotations disperse interleaf leakage for each
arc.

Figure 7: Beam angles of prostate treatment plan.

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Dose Volume Histogram (DVH):

The DVH is a graphical representation of the dose by volume for each region of interest. For this
plan the physician requested 98% coverage of the dose to the PTV. The pelvic lymph nodes were
covered by 100% of the dose. Several avoidance structures were contoured and tolerance doses
were limited as described previously. During treatment planning optimization, 4 rings were
placed at specific intervals around the PTV to instruct the treatment planning system to push
dose centrally to the PTV, creating tight isodose lines and uniform dose around the volume. Dose
objectives set on the critical structures included max dose and uniform dose targets (Figures 8 &
9). This distributed dose away from the critical structures keeping them within the tolerances set.
This DVH correlates with our OAR worksheet.

Figure 8: Dose planning objectives

Figure 9: Dose planning objectives

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Figure 8: DVH for prostate treatment plan

Conclusion:

Treatment planning for prostate cancer includes many overlapping structures that need to be
accounted for. Overall this plan developed smoothly. We were able to keep all of our avoidance
structures under the tolerance doses. We achieved our goal of 98% dose coverage on the PTV
and 100% coverage on the pelvic lymph nodes. Based on all of the criteria being met, this patient
should tolerate treatment well.
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References:

1. Vargas CE, Martinez AA, Boike TP, et al. High-dose irradiation for prostate cancer via a
high-dose-rate brachytherapy boost: Results of a phase I to II study. International Journal of
Radiation Oncology*Biology*Physics. 2006;66(2):416-423. doi:10.1016/j.ijrobp.2006.04.045

2. Bentzen SM, Constine LS, Deasy JO, et al. Quantitative analyses of normal tissue effects in
the clinic (QUANTEC): An introduction to the scientific issues. International Journal of
Radiation Oncology*Biology*Physics. 2010;76(3). doi:10.1016/j.ijrobp.2009.09.040
3. Cox JD, Stetz J, Pajak TF. Toxicity criteria of the Radiation Therapy Oncology Group
(RTOG) and the European organization for research and treatment of cancer (EORTC). Int J
Radiat Oncol Biol Phys. 1995;31(5):1341-1346. doi:10.1016/0360-3016(95)00060-c.

4.Kahn FM, Gibbons JP, Sperduto PW. Cancer of the genitourinary tract: prostate cancer.
Treatement Planning in Radiation Oncology. 4th Edition. Philadelphia, PA.:Wolters
Kluwer;2016:453-467
5. Androgen-Deprivation Therapy and Radiation Therapy in Treating Patients with Prostate
Cancer. Radiation Therapy Oncology Group. ClinicalTrials.gov Identifier: NCT01368588.
Updated April 8, 2022. Accessed April 19, 2023. https://clinicaltrials.gov/ct2/show/NCT
01368588
6. National Comprehensive Cancer Network. Prostate Cancer Version 1.2023.
https://www.nccn.org/login?ReturnURL=https://www.nccn.org/professionals/physician_gls/
pdf/prostate.pdf. Accessed April 18, 2023.
7. Lenards, N. Cross-sectional anatomy- Male and Female Pelvis. [SoftChalk]. La Crosse, WI:
UW-L Medical Dosimetry Program; 2017