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Jacob Wudtke

Clinical Oncology Paper

Dos 531

Introduction

The lymphatic system is a that filters the body and allows white blood cells to be
distributed throughout the body. The system plays an important role in regulating a person’s
immune response. However, the lymphatic system is also a vessel cancer cells can utilize to
spread throughout the body. Primary cancers of a prostate, rectum, and gynecologic origin can
utilize the pelvic lymph nodes to spread superiorly throughout a patient’s body. If imaging
detects lymphatic involvement of a primary tumor, it is important to develop a treatment strategy
quickly to ensure the cancer does not fully metastasize.

The following paper will outline the external beam radiation rationale and methodology
utilized for a 71-year-old gentleman with prostate cancer that has local extension into the pelvic
lymph nodes. The histology of the prostate cancer is adenocarcinoma with a Gleason score of
3+4 and PSA of 8.01 and according to the consultation note, which places the patient in the
intermediate risk category.1 PET-CT scan confirmed the extension of disease, which was utilized
to aid in target contouring. The patient was planned on an Accuray Tomotherapy machine
utilizing IMRT.

Simulation and Treatment Schema

At UW-Health, all prostate patients except for SBRT, are simulated headfirst supine on a
mattress. It is rare to use a vaclok or bodyfix immobilization for these patients as the therapists
simply place a velcro strap around the patient’s feet to ensure similar setup daily. At first the
velcro strap seems pointless, but it does a great job ensuring proper alignment because if the
patient’s feet were splayed sideways one day, the femoral heads would be rotated, and the patient
would likely need to be re-setup and re-imaged. The patient’s hands are positioned on their chest
holding a ring with a cushion under his head. There are BBs added to the patient for the CT scan
which are followed by permanent tattoo marks to ensure the therapists can align the patient the
consistently with the room lasers.
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Another important factor in the simulation process is ensuring the patient has a
comfortably full bladder. The full bladder plays an important role in the treatment process
because the bladder pushes the bowel out of the treatment field. If the patient was not planned
with a full bladder, they run a larger risk of higher bowel dose which could lead to more severe
acute toxicities throughout treatment. Comfortably full is a key point because the patient needs
to hold their bladder throughout treatment. If the bladder is excessively full there is risk of the
patient clinching during the simulation and not being in a reproducible position.

For this treatment, the MD prescribed the prostate volume to receive a total of 70 Gy in
28 fractions and the nodal volume to receive 50.4 Gy. This fractionation schema follows a SIB
technique because the nodal volume is receiving 1.8 Gy per fraction and the prostate is receiving
2.5 Gy per fraction. The prostate and nodal volumes are illustrated by figure 1. The target
contours and dose levels were utilized following NRG guidelines which were established in
2020, from which they confirmed and revised RTOG guidelines from 2009.1 Per protocol, the
PTVs, which are colored red, have a .5cm expansion from the CTVs, which are orange, to allow
for setup uncertainties and interfraction movement of the prostate.

Contouring and Organ Constraints

AT UW-Health, the MD prescription is described in what is referred to as a treatment

planning order (TPO). In the TPO, the MD prescribes the fractionation as well as gives organ
objectives. The organ objectives are referenced as priority 1, 3, and 5 with 1 being the most
important organ tolerances to meet. The priority 1 objectives are to be met at the expense of
undercovering the PTV targets, if need be, while priority 3 and 5 are to be met if PTV coverage
is not compromised. In cases such as prostate cancer, the usual three organs at risk that are of
the most importance are the bowel, bladder, and rectum. Those three organs at risk are
contoured and illustrated in Figure 2. As mentioned above, it is important to have a full bladder
to push the bowel away from the treatment field. Figure 2 illustrates how well this technique
works and gives a great visual as to why it is so important to not only have a full bladder, but one
that is also reproducible.

Some other important contours to draw are the femoral heads, penile bulb, and sigmoid
colon. Proper contouring is critical to ensure an accurate representation of the dose distribution
and organ involvement in the treatment field. Referencing the NRG guidelines for prostate
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treatment planning with lymphatic involvement, the bladder, rectum, sigmoid colon, femoral
heads, and bowel bad are given priority one and three dose clinical goals.1 Figure 4 is an image
of all the priority 1, 2, and 3 clinical goals and if they were met in this treatment plan.

When the MD contoured the prostate CTV and PTV it was a straightforward approach.
The CTV for the prostate is simply the prostate tissue contoured in addition to the seminal
vesicles. As mentioned above, the PTV was created by expanding the CTV by .5cm.1 The
contouring for the nodal CTV is a bit trickier. Lymph nodes associated with this plan are
commonly the internal and external iliac nodes, presacral node, and obturator node. The internal
and external iliac nodes coincide with the location of the internal and external iliac vessels and a
visual of an external iliac lymph node is show in Figure 5. The presacral lymph node is found at
the level of S1 (Figure 6). This node is very small hard to locate at times. The last lymph node I
will mention is the obturator node. This node is difficult to localize on a treatment planning CT
but is often found in the same axial slice as the seminal vesicles. In this case I could not
definitively locate a visual of the obturator node.

The nodal CTV starts superiorly where the aorta bifurcates into the common iliac arteries
(Figure 7) with a 5mm expansion around the vessels. The CTV then extends inferior, ensure the
contour extends 5-7mm around each iliac vessel while not including the bone, bowel, or bladder
(Figure 8), while ensuring the inclusion of the presacral nodes. Finally, the CTV contour extends
inferiorly to encompass the obturator nodes that run close to the prostate. The MD drawn
contour appears to end at the mid-level of the prostate which is shown in Figure 9. The PTV
then is created by adding a 5mm expansion to the CTV.1

Treatment Planning

At UW-Health, our primary treatment machines are the Varian Truebeam and the
Accuray Tomotherapy machine. Majority of the prostate cases are treated with Tomotherapy
due to the high level of advanced cases that require the 6 degrees of freedom treatment table that
the Truebeam offers. The Tomotherapy machine at our facility only can treat patients with a 6
MV energy. There is only MV imaging with our Tomotherapy machines, but fiducial placement
aids the therapists with alignment. An IMRT Tomotherapy plan treats the patient in a helical
fashion, meaning the machine continually rotates within the housing while the patient slowly
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moves through the bore. The treatment replicates what a CT scan feels like if we were to look
through the patient’s perspective.

When learning about IMRT planning, it is common to learn about applicable gantry and
collimator angles as well as couch position when referencing the beam arrangement.
Tomotherapy provides a learning curve to those who create treatment plans because it uses a
separate set of metrics to dictate how long the patient will be on the treatment table. The
Tomotherapy system does not utilize monitor units to analyze the dose rate, rather, it uses
seconds to show how long the treatment will take. There are several factors that can make the
patient’s treatment go faster or slower which are jaw size, gantry period, and pitch.

The jaw size is the size of the opening which the beam can travel through. The
Tomotherapy system uses MLCs like the Truebeam, but the jaw size is dictated during treatment
planning. The available jaw sizes are 5cm, 2.5cm and 1cm.2 In this case I utilized a 2.5 cm jaw
size because the treatment field has an irregular shape and more precise MLC positions offered
more benefit, especially around areas of the rectum and bladder. The gantry period is the time it
takes the treatment head to make one full rotation around the patient.2 In the perfect world we
would like this to be fast, but sometimes the machine needs more time to offer more modulation
by having more time to open and close MLCs at points.

The pitch factor in my opinion is the trickiest to get a grasp on. The pitch is defined as
the extent of couch movement per gantry rotation.2 If the pitch is not correctly established, there
is a threading effect, which appears as spikes of high dose at regular intervals on the axial plane.
If there is excessive threading, it is important to lower the pitch and slow down the table speed to
lower the amount of overlap the beam exhibits within the body. Generally, a lower pitch is used
when a higher dose is delivered per fraction.3 The final jaw size, gantry period, and pitch are
shown in figure 10.

When creating optimization parameters for this case is put a minimum dose, maximum
dose, and a uniform dose objective on both PTVs. The minimum dose objective number I utilize
is 102.5% of the PTV and maximum dose is 105% of the PTV. The reasoning behind the higher
values is to ensure proper coverage and push past the absolute minimum as long as there are no
hot spots. The major organs at risk treatments such as this are the bladder and rectum because
the highest dose is treated to the prostate itself. With the bladder and rectum being in such
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proximity to the prostate, they are given volumetric constraints as opposed to max dose
constraints. An optimization tool in Raystation that I frequently use in cases such as this is
called “dose fall-off”. This allows the user to input how quickly they want the dose to fall over a
range of space within an OAR. All target and organ optimization objectives are shown in figure
11.

The final plan created had sharp falloff around organs at risk but maintained great
conformity. The axial, sagittal, and coronal view of the dose distribution shows a good falloff
from the prostate target of 70 Gy to the nodal target which is treated to 50.4 Gy (Figure 12). The
plan met most of the MD clinical objectives except for two which can be seen in the clinical
goals shown in figure 4. The final DVH (Figure 13) shows a sharp falloff of dose on the targets,
which is ideal in IMRT planning but sometimes impossible in 3D planning. The PTV coverages
were great, and the plan has a max overall hotspot of 74.34 Gy (Figure 12) which did not fall
within any organs at risk. 97.7% of the nodal PTV received 50.4 Gy and 96.9% of the prostate
PTV received 70 Gy which both met the target objectives.

Conclusion

Creating IMRT plans requires a deeper level of thinking opposed to 3D due to the large
number of moving parts. It is important to evaluate the clinical goals given by the MD during the
planning process. The biggest one to mention in this case is the volumetric bag bowl objective
of no more than 2cc not receiving 46.5 Gy. It would be easy to get caught up in the goal not
meeting, but in this situation the goal is impossible to achieve without undercovering as 65cc of
the bowel bag is overlapping the nodal PTV which is being treated to 50.4 Gy. With this being a
priority 3 objective, an effort was made to ensure the dose was as low as possible while
understanding it could not be met.

It was great to do a deep dive into the process of target contouring and lymphatic
involvement because it can get easy to go through the motions and just utilize what the doctor
draws without much thought. As the year progresses, I am excited to tackle more advanced
planning and see what techniques I learn along the way. The biggest reason I wanted to pursue
dosimetry was the lack of monotony and the ever-changing technology. With advancing
technology, it will be interesting to see what direction the planning techniques will take.
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Figures

Figure 1: Prostate and Nodal CTV and PTV Volumes

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Figure 2: PTV, Bladder, Bowel, and Rectum Contours

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Figure 3: Bladder and Rectum Contours with Proximity to PTVs

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Figure 4: Priority 1-3 Clinical Goals

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Figure 5: External Iliac Lymph Node

Figure 6: Presacral Lymph Node

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Figure 7: Superior Aspect of Nodal CTV Contour

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Figure 8: CTV Contour Encompassing Iliac Lymph Nodes

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Figure 9: Inferior Aspect of Nodal CTV

Figure 10: Beam Parameters

Figure 11: Optimization Objectives

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Figure 12: Final Dose Distribution

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Figure 13: Final DVH

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References

1. Hall W. Paulson E, Davis B, et al. NRG Oncology Updated International Consensus Atlas on
Pelvic Lymph Node Volumes for Intact and Postoperative Prostate Cancer. International Journal
of Radiation Oncology. 109(1) 174-185. 2021. Doi: 10.1016/j.ijrobp.2020.08.034. Accessed
April 24, 2023

2. Shimizu H, Sasaki K, Fukuma H, et al. Interfacility variation in treatment planning

parameters in tomotherapy: field width, pitch, and modulation factor. Journal of Radiation
Research. 2018:59(5). DOI: https://doi.org/10.1093/jrr/rry042. Accessed April 24, 2023

3. Kissick M, Fenwick J, James, A, et al. The helical tomotherapy thread effect. The
International Journal of Medical Physics Research and Practice. 2005 32(5). DOI:
https://doi.org/10.1118/1.1896453. Accessed April 24, 2023