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Clinical Oncology Assignment

Kathryn Williams

Prostate cancer is the most common type of solid malignant cancer in men in the United
States.2 Roughly one out of twelve men will be diagnosed with prostate cancer at some point in
their lifetime.1 A patient presented to The James Cancer Center with The Ohio State University
Wexner Medical Center with a history of prostatic adenocarcinoma. The patient was originally
seen due to elevated prostate-specific antigen (PSA) in 2020 and the patient underwent a biopsy
which confirmed the diagnosis. The ordering physician prescribed radiation treatment to the
patient with a simultaneous integrated boost. Radiation to the lymph nodes has become standard
of care for high-risk pelvis cases to reduce reoccurrence with cervical, endometrium, bladder,
rectum and prostate cases.1 Clinical Target Volumes (CTV’s) are typically drawn a certain
distance around blood vessels as part of the lymph node PTV.1 Currently, Intensity-Modulated
Radiation Therapy (IMRT) is the most common radiation treatment technique for prostate
cancer.2

The patient was brought into Computed Tomography Simulation (CT Sim) and instructed
to arrive with a full bladder and empty rectum to help reduce dose to crucial anatomy. The
patient was told to remove all clothing and external objects were removed from around the
patient’s thorax and pelvis. The patient was instructed to lay on the table in the supine position
and covered with a sheet for privacy. A knee sponge was given for comfort and indexed on the
table to be reproduced during radiation treatment. The patient was given a specific head and neck
cushion for comfort, and this was documented as well. Images of the CT Sim set up were taken
and documented in the patient’s chart for reference. Markers were placed on the patient in order
to set the user origin for treatment planning and help the radiation therapists to landmark during
treatment.

The Planning Target Volume (PTV) was drawn with an eight centimeter expansion from
the Clinical Target Volume (CTV) anteriorly and laterally, however only a six centimeter
expansion from the CTV was drawn posteriorly to spare the rectum. The ordering physician
contoured three different PTV structures on the patient: a larger volume that included lymph
nodes, a smaller volume that will receive a high dose of radiation within the larger lymph node
volume, and then a volume was drawn around the prostate bed within the largest initial lymph
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node volume. The ordering physician requested the prostate bed to receive 68Gy in 34 fractions,
with the initial 50.4Gy in 28 fractions to the pelvis with a simultaneous integrated boost (SIB) to
prior gross nodal disease region to 61.6Gy. The high-dose volume had a planned dose per
fraction of 2.2Gy, the prostate bed had a dose per fraction of 2.0Gy, and the whole pelvis with
lymph nodes had a dose per fraction of 1.8Gy. As mentioned earlier, the prostate bed was then
given an SIB treatment of 12Gy in 6 fractions with a 2.0Gy dose per fraction to complete the
treatment. The prescribed dose states that at least 98% of the PTV receives more than 100% of
the prescription dose.

Figure 1 High-Dose Volume PTV shown by the Pink Line in an Axial Plane.
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Figure 2 Prostate bed PTV shown by the Red Line in an Axial Plane.

Figure 3 Large Lymph Node PTV shown by the Orange Line in an Axial Plane.

For low-risk patients, the physician may choose to only irradiate the prostate itself. The
probability of seminal vesicle involvement increases with intermediate to high-risk prostate
cancers, therefore, seminal vesicles are typically included in the prostate bed PTV.3 As
mentioned previously, treatment of lymph nodes has become more common for high-risk, T3-T4
tumors and improves the chances of disease free survival. However, the physician’s decision to
include lymph nodes takes multiple factors into account such as the recurrence risk, probability
of future lymph node involvement, and patient life expectancy. Once lymph node metastasis is
confirmed, the physician will include the lymph node PTV structure for treatment.3 The
Radiation Therapy Oncology Group (RTOG) 9413 suggests pelvic lymph node radiation may be
beneficial for patients that have at least 15% lymph node involvement.2 The conventional
fractionation is 1.8 to 2.0Gy/fx for prostate cancer treatments.3 As technology and treatment
techniques have improved, outcomes have shown improvement with doses of 70Gy or higher.2 It
is not uncommon for high range doses of 70Gy to 80Gy to be used in prostate treatments.3 The
use of higher doses with a smaller number of treatments has become more popular in recent
years. This method is called hypofractionation and is currently ongoing in many clinical trials.2
The use of hypofractionation treatments has increased due to the nature of prostate cancer having
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a lower alpha/beta ratio indicating a potential benefit to using larger fractionated doses.4
According to Gibbons2 the alpha/beta ratio for prostate cancer is in the range of 1.2 to 3.0Gy
compared to the range of 10Gy which is commonly used for other tumor cells. Therefore, by
utilizing large fractionations, patients may experience reduced treatment times, smaller total
doses, and maintain a similar rate of late toxicity for their prostate cancer treatment.2 For the
patient that presented to The James Cancer Center, the patient had a history of a prostatectomy in
2020 to remove an adenocarcinoma. Since then, the patient has been experiencing a rise in
Prostate-Specific Antigen (PSA). Therefore, the entire prostate bed, including seminal vesicles,
was recommended to be included by the physician. There was a region noted on a CT scan in
2021 along the left hemipelvis that enhanced with intravenous contrast. Although no lymph node
involvement was concluded on a recent Positron Emission Tomography (PET) scan, due to the
history of prostatic adenocarcinoma and rising PSA levels, the ordering physician recommended
to the patient an inclusion of lymph node radiation would be beneficial to reduce possible
reoccurrence.

During the contouring phase, the rectum, bladder, penile bulb and femoral heads were a
few of the important Organs At Risk (OAR) or avoidances structures that were drawn. Below the
OAR structures can be seen surrounding the PTV structure located in the center or the pelvis.

Figure 4 Organs At Risk (Femoral Heads, Bladder, and Rectum) were Contoured Around the Orange PTV in an Axial Plane.
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Figure 5 Organs At Risk (Rectum and Penile Bulb) were Contoured in an Axial Plane.

Figure 6 The PTV structures for the Prostate Bed (red) and Lymph Node Volume (orange) in an Axial Plane.
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Figure 7 The PTV structures for the Lymph Node Volume (orange) and the High Dose Volume (pink) in an Axial Plane.

Below are the national guidelines for the OAR structures within the planning volume
utilizing conventional fractionation 1.8-2.0 Gy/fraction.

Organ At Risk Constraint

Bladder V80Gy < 15%5
Bladder V75Gy < 15%5
Bladder V70Gy < 15%5
Bladder V65Gy < 50%5
Femoral Heads Max Dose 50Gy5
Femoral Heads V45Gy < 25%5
Femoral Heads V40Gy < 40%5
Penile Bulb Mean Dose to 95% of volume < 50Gy5
Rectum V75Gy < 15%5
Rectum V70 < 20%5
Rectum V50Gy < 50%5
Figure 8 The National Guidelines for Dose Limits to the Bladder, Femoral Heads, Penile Bulb, and Rectum using Conventional
Fractionation.

Below are treatment goals that the physician sets for prostate planning using Volumetric
Arc Therapy (VMAT) and Intensity-Modulated Radiation Therapy (IMRT) when treating with
28 fractions.
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Figure 9 Guidelines for Dose Limits to the PTV, Rectum, Bladder, Bowel Space, Femoral Heads, and Penile Bulb using 28 Fractions
at The James Cancer Center with The Ohio State University Wexner Medical Center.

Once the guidelines are given, a plan is put together in Medical Dosimetry to maximize
dose to the PTV volume, while sparing the Organs at Risk as much as possible. The guidelines
set at The James Cancer Center with The Ohio State University Wexner Medical Center are
based on the national guidelines set by QUANTEC and adjusted accordingly to a 28-fraction
prostate treatment. When tolerance limits are for any reason not able to be met, it is reviewed by
the physician to see if any adjustments may be required to the volumes drawn or if the physician
is content with not meeting the restriction. For instance, if the bladder is not able to meet the
treatment planning limits, the physician may be okay with this if the majority of the PTV
overlaps with the bladder. Coverage to the PTV will take precedence over many OAR limits,
unless the OAR is a serial organ, such as the spinal cord. In terms of contraindications if the dose
limit were to exceed the planning goals set by the physician, the patient may experience
undesirable side effects such as fecal incontinence, bony fractures, bladder dysfunction, blood in
the stool or urine, diarrhea, fatigue, constipation, and many others. The patient that presented to
The James Cancer Center reported feeling occasional incontinence as well as mild fatigue, but
the fatigue may be due to immunotherapy the patient was undergoing. It is important as a
dosimetrist to do everything possible to meet the treatment goals and remain under the dose
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limits, while still maintaining PTV coverage to ensure the best treatment plan is delivered to the
patient. At The James Cancer Center, an algorithm is used that uploads these guidelines into a
software program to then calculate what each OAR is receiving and the coverage to the PTV.
This software used is called ClearCheck. When targets are met, the values show up in green
underneath the plan name “Pelvis”. When a structure or target cannot be met, a discussion is had
with the ordering physician and if they approve the discrepancy, they sign off in ClearCheck.

F
igure 10 ClearCheck Calculation After the Plan is Finalized for the Primary Field.

Lymph nodes that are involved when treating prostate cancer include the common iliac
lymph nodes, internal and external iliac lymph nodes, presacral lymph nodes, periprostatic
nodes, and obturator lymph nodes.2 When physicians contour the lymph node CTV, they include
the surrounding vessels with a 0.7 centimeter radial margin while abutting but not overlapping
with the bladder, bowel, bone and muscle.2 The RTOG recommends for prostate cancer pelvic
lymph node volumes begin at distal common iliac at the level of L5/S1, and end at the top of the
pubic symphysis. The external iliac contours should end at the superior border of the femoral
heads, and the obturator lymph node should end at the superior border of the symphysis pubis.3
The prostate case that presented in clinic included the common iliac nodes, the internal and
external iliac nodes, and the obturator lymph nodes.
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Figure 10 The Common Iliac Node in the Coronal Plane.

Figure 11 The Internal Iliac Nodes, External Iliac Nodes, Periprostatic Nodes, and Obturator Nodes in the Coronal Plane.

The anatomy boundaries or physical limits for prostate cancer typically include the whole
pelvis for the primary or initial treatment field. The inferior border includes the inferior border of
the prostate with a 1.5 to 2 centimeter margin, equal to or just below the ischial tuberosities.
Superiorly, the top border includes the common iliac lymph nodes or the L4-L5 disk space.
Laterally, the field should include the entire bony pelvis with a 1.5 to 2 centimeter margin. From
the lateral fields, the superior and inferior borders are the same as the anterior and posterior
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fields. The posterior margin of the lateral fields should include the half of the rectum closest to
the field and anteriorly through the symphysis pubis. The treatment field for the SIB treatment is
much smaller and focused on the prostate gland, seminal vesicles, and periprostatic tissue.2
Below are images of the primary treatment field borders. The boosted field was centered around
the prostate and maintained a small more conformal field around the prostate bed itself.

Figure 12 The Treatment Field of the Primary Field in the Coronal Plane.

Figure 13 The Treatment Field of the Primary Field in the Sagittal Plane.
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Figure 14 The Treatment Field of the Boost Field in the Coronal Plane.

Figure 15 The Treatment Field of the Boost Field in the Sagittal Plane.

The treatment technique used for the prostate patient that presented to The James Cancer
Center was a type of IMRT called Volumetric Modulated Arc Therapy (VMAT). This type of
treatment utilizes a continuous and fluent arc around the patient where the linear accelerator
rotates around the patient with the radiation beam constantly on. During the rotation, Multileaf
collimator (MLC) devices move in and out continuously to block and unblock vital anatomic
structures and targets. There were three arcs with an energy of 10MV positioned around the
patient. The energy selection of 10MV was chosen for the initial plan and the boost plan to
adequately penetrate the tumor that sits deep and central within the patient, thus 6MV would not
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have been high enough energy to use. When the VMAT technique is used, information is
collected through control points that are located around each degree around the patient. Thus, for
the primary field, to maximize the number of control points used to gather information, the first
field arc rotated around the patient from 181 through 179 degrees in the clockwise direction,
followed by the second field arc rotating 178 to 182 degrees in the counterclockwise direction,
and finally ending with the third arc rotation back 181 to 179 degrees in the clockwise direction.
Next the collimator was turned for each field to encompass the tumor volume in the primary
field. For field one, a five degree collimator rotation was placed to maximize MLC coverage
during the rotation as opposed to zero degrees. For field two and three, a 90 degree collimator
rotation was placed on each field. At The James Cancer Center, the maximum field size in the x-
direction is 15 centimeters. Once the collimator turns to 90 degrees, the x-direction extends
superior to inferior and the primary PTV volume did not fit within 15 centimeters. Therefore,
fields two and three were broken up into a superior field that covered the top half of the PTV
volume and the bottom half of the PTV volume. No couch rotations were done nor were any
wedges used.

Figure 16 The Primary Beam in the Axial Plane.

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Figure 17 The Primary Beam in Beam’s Eye View Demonstrating the Field
Coverage. The First Field on the Left, Second in the Middle and Third Field on the Right. The Second and Third Fields are Split to
Treat the Top and Bottom of the PTV.

The boost field was set up with two arcs, each with an energy of 10 MV due to the central
location. Full arcs were once again chosen to maximize control points and because the volume
was centrally located, there was not a beneficial way to spare an entry point. For instance, with a
tumor located on the side of the head that may be treated with VMAT, we could control the arc
to only enter through the side of interest to spare the unaffected side. With this prostate case, it is
located in the center of the patient’s body so entering from any degree could help make the plan
more conformal. The first arc for the boost plan went from 181 to 179 degrees in the clockwise
direction. The second arc ran from 178 to 182 in the counterclockwise direction. The first field
had a collimator turn of five degrees, and the second collimator was turned 85 degrees. The boost
PTV was significantly smaller than the primary PTV, so the volume was able to fit into the
treatment field with ease. No couch rotations were done nor were any wedges used.
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Figure 17 The Boost Beam in the Axial Plane.

Figure 18 The Boost Beam in the Beam’s Eye View. The First Field is Shown on the Left and the Second Field on the Right.

Once the fields were set for the primary beam, the patient was loaded into an
optimization program to begin planning. In the contouring stage, structures were created to help
move dose into desirable locations and keep it out of undesired locations. As mentioned earlier,
OAR structures for this plan were bladder, rectum, small bowel, penile bulb and femoral heads.
The PTV overlapped with only the bladder and the rectum, however, nearly the entire part of the
bladder was encompassed by the PTV. Therefore, the decision was made that it would be
difficult to push dose out of the bladder without losing coverage to the PTV, so a structure was
created to control dose to the part of the PTV that overlapped with only the rectum. This
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structure was titled “PTV OAR” so that dose could be optimized to this location to minimize
dose to the rectum that overlaps with the PTV, but maintain sufficient coverage to the PTV.
Additionally, bladder minus PTV and rectum minus PTV structures were created in order to push
dose out of the OAR structures that do not overlap with the PTV and minimize dose to these
areas. Lastly, structures called “Rings” were created around the PTV to help corral dose at a
certain level. Three rings were created for this plan: a ring to control the 95% isodose line, a ring
to control the 80% isodose line, and a ring to control the 50% and below isodose lines. These
rings were utilized to ultimately make the plan more conformal around the PTV. Once these
structures were created, the patient was loaded into the optimization program. Then, the PTV,
PTV OAR, bladder minus PTV, rectum minus PTV, and the three rings were loaded into the
optimizer. Each structure was set with a desired dose upper and lower limit, while also giving
each structure a priority. By giving upper and lower limits for different structures different
priorities, it is providing the optimization software with a series of instructions and their level of
importance. For instance, the PTV structures need to receive a certain minimum amount of
radiation dose to properly treat the tumor, therefore, the priority to the lower limit of dose to the
PTV was given the highest priority. PTV OAR was also given a high priority so that dose to that
part of the PTV could be controlled to meet the minimum requirements for coverage, but spare
the overlapped part of the rectum as much as possible. The ring that controls the 95% isodose
line was also given a high priority to help the overall conformality of the plan. Lower priority
was given to the 80% and 50% rings, knowing that it is harder to control lower isodose levels.
Lower priority was also given to the maximum dose received by the femoral heads, small bowel,
and penile bulb because these structures did not overlap with the PTV or have any issues meeting
the constraints. The bladder minus PTV and rectum minus PTV were given strict instructions to
push the optimizer as hard as possible to spare these organs at risk. By doing so, radiation will
essentially carve out of the organs at risk and minimize dose to the bladder and rectum. A similar
process with the exact same principles was carried out for the boost plan during the optimization
process with the same structure set, but different PTV volume.
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Figure 19 The Final DVH for the Plan Sum of the Prostate Treatment for all Structures. DVH Includes all PTV volumes from the
Primary Plan and the Boost Plan.

The final DVH is shown in absolute dose with the total dose on the x-axis and ratio of
total structure volume as a percent on the y-axis. A more simplified DVH is shown below of
target structures and OAR structures that were of concern based on the goals and constraints set
by the physician.

Figure 20 The Final DVH for the Plan Sum of the Prostate Treatment. DVH Includes PTV Volumes and Organs at Risk.
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The plan was able to meet most of the constraints and goals set at the beginning of the
planning period. Attached is the final ClearCheck of the plan sum for the prostate plan.

Figure 21 The Final ClearCheck for the Plan Sum of the Prostate Treatment Showing the Targets and Organs at Risk Meeting the
Goals and Desired Constraints.

The PTV in the primary plan and in the boost plan were prescribed to 100% of the dose
covers 98% of the target structure and this was met. The bladder, sigmoid colon, and femoral
heads were able to meet the constraints, but the rectum struggled to meet the V40Gy < 50%.
With the rectum being so close to the PTV, the physician was okay with this constraint not being
met because the physician did not want to lose coverage to the PTV. The small bowel met most
of the constraints and fell within the appropriate allowed dose range. The penile bulb had a mean
dose goal of 52.5Gy, but that was not able to be met in this plan due to its proximity to the PTV.
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Once again, the physician allowed this to ensure proper coverage to the PTV. The goals and
constraints were for the most part able to be met and the patient was given the best treatment
possible.
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References

1. Liu Z, Liu X, Zhang F, Hu K. How much margin do we need for pelvic lymph nodes
irradiation in the era of IGRT? J Cancer. 2018;9(20):3683-3689. doi:10.7150/jca.27220

2. Gibbons JP. In: Khan's Treatment Planning in Radiation Oncology. Philadelphia: Wolters
Kluwer; 2022:189-213.

3. Li G, Li Y, Wang J, et al. Guidelines for radiotherapy of prostate cancer (2020 edition).

Precis Radiat Oncol. 2021;5(3):160-182. doi:https://doi.org/10.1002/pro6.1129

4. Hegemann, NS., Guckenberger, M., Belka, C. et al. Hypofractionated radiotherapy for

prostate cancer. Radiat Oncol. 2014;9(1). https://doi.org/10.1186/s13014-014-0275-6

5. Chun M, Choi CH, Kim J-in, et al. Dosimetric evaluation of plans converted with the DVH-
based plan converter. Prog Med Phys. 2018;29(4):157. doi:10.14316/pmp.2018.29.4.157