‭Clinical Oncology Assignment‬

‭Oftentimes when a patient receives radiation cancer treatments, the primary tumor is not‬

‭the only point of emphasis when it comes to a target volume. Patients that present with different‬

‭types of cancer may have cancer extending to nearby parts of their body which have the potential‬

‭to be other primary cancer sites, but are often metastatic from the original primary site. In this‬

‭case, the physician has drawn the primary tumor volume but has also included many different‬

‭lymph nodes that the cancer could or potentially may have spread to. In patients with prostate‬

‭cancer, lymph nodes are often added as part of the treatment volume. The most common lymph‬

‭node chains associated with prostate cancer are the obturator- hypogastric or the presacral‬

‭nodes.‬‭1‬ ‭My patient presented with adenocarcinoma of‬‭the prostate and had positive lymph node‬

‭involvement based on his PET scan. He has since had his prostate removed and will be getting‬

‭salvage radiation to his prostate fossa and nodes. He also presented with a PSA of 38.06ng/ml‬

‭which is well above the normal range of 0-4 ng/ml and had a Gleason score of 4+4 which puts‬

‭him in the poorly differentiated range.‬

‭Set-up‬

‭When treating patients with prostate cancer, many of my clinic's methods are consistent‬

‭for every prostate case we see. My patient is no different and has a very consistent and‬

‭reproducible setup. My patient was simulated and treated with a normal table insert and was‬

‭lying supine to ensure the most consistent setup. The patient also has an “F” head rest to support‬

‭his head for treatment and is holding a blue ring to ensure that his arms are not only comfortable‬

‭on his chest, but high up out of the treatment field so his arms do not receive extra unwanted‬

‭dose. Since the prostate is toward the inferior aspect of the trunk, a lower vac loc bag is used for‬
‭the legs to ensure the patients legs are in the correct place daily. At my clinical site, we use a‬

‭small knee sponge under the vac loc bag to help with indexing, but primarily to help with the‬

‭patient's pelvis pitch when they come for treatment daily. The patient is also told to have a full‬

‭bladder for treatment to help push the small bowel out of the way of the beams that will be‬

‭entering close to the area. All of these tools are used to ensure that the patient is in the most‬

‭reproducible setup for their daily treatments.‬

‭Dose and Fractionation‬

‭In my patient's case, he had his prostate removed and got salvage radiation to his prostate‬

‭fossa and nodal region. For this type of treatment, the patient received a total of 68Gy over the‬

‭course of 34 treatments. This means that each day my patient came for treatment, he was‬

‭receiving 200cGy to the prescribed treatment area. My patient's treatment was broken into two‬

‭and he received a sequential boost which means that part of his treatment was targeted to one‬

‭area, and the other part of the treatment was targeted to a smaller area in the original treatment‬

‭volume. The first portion of the treatment which was 23 fractions long was planned to the entire‬

‭prostate fossa region along with the accompanying lymph nodes as you can see in figure 1.1.‬

‭This portion of the treatment was also planned to 46Gy total. The second portion of the treatment‬

‭which is shown in figure 1.2 was planned to only the prostate fossa as part of a boost and was‬

‭planned to a total of 22Gy in 11 fractions. Both plans were prescribed to 100% of the dose‬

‭covering 98% of the treatment volume.‬

‭Figure 1.1 (Above) - The orange contour is the total PTV going to 46Gy in 23 Fx‬

‭Figure 1.2 (Above) - The red contour is the boost PTV going to 22Gy in 11 Fx‬

‭Avoidance Structures‬

‭When planning a prostate plan that has nodal involvement, there are a few structures that‬

‭need to be contoured to ensure they are not receiving too much dose. The required structures in‬

‭my patient's case are the bladder, rectum, both right and left femoral heads, penile bulb, sigmoid‬
‭colon, and the small bowel. Figure 1.3 gives a general outline of where the structures are in‬

‭relation to the PTV. Each of these structures also has an eval type structure that is cropped away‬

‭from the PTV to make sure the dose is “scooping” out of these structures. Also, structures like‬

‭the small bowel and sigmoid colon are given max objectives in the optimizer to make sure hot‬

‭spots are not falling in these contours. Figure 1.4 shows the dose that each of these structures are‬

‭getting along with figure 1.5 showing the QUANTEC recommended values for these structures‬

‭as well. As you can tell in the figure 1.4 below, all of the avoidance structures are meeting the‬

‭physician requirements. According to the QUANTEC requirements, all of the structures are‬

‭meeting the dose requirement for these as well. After the plan was finalized, the rectum ended up‬

‭receiving V40Gy = 21.5%, bladder V40Gy = 27.28%, small bowel D0.03cc = 4902cGy, sigmoid‬

‭colon = D0.03cc = 4834cGy, femoral heads both received a dose that was much less than the‬

‭constraint, and the penile bulb received a mean dose of 2271cGy.‬

‭Figure 1.3 (Above) - Avoidance structures (Labeled)‬

‭Figure 1.4 (Above) - Physician constraints per OSU‬

‭Figure 1.5 (Above) - QUANTEC constraints‬‭2‬

‭Lymph Node Involvement‬

‭Most people who present with prostate cancer will have lymph node involvement or‬

‭physicians will treat the surrounding lymph as a precaution. The nodes that are included are the‬

‭common iliac nodes, preaortic nodes, internal iliac nodes, external iliac nodes, obturator nodes,‬

‭and the middle/lateral sacral nodes. Figure 1.6 - 1.8 show the location of the different lymph‬

‭nodes chains in relation to my patients' treatment fields. Many times the nodal regions will‬

‭receive less dose than the primary prostate area. In my patient's case, the nodal region was‬

‭treated to a lower dose and then the actual prostate region was boosted to a higher dose after the‬

‭larger volume was treated. The first line of drainage for the prostate is the obturator nodes, so‬

‭more often than not, this nodal region will be covered by the treated volume. These nodal regions‬

‭also play a part in defining the field borders that are used for prostate planning as well.‬

‭Figure 1.6 (Above) - Sagittal view of treatment field with nodal regions‬
‭Figure 1.7 (Above) - Frontal view of treatment field with nodal regions‬

‭Figure 1.8 (Above) - Axial view of treatment field with nodal regions‬
‭Boarders‬

‭When defining treatment borders for prostate planning, they can widely differ based on‬

‭the extent of spread. For conformal prostate fields there are usually some specific borders that‬

‭are set to include certain aspects. In my patient's case, he received an IMRT/VMAT treatment,‬

‭but many of the same borders still apply. At the superior border, the doctor usually defines the‬

‭border to include or block out as much lymph node spread as they want. Usually this border falls‬

‭around the inferior aspect of L5, but again is doctor defined. The inferior aspect of the field‬

‭usually falls around the inferior aspect of the ischial tuberosity. For the lateral borders, the‬

‭anterior aspect usually splits the pubic symphysis and the posterior aspect usually splits the‬

‭rectum. The left to right border is dependent on the lymph node extent along with what stage the‬

‭patient’s cancer is.‬‭3‬ ‭For lower stage patients, the‬‭borders are between 8 and 10 cm and if the‬

‭stage is higher, the field can be as wide as 15 to 16 cm wide. These borders are consistent with‬

‭how a conformal treatment would be planned. The borders are still the same however for‬

‭IMRT/VMAT treatments, but the isodose lines are manipulated in the optimizer to conform‬

‭around the PTV volume better and avoid organs at risk. In the figures below, the fields are‬

‭defined by the different color lines and the treated volume is also available for reference. In my‬

‭patient's case, the superior border goes up to L4 to be able to treat a bit more of the superior‬

‭lymph node region.‬

‭Figure 1.9 (Above) - Lateral field outlined in blue‬
‭Figure 1.10 (Above) - Frontal field outlined in blue‬

‭Treatment Technique‬

‭As previously stated, my patient received a VMAT treatment for his prostate. There are‬

‭many aspects to a VMAT treatment that are manipulated by the dosimetrist and then there are‬

‭some tasks that are completed by the software. When this is the case, this method is also called‬

‭inverse planning. Inverse planning is when the dosimetrist sets the isocenter, energy, gantry,‬

‭collimator angle, and potentially the table angle. The software then sets the field aperture, weight‬

‭and dose rate after the dosimetrist has run the plan through the optimizer. The parameters for my‬

‭patient are as follows. Isocenter is placed in the center of the low dose target with keeping in‬

‭mind that we only want a longitudinal shift to the separate boost iso. This is illustrated in figure‬
‭1.11 and 1.12 by showing how the “Z” shift was the only direction that had a different shift. The‬

‭energy that was selected for both the primary PTV and the boost PTV was 10MV because the‬

‭PTV is located in the center of the patient and this energy gives us more penetrating power to‬

‭reach the target volume. The gantry arrangement that was used for each of the plans were full‬

‭360 degree arcs. For the low dose volume, three arcs were used to treat the patient. The first arc‬

‭had a collimator seting of 0 where the second and third arcs had the collimator turned to 90‬

‭degrees. For VMAT arcs, the MLCs can only travel 15cm in the X jaw directions. Therefore,‬

‭when the collimator is in the 0 position, the X jaw is set to a max of 15cm and the Y jaw is set to‬

‭encompass the whole field. Since the other two arcs are set at 90, one has an upper field and the‬

‭other is a lower field. This is because with the field being longer than 15cm, two fields are‬

‭needed to cover the whole field in the X direction. The field direction starts at 182 and ends at‬

‭178. The other two arcs follow suit and rotate from 179 to 181 and the third arc travels from 182‬

‭to 178 once again. All parameters and fields are shown in the figures below. The table angle for‬

‭my patient was set at 0 for all fields.‬

‭For the boost plan, the PTV was much smaller. The isocenter was also shifted, but only in‬

‭the longitudinal direction. Since the PTV was so much smaller, the collimator was able to‬

‭encompass the whole treatment volume within the 15cm jaw limit in both directions. Since this‬

‭was the case, the plan was able to be completed by only using two arcs. The first arc traveled‬

‭from 182 to 178 with the collimator being turned to 0. The second arc traveled from 179 to 181‬

‭with a collimator rotation of 90. The collimator is changed in different directions in both plans to‬

‭allow the optimizer to block organs at risk in different directions. The beam energy was still‬

‭10MV for both arcs in the plan. The optimizer was used to set field weight, dose rate and the‬

‭final field aperture that was used in the final product for both plans.‬
‭Figure 1.11 (Above) - Parameters for 46Gy primary plan (Red box indicated shifts for isocenter‬

‭as stated above)‬

‭Figure 1.12 (Above) - Parameters for 22Gy boost plan (Red box indicated shifts for isocenter as‬

‭stated above)‬

‭Figure 1.13 (Above) - Shows arc arrangement and dose distribution for 46Gy primary plan‬
‭Figure 1.14 (Above) - Shows arc arrangement and dose distribution for 22Gy boost plan‬

‭Figure 1.15 (Above) - Field arrangement for 46Gy primary plan with treatment volume outlined‬

‭in orange (Field 1 on left - collimator 0 degrees, Field 2 in middle - collimator 90 degrees, Field‬

‭3 on right - collimator 90 degrees)‬

‭Figure 1.16 (Above) - Field arrangement for 22Gy boost plan with treatment volume outlined in‬

‭red (Field 1 on left - collimator 0 degrees, Field 2 on right - collimator 90 degrees)‬

‭Final DVH‬

‭VMAT prostate planning can be a bit tricky because the dosimetrist wants the dose to dip‬

‭and carve out some complex shapes. Also with going to two different dose levels, I planned both‬

‭of the volumes to a total of 68Gy to try to meet all the constraints with the higher dose. This way‬

‭when I scaled the number of fractions back to the prescribed amount for each, the tolerance‬

‭doses met with ease. As shown in figure 1.17 and in figure 1.4, the targets and the OARs were‬

‭able to meet all the tolerance guidelines.‬

‭Figure 1.17 (Above) - Final DVH from plan sum between 46Gy and 22Gy plans‬

‭Many prostate patients today are treated with a VMAT technique as the standard method‬

‭of care in radiation. Most will also have some kind of lymph node involvement as well which is‬

‭commonly encompassed in the field like the figures have shown above. All in all, this prostate‬

‭treatment was fairly simple to plan and the constraints that were set by the physician were very‬

‭achievable.‬
‭References‬

‭1.‬ ‭Dubhashi SP, Kumar H, Nath SR. Prostate cancer presenting as cervical‬

‭lymphadenopathy.‬‭Am J Case Rep‬‭. 2012;13:206-208. doi:10.12659/AJCR.883334‬

‭2.‬ ‭Emami B.‬‭Reports of radiotherapy and oncology‬‭. doi:10.5812/rro‬

‭3.‬ ‭Vann AM, Dasher BG, Wiggers N, Chestnut S.‬‭Portal‬‭Design in Radiation Therapy‬‭.‬

‭Phoenix Printing.; 2013.‬