Clinical Oncology Assignment

Sawyer Peterson

Introduction

Treatments for tumors located in the pelvis may be comprised of different methodology

depending on multiple factors that include patient workup, staging, site, and much more. This

paper will review a 52-year-old female being treated to the pelvic region. This patient’s

diagnosis that we are treating is a sigmoid adenocarcinoma, moderately differentiated stage IIIC

(cT4N+M0), and receiving neoadjuvant therapy. At the time of consult, the patient was receiving

their fourth cycle of FOLFOX chemo regimen. The patient’s tumor has extension to the adjacent

peritoneum and the rectum. The patient also has involvement of the mesorectal and superior

rectal lymph nodes that will be included within the treatment field.

Patient Simulation/Setup

For pelvic patients, when the treatment will include nodal regions, a mold is created to

ensure immobility of the patient as well as reproducibility of the setup. For this patient, a body

fix mold was created and the patient was scanned in the head-first supine position. A wingboard

was used to keep the patients’ arms raised and out of the potential field. Legs were kept straight

and together which aids in the reproducibility of the treatment and is easiest when utilizing the

mold. Feet were also held together using a large ring that aids in the immobilization of the

patient.

In addition to the positioning of this patient, other simulation tactics were used to provide

the best treatment planning and target delineation. The patient was scanned with a full bladder,

which will be required every day for treatment and used as a method to push the radiosensitive
small bowel out of the treatment field. Without using this technique, the small bowel would

receive higher doses which would lead to more side effects the patient could experience during

and after the treatment course. To visualize vessels more, IV contrast was administered with

another CT scan and then fused to the treatment planning CT. The IV contrast can significantly

help with the visualization of the bowel, iliac and inguinal vessels.1 Then finally, two additional

MRI images were fused to the treatment planning CT scan for the MD to visualize the tumor

volume better for contouring to create the GTV and CTV volumes.

Prescription/Dosing

For the prescription dose, the MD followed the RTOG 0529 protocol for IMRT

treatments of anal cancers with a combination of IMRT and chemotherapy. The RTOG 0529 was

a phase II trial studying the combination of IMRT with 5-FU and Mitomycin-C.1 Even though

the following treatment was planned to use a 3D conformal arc method, the same prescription

doses were used for each target volume. For T3-4/N0-3 staged patients, this protocol follows a

prescription of 45 Gy to elective nodal volumes, 50.4 Gy to lymph nodes less than 3.0cm, and

54Gy to lymph nodes greater than 3cm and the gross tumor volume in 30 fractions.1 This was the

layout the MD chose for this particular treatment using the sequential boost method because the

treatment was planned 3D. The PTV45 was prescribed 45 Gy in 25 fractions, the PTV50.4 was

prescribed 5.4Gy in 3 fractions, and PTV54 was prescribed 3.6 in 2 fractions. Each of these used

1.8Gy/Fx, and the PTV50.4 and PTV54 were the sequential boosts, with the total number of

fractions being 30.

Contouring

The MD included organs at risk (OAR) in the treatment planning order and contoured

these organs while providing goals and objectives that were to be met for each one. These organs
included the bladder, small bowel, femoral heads, and the spinal cord. The rectum is another

OAR that is commonly included in pelvic radiation treatments, however this is an area we are

treating, so no goals were added in terms of sparing this structure as it was included within the

PTV. In figure 1, all contours either created, checked, or included in the treatment planning order

are listed while figures 2 and 3 show the different organs at risk at isocenter.

Figure 1- Contour list for organs at risk and target volumes

Figure 2- Sagittal view of organs at risk and targets at isocenter

Figure 3- Axial view of organs at risk at and targets.

 The physician took most goals from the RTOG 0529 protocol, however they adapted

some of the goals to make them either tighter or different for this patient. The planning goals set

by the physician can be found below in table 1. The different priority levels are how much the

physician wants to focus on meeting the goals, priority 1s being constraints the plan absolutely

needs to meet if necessary underdose for, while priority 3s and 5s are goals that should be met,

but not at the expense of PTV coverage.

Table 1- Physician provided OAR objectives and goals.

Priority 5 Priority 3 Priority 1

Bladder V35Gy<50%

V40Gy<35%

V50Gy<5%

Bowel Bag V30Gy<150cc

V45<20cc

V52<1cc

Femoral Head V40Gy<35% V44Gy<5% V44Gy<10%

V30Gy<50%

Spinal cord Dmax<45 Gy Dmax<50Gy

When comparing these constraints to the RTOG 0529 protocol, there were only slight

differences. The RTOG 0529 protocol has constraints for the bowel bag of V35Gy<150cc.1 Out

physician decided to make this constraint tighter, lowering it to V30Gy<150cc. It is also

important to compare associated QUANTEC goals and their associated toxicities. Below in table

2 are QUANTEC values with their clinical endpoints/outcomes.

 Organ Constraint Outcome Met in plan

Small bowel V45Gy<195cc Grade ≥ 3 acute Yes: 23.61cc

(for entire toxicity
potential space
in peritoneal
cavity)
Bladder V65Gy<50% Grade ≥ 3 late Yes:
V70Gy<35% effects Dmax=56.16
V75Gy<25%
V80<15%
Femoral V44Gy<5% Yes:Left is
head/neck V40Gy<35% 1.12% and right
V30Gy<50% is 2.12% at
30Gy, rest are
0.0%.
Spinal canal Dmax<45-50Gy Myelopathy Yes: 0.0Gy (no
dose)
Table 2- QUANTEC values and their toxicities/clinical endpoints2,3

Lymph node involvement

This patient is being treated to the involved lymph nodes and elective lymph nodes that

include a portion of the common iliac, the internal iliac, external iliac, mesorectal, and superior

rectal groups. The common iliac nodes start below the bifurcation of the aorta, usually in front of

the level of L5 which is near where our CTV45 volume starts as seen in figure 4. This volume

includes the common iliac nodes as well as the internal and external iliac nodes which follow the

internal and external iliac artery as they branch apart. A reference is provided in figure 5 as to

where the lymph node chains are located near anatomical structures. The CTV50.4 starts with the

involvement of the superior rectal lymph nodes, which are located superior to the

rectum/sigmoid colon. This volume additionally includes the affected superior rectal and

mesorectal lymph node groups, while the CTV50.4 includes the tumor and lymph nodes regions

greater than 3cm in size.

Figure 4- CTV 45 lymph nodes
Figure 5- Pelvic lymph node reference
 Figure 6- CTV50.4 with involved superior rectal and mesorectal lymph nodes

Anatomical boundaries

Anatomical boundaries are an important consideration when looking at what to include in

the treatment field and how to avoid dosing critical organs at risk that don’t require the field to

encompass them. The physician drew the 3 CTVs, then used a 5mm expansion from each one to

create the PTVs. To include the elective nodes, the MD made the CTV45 to include the nodes

superiorly near the top of S1. For the rest of the contours, MR imaging was used to draw the

CTVs for the involved nodes and the tumor volume, the CTVs extending to the pelvic inlet in

most cases and the PTVs encompassing further. Inferiorly the volumes are just superior of the

pubic symphysis. The posterior border was encompassing a portion of the sacrum, while the
anterior border was aligned to the posterior border of the bladder. For treatment, a 0.7cm margin

was made around the PTV volumes to deliver a reasonable dose distribution to the targets.
Figure 7- Anatomical borders for treatment showing PTVs
Treatment plan-

For this plan, the MD requested a 3D plan to be made and follow the OAR and PTV

constraints and objectives to the best extent. The RTOG 0529 protocol goals and objectives are

provided for IMRT plans, which are more challenging to meet using a 3D planning method

instead.1 The 3D treatment method of choice for this case was a conformal arc plan for the initial

plan treating to 45Gy as well as each boost plan treating to 50.4Gy and 54Gy. A total of 3 beam

sets were created, each composed of one conformal arc beam. The first beam encompassed the

PTV45Gy using the 0.7 margin for MLC, and a 5-degree collimator angle. The beam used 10MV

for the energy, as the patient was being treated at a machine that was limited to 10MV as that

was the highest energy available for the machine the patient was being treated on. The arc was

set to move clockwise from 182 degrees to 178 degrees for the gantry angle.

Figure 8- Beam information for the PTV45Gy conformal arc

The second and third plans used the same beam parameters for their arcs as well- 10MV

energy, a 5-degree collimator angle, and gantry angles moving clockwise from 182 to 178

degrees. The only thing that changed was the volumes encompassed for each beam, each plan

adding a 0.7cm margin for the MLC from the PTV. No wedges were used because the plan was

using an arc. To make the conformal arc, some parameters were put into the treatment planning

system to follow to create a plan that makes the dose distribution uniform and conformal to the

target volume. This plan is 3D, so no modulation of the field or intensity is changed, only the

dose rate is the gantry rotates around the patient. The parameters can be seen in figure 9 for what

the system was given to create the conformal arc plan. Each plan used the same objectives, but
just modified so that the PTVs were assigned to their associated beam set. Figure 10 shows the

final isodose distribution for all 3 beam sets combined in the axial plane. The final plan was then

compared to the goals and objectives given by the MD, and necessary changes were made. Goals

were also created to evaluate each boost plan beam set individually with the smaller dose values

of 5.4 Gy and 3.6 Gy. Each plan was normalized so that 95% of the PTV volumes were receiving

100% of the prescription dose per the MD’s PTV objectives.

Figure 9- Objectives for the PTV45 plan.

Figure 10- Isodose distribution of all 3 conformal arc beam sets

Target and OAR coverage

For this case the MD included PTV and OAR goals and objectives organized by different

priorities to specify which objectives were absolutely required and which wouldn’t require

underdosing of the PTV/overdosing of OARs. As stated before, a lot of these goals were adapted
from RTOG 0529, which was for IMRT planning. This case however was planned using a 3D

conformal arc, so the plan did not adequately meet a couple of the tight OAR goals the MD

included. The MD was ok with this, as PTV coverage was good and the goals that did not meet

were not a significantly large value off from what was set. In total, three OAR goals did not

meet- two for the bowel and one for the bladder. The bowel goals of V52<1cc and V45<20cc

were not met. In comparison to the QUANTEC values these goals given by the MD were very

tight, and the goals were not far from meeting as seen in figure 11. The bladder goal of V50<5%

was also not meeting, however a portion of the PTV included the bladder, and dose to the

bladder could not be decreased without not meeting the PTV coverage goals from the MD. All

other objectives and goals were met for both the PTV and the OARs.
 Figure 11- PTV and OAR clinical goals

Figure 12- Final DVH showing OARs and PTVs

Conclusion

Overall, the 3D conformal arc plan came together nicely, meeting most of the set

objectives and goals made by the physician and meeting all the QUANTEC constraints. When

treating patients with lymph node involvement it is important to consider the dose of nearby

OARs and the borders of the treatment field to ensure the whole treatment volume is

encompassed and other structures are being blocked out. An IMRT plan can deliver conformal

doses of radiation and be optimized to spare and modulate dose to OARs, which is not a feature
of 3D conformal plans. Using a sequential boost prescription, all PTVs met a coverage of 95%

percent of the volume receiving 100% of the prescription dose. Using the conformal method of

treatment planning, an optimal 3D plan was created that spared OARs to best extent using the

tools available with strict constraints to provide and efficient yet safe treatment.

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