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Destiny Jacobs

DOS 791- Clinical Lab II


April 10, 2016
GYN Pelvis Lab- RTOG 0418
Patient JW is a 68 year old female patient who originally presented with abnormal vaginal
bleeding. She was under the care of her primary care physician, who referred her to a
gynecologist. A total hysterectomy surgery was recommended and performed. The results of
pathology revealed a stage pT1bpNxmMx carcinoma of the endometrium. Due to the fact that
her disease extended into the outer half of the myometrium, she is grade II disease with evidence
of lymph-vascular invasion. She will receive post-operative radiation therapy via external beam
radiation.
Target Volumes: JW was simulated on a CT scanner. The patient was immobilized during
simulation using the Vac Lock system positioned under her pelvis. Her hands were positioned
high on the chest, and some bed pillows were placed under her head for comfort. After obtaining
the treatment planning CT, the images were uploaded into the treatment planning system to
define the volumes and organs at risk. RTOG_CTV target volume was defined as an area that
contains potential microscopic disease as well as potential lymph node involvement. The
RTOG_CTV was outlined on all CT slices encompassing lower common iliac nodes 7mm below
L5, internal iliac nodes, external iliac nodes up to the femoral head level, presacral nodes down
to S3, and the obturator nodes up to the obturator fossa. The RTOG_PTV was defined 7mm
anteriorly, posteriorly, laterally, superiorly, and inferiorly from the RTOG_CTV. The organs
found at risk (OR) defined in the treatment area included the rectum, bladder, small bowel, and
bilateral femoral heads (Figure 1-3).
Prescription and Objectives: JW was planned to a total dose of 50.4Gy prescribed to the
RTOG_CTV. The prescribed dose encompassed at least 97% of the PTV vaginal and nodal
region. No more than 20% of the PTV was greater than 110% of the prescribed dose. For the
OR, no more than 30% of the small bowel received more than 40 Gy, no more than 60% of the
rectum received more than 30 Gy, no more than 35% of the bladder received more than 45 Gy,
and no more than 15% of the femoral heads received more than 30 Gy (Table 1).
Beam Arrangement and Planning Technique:

In order to achieve the planning objectives of

the protocol, a 9 field IMRT technique was generated using 6MV energy. The beams chosen

were equidistant to one another about the 360 rotation of the gantry. Beam angles used for
treatment planning included angles 340, 300, 260, 220, 180, 140, 100, 60, and 20
(Figure 2). These beam angles allowed for the best diversification of dose with respect to the OR
around the defined tumor volume.
The PTV optimization technique was set to 100% of the prescription dose since 97% of the PTV
volume was to receive 100% of the prescribed dose. The CTV volume was set slightly higher
than the prescribed dose in order to force the hottest areas of the plan to the CTV. The limits of
the OR were set in accordance with the dose limits outlined in the protocol (Table 1). These
constraints were adjusted as the plan actively optimized. After the initial optimization the
prescription coverage of the PTV was not being met per the protocol. In order to help the
optimization algorithm work more efficiently for the large volume, the PTV was split into
sections. The PTV sections included an upper, lower, right and left volumes. The new PTV
volumes were expanded 3mm outside the RTOG_PTV. Each of these new PTV volumes were
set to an optimization constraint to receive 100% of the prescription dose. After optimizing
several times, the RTOG_PTV received adequate coverage, but the OR were being overdosed.
In order to meet the OR objectives each was worked with one at a time. The small bowel
objective was the first OR worked with. The small bowel objective was finally met when
anterior margin of the new PTV volume were decreased to match the RTOG_PTV. This decrease
in margin allowed the small bowel to be kept under tolerance doses as well as keeping adequate
coverage to the RTOG_PTV. After the small bowel was met next came the rectum, bladder, and
then the femoral head. In order to meet all OR objectives the optimization PTV volumes was
reduced to 1mm beyond the RTOG_PTV. These adjustments allowed for 97% of the
RTOG_PTV to be covered by the prescription dose as well as the OR to meet the protocol
requirements.
Plan Outcome:

Upon final evaluation of the IMRT plan 97% of the PTV volume received

100% of the prescribed dose and 100% of the CTV volume received 98% of the prescribed dose.
All organs at risk objectives were met as outlined in the protocol (Table 2 and Figure 6).

Figure 1: Target volumes and OR, transverse view.

Figure 2: Target volumes and OR, frontal view.

Figure 3: Target volumes and OR, sagital view


Small bowel
Rectum
Bladder
Femoral Head
Table 1: OR dose limits

<
<
<
<

30%
60%
35%
15%

volume
volume
volume
volume

40
30
45
15

Gy
Gy
Gy
Gy

Figure 4: Sagittal view beam arrangement.

Figure 5:

Beam arrangement.

Prescription:

50.4Gy in 28 Tx=
1.8Gy/Day

Organs at risk

Desired objective(s)

Small Bowel

< 30% volume 40 Gy

Achieved Objectives

< 30%
Gy
Rectum
< 60% volume 30 Gy < 60%
Gy
Bladder
< 35% volume 45 Gy < 35%
Gy
Femoral Head
< 15% volume 30 Gy < 15%
Gy
Table 2: OR Desired objectives vs Achieved objectives

Figure 6: DVH

volume 38.4
volume 29.6
volume 40.4
volume 28.4