Helen Nguyen

Clinical Oncology Assignment - Primary Pelvis with lymph nodes

1. How was this patient positioned for simulation? What positioning devices/accessories were
used, how and why? (5 points)

The patient was simulated in the supine position with a 3D board and custom
thermoplastic cast over the patient’s pelvis. At my clinical site, custom thermoplastic
cast are used for pelvic cases to keep the patient in the same position everyday. The
patient also had a footlock, which holds the feet in place. This is important because it
can throw off hip alignment if the patient has their feet in a different position. The
patient had their arms on the chest, which moves it out of the treatment field. The
patient rests their head on a large square sponge (LSS) which is used as a cushion for
the patient.

2. Discuss the target dose as defined by your physician and the rationale behind the total
dose and fractionation regimen. Include any references or current research to help answer
the question. (5 points)

The patient has a gleason score of 7, T2a, PSA is 13 ng/ml. With this information, the
physician got their fractionation regimen from RTOG 0924. This patient was part of the
RTOG 0924 study arm 2, so his treatment was based on that protocol. The initial plan
called for 4500cGy in 25 fractions then a sequencial boost plan of 3420 cGy in 19 fractions,
giving the boosted area a total of 7920cGy in 45 fractions.1 The physician contoured the
CTV and PTV based on RTOG 0924 guidelines, which are dicussed in question #5.

3. What specific avoidance structures were contoured? Include a screen shot of your
contoured target and organs at risk. Create and embed a table of OAR tolerance doses
based on your physician prescription and include any associated QUANTEC values. List the
contraindications if tolerance doses were to be exceeded. (20 points)

OAR Tolerance from QUANTEC value Contradictions if

tolerance dose is
 physician prescription exceeded

Rectum V75<15%, V70<25%, V50<50% Procitis, necrosis,

V65<35%, V60<50% fistula, stenosis

Femoral heads V50<10%, Max 45 Gy V50<5% necrosis

Bladder V80<15%, V75<25%, V65<50% contracture

V70<35%, V65<50%

4. Identify any involved lymph node regions (chains) in your treatment port. Embed a screen
shot of the nodal regions with corresponding labels. (15 points)
5. Use your IMAIOS Subscription: http://www.imaios.com/en (Links to an external site.)Links
to an external site. and other anatomy references to describe the anatomical “boundaries”
(physical limits) of the area treated. (examples: hard palate, nasal chonae). Embed a
diagram and/or screen shot of your CT data to point out the boundaries. (20 points)
From RTOG 0924:

“The CTV_4500 will include the prostate and entire seminal vesicles and the pelvic
nodes CTVn, which include, the obturator, external iliac, proximal internal iliac and
common iliac nodes, using the vascular structures, up to a level corresponding to the
top of L4-L5 so that the entire common iliac nodes are included. For those patients with
significant small bowel adjacent the common iliac nodes, the superior contour may be
reduced to the top of L5-S1.
The presacral nodes from L5-S1 to S3 may be included if desired depending on whether
the dose constraints to the rectum are achievable. The CTV_4500 will extend superiorly
from at least L5-S1 (L4-L5 if feasible) to 0.5 cm below the tip of the urethral contrast
dye (if used) and no less than the entire prostate gland. The inferior extent of the
external iliac lymph nodes is at the top of the femoral heads. The inferior extent of the
obturator lymph nodes is at the top of the symphysis pubis. The CTV_4500 will include
a 7 mm margin in 3-dimensions to the contoured iliac vessels, but not extend outside of
the true pelvis, into the pelvic musculature nor into adjacent identifiable organs, such as
the bladder, rectum or other bowel. Extension of the CTV_4500 into adjacent bone may
be carved out.

Planning Target Volume (PTV_4500): The PTV_4500 margins should be a minimum of

0.5 cm and a maximum of 1.5 cm in all dimensions.”1

For Boost plan from RTOG 0924:

“Clinical Target Volume (CTV_7920): The CTV_7920 is the GTV (prostate) plus areas at
risk for microscopic disease extension plus the proximal bilateral seminal vesicles
(ProxSV). Only the proximal 1.0 cm of seminal vesicle tissue adjacent to the prostate
shall be included in the clinical target volume. This 1.0 cm of seminal vesicles refers to
both radial (in plane) and superior (out of plane) extent. If both prostate and seminal
vesicle are visualized in the same CT slice, this seminal vesicle tissue will contribute to
the 1.0 cm of tissue.

Planning Target Volume (PTV_7920): The PTV_7920 will provide a margin around the
CTV_7920 to compensate for the variability of treatment set up and internal organ
motion. A range of 5-10 mm around the CTV is required to define each respective PTV.
Individual selection of a PTV margin should be based on the institution’s level of
confidence in patient set-up and the availability of image guidance. Superior and
inferior margins (capping) should be 5-10 mm cm depending on the thickness and
spacing of the planning CT scan. Careful consideration should be made when defining
the 5-10 mm margin in 3 dimensions.“1
6. Describe, in detail, the radiation treatment technique used to treat this anatomical region.
(20 points)

Examples: Technique type (VMAT, IMRT, Conformal), VMAT-Number of arcs, their direction,
collimator rotations, number of degrees. Beam angles, couch rotations, field design, wedges,
use of split fields, etc. Include all specific setup information to describe your process. Include
any screen shots to help describe your plan design.
The technique used was VMAT. Three arcs were used.
Arc descriptions:
1 ARC CCW. 179 to 181. Collimator rotation 15.
2 ARC CW. 181 to 179. Collimator rotation 0.
3 ARC CCW. 179 to 181. Collimator rotation 345.
The field sizes were shaped and collimated so they would make the plan more conformal to
the PTV without introducing hot/cold spots. In arc 1, we clip part of the PTV because in arc 3, it
will catch it. Arc 2 has no collimation and it’s purpose is to catch the middle part of the PTV. No
couch kicks or wedges were used.
The initial plan fields are shown below from a beam’s eye view perspective. The boost plan
followed the same technique, but conforming to the boost PTV instead of the initial PTV.
7. Include a final DVH of your treatment plan with appropriate labels and discuss your ability
to meet the target and OAR tolerance guidelines. (15 Points)

All constraints were met for both the intial and boost plan. This was done with the use of
optimization structures (opti ptv 45, opti ptv 79, opti bladder 45, opti rectum 79, etc) which
work to push dose to the PTV while sparing the organs at risk. If there is overlap of a PTV
and OAR, then optimization structures can be made to make sure the overlapped
structures only get what they need to reach the dose, which prevents hot spots in the
overlap region (which helps the OAR not get more than it needs, while still providing the
PTV with the dose needed).
References:

1. NRG-alias Broadcasts. RTOG Foundation Inc.

https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?ptid=387&mode=b
roadcasts&page896=6&study=0924. Updated April 22, 2014. Access February 28, 2019.