Benjamin Smith

DOS 531 Clinical Oncology

Clinical Oncology Assignment

For this project, I chose a primary pelvis with lymph nodes. More specifically, this particular
patient was diagnosed with node positive, locally advanced rectal adenocarcinoma. I was able to
contour all the structures for this patient aside from the PTV and lymph nodes involved. I also
planned the patient which will be discussed later in the paper.

1. The patient was simulated prone on a belly board that is indexed to the treatment table.
The belly board is often used for rectal patients for a few reasons. The belly board is
raised with a hole cut out in the middle which allows the abodmen to fall through it. This
helps push the small bowel more superior and anterior, thus farther away from the rectum
which will ultimately help with dose sparing. Small bowel is an OAR which is why this
process is important. There is another hole inferior to the abdomen which is designed for
the male genitalia. Like the small bowel, the genitals are an OAR which is why is
important to have them as far away from the treatment fields as possible. The patient has
a prone head rest for comfort with his arms up around his head. The patient must not
have any accessory metal objects in the CT scan, which is why it is imperative that he
have his pants with belt down for the scan and future radiation treatments.

2. The physician prescribed 180cGy for 25 fractions with a total dose of 4500cGy (45Gy).
The patient will also be receiving a boost of 180cGy for 3 additional fractions to a
smaller area for a total dose of 5040cGy (50.4Gy). This fractionation scheme of 45-50Gy
in 25-28 fractions is the standard when treating preoperative locally advanced rectal
cancer.
This is referenced in several publications including the following:
a. Huang MY, Lee HH, Tsai HL, et al. Comparison of efficacy and safety of
preoperative Chemoradiotherapy in locally advanced upper and middle/lower
rectal cancer. Radiat Oncol. 2018; 13(53). https://doi.org/10.1186/s13014-018-
0987-0.
b. Park SH, Kim JC. Preoperative chemoradiation for locally advanced rectal cancer:
comparison of three radiation dose and fractionation schedules. Radiat Oncol J.
2016; 34(2): 96-105. doi: 10.3857/roj.2016.01704.

3. For this patient, I contoured the bladder, the bowel bag (small bowel), femoral heads, and
genitals. I have included a screenshot of the axial, sagittal, and coronal planes
showcasing the contours. I also embedded a screenshot of the 3D view showing the PTV
(rectum) as well as the OAR contoured and labeled.
Here is the Table of OAR tolerance doses based on the physician prescription. I made sure to include the
QUANTEC or RTOG values for each OAR. The QUANTEC value for bladder is V65Gy<50%. The QUANTEC
value for small bowel is V45Gy<195cc. The RTOG value for femoral heads is V50Gy<5%. Even though
there is not a QUANTEC or RTOG value for genitals, my clinical site has a set of variables they use that
need to be met. The only variable that was not met was the Femurs_Head V30Gy<50%. The acceptable
variance at my clinical site is Femurs_Head V44Gy<5%. This was met. The RTOG value for femoral
heads was met as well. With some of the femoral heads within the treatment fields, this higher dose is
expected which is why there is an acceptable variance should the first tolerance not be met.

4. For this patient, the physician contoured the common Iliac as well as the internal iliac lymph
nodes. I have included 3 screenshots. The first one shows the nodal regions in the contouring
window with both regions labeled.
This is a PA port for the patient showing the nodal regions being in the treatment field. They are
labeled.

This is a 3D view of the patient with the nodal regions labeled.

 5. For rectal cancer patients being treated with external beam radiation therapy, certain
anatomical boundaries need to be covered in the treatment fields. In this case, the physician
chose to use 3 fields to treat the patient. There is a posterior, right lateral, and left lateral field.
With the posterior field, the width covers the pelvic inlet with a 2cm margin. The superior
margin is at the L4-L5 junction to include the common iliac and internal iliac lymph nodes with
margin. The inferior border is about 1.5-2cm below the obturator foramen to fully include the
rectum with a 3cm margin. In the lateral fields, the posterior region is 1-1.5cm behind the sacral
canal. This is for patients with locally advanced disease to avoid possible sacral recurrence along
the sacral nerve roots. The margin allows for daily setup error as well. The anterior border is
placed anterior to the femoral heads. This allows for coverage of the internal iliac and common
illiac lymph nodes.

Right Lateral Field

PA Field

6. For this rectal case, a 3 field, 3D conformal plan was used for treatment. The 3 fields were a PA,
right lateral, and left lateral. The gantry angle for the PA was 0 degrees (patient is prone) with
the right lateral field having a gantry angle of 90 degrees. Lastly, the left lateral field had a
gantry angle of 270 degrees. The couch and collimator angles were at 0 degrees for all 3 fields. I
used a field weight total of 1 and planned to 100% in Body Maximum. I used segments (field in
field) for dose distribution. I ended up with 6 segments for the left lateral field and 5 segments
for the right lateral field. I also used one segment for the PA field. With these segments, I used
MLC leaves to cover certain isodose levels to push the dose anterior, superior and inferior as
well as reducing any hotspots. With my final plan, I was able to normalize to the 94% isodose
line which covered the PTV and lymph node region with 100% of the prescribed dose.
This screenshot shows how 3 fields were used to treat this prone patient.

The screenshot below of the right lateral field shows the various segments used for dose distribution.
The screenshot below shows how the 94% isodose line fully encompases the PTV with lymph nodes. I
normalized to this 94% isodose line.

7. Below is the final DVH of my treatment plan

I was able to meet the Target guidelines with my treatment plan. The V45Gy target value for the PTV
was 95% and the actual value was 100% of the volume covered. The V45Gy also covered 100% of the
volume for the internal iliacs and common iliac. For the bladder, the QUANTEC tolerance value is
V65Gy<50% and the actual value for my plan was 0% which definitely meets the guideline. For the
femoral heads, the RTOG tolerance value is V50Gy<5% and the actual value was 0% which meets the
guideline. The QUANTEC tolerance value for the small bowel is V45Gy<195cc and the actual value was
126.9cc which meets the guideline. For the genitals, my clinical site has a tolerance value of V20Gy<50%
and the actual value was 2.37% which meets the guideline.