ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

SCHOOL OF MEDICINE ONCOLOGY UNIT
PROTOCOL FOR PROSTATE PLANNING

Authors: Dr. Wondemagegnhu, Molalgn, Mitiku, Written on: 30 Apr 2017

Approved by: Dr. Wondemagegnhu Next revision date: 30 Apr 2019

To be revised by:

OBJECTIVE: To facilitate dose planning to prostate cancer patients with high energy photon
radiation.
SCOPE: This protocol is mainly focus on for 5 field arrangement for intermediate risk group of
prostatic ca.
1. Pre planning
Consent note and signature:
The aim of treatment, advantage and possible side effect will be explain by responsible
oncologist. The consent note has to be done and completed by the responsible clinical
oncology nurse.
Patient Positioning and immobilization: Supine-head to gantry, Hands on chest and use
Head foam, knee rest, and ankle stock for immobilization
Laser alignment and markup: Put three lead markers at the level of sagittal and two
side lazars as reference point for dose calculation and treatment setup.
Reference: In midline and 10cm above couch on left and right lateral sides and mark
using blue dotted line and add green sold line for isocentre.
Rectum and Bladder preparation for CT and Treatment protocol:
During CT and treatment; Rectum - empty and Bladder- full.
Drink 500ml water and wait 30min for scan and during treatment.
Radiotherapy planning imaging modality:
CT: Use of contrast- Oral contrast 20ml Gastrograffin diluted in 20ml of water-barium
mixture to delineate bowl.
MRI: Axial T2 weighted MR image to better visualize the apex of prostate.
Scan size and scan limits: Scan from L2/3 to 3 cm below ischium tuberosity using
3mm slice thickness + contrast.

2 Planning
Contouring and volume specification: The contouring shall be performed by a qualified
oncologist.
 Target Volumes and OARs:
Contour/organ Color landmark
name
Body Grey Skin
GTV Light The same as CTV
pink
CTV pink Vesicourethral anasthomosis (VUA) in the retropubic area 3-5
mm below the urine containing image and extending down up
to penile bulb, the anterior boarder will be the posterior aspect
of the pubic bone and extending to anterior muscular wall of the
rectum. Above the superior aspect of the pubic bone the
anterior boarder of the CTV encompasses the posterior 1 -2 cm
of the bladder wall and is bound posteriorly by mesorectal
fascia. At this level the later boarder is the
sacrorectogenitopubicfascia.
PTV Red 1 cm margin added anteriorly and laterally and 0.75 cm
posteriorly to the CTV
Organ at risk
Bladder Dark Inferiorly from its base, and superiorly to the dome
Yellow
Rectum Yellow Inferiorly from the lowest level of the ischialtuberosities (right
or left). Superiorly before the rectum loses its round shape in
the axial plane and connects anteriorly with the sigmoid.
Green The proximal femur inferiorly from the lowest level of the
Proximal femur/ and dark ischial tuberosities (right or left) and superiorly to the top of the
Femoral head (Left green ball of the femur, including the trochanters.
and right)
Small intestine Brown The small bowel can be outlined as loops containing contrast.
Bowel bag Light Contour the abdominal contents excluding muscle and bones,
brown then subtract any overlapping non-GI normal structures.

Dose prescription: The dose to the tumor shall be prescribed by a certified radiation
Oncologist. Radiotherapy is given daily (5 days/week) for 37 - 39 fractions 2 Gy per
fraction for a tota1 dose of 74 -78 Gy.
 Dose constraints (QUANTEC):
Priority Volume Constraints Endpoint (side
effects)

PTV V100 ≥ D95 No

slice with PTV
getting > 107%

Bladder Bladder Whole organ< 65 < 6% chance for

Gy Grade 3 toxicity

Rectum Rectum V50 < 50% of < 15 % chance for

whole organ grade ≥ 2 late
rectal toxicity
necrosis

< 15 % chance for

V60 < 35% of
grade ≥ 2 late
whole organ
rectal toxicity
necrosis

V65 < 25% of < 15 % chance for

whole organ grade ≥ 2 late
rectal toxicity
necrosis

< 15 % chance for

V70 < 20% of grade ≥ 2 late
whole organ rectal toxicity
necrosis

Femoral head/ Femoral head Whole organ ≤ 5% chance of

Proximal femur 52Gy necrosis

Bowel bag Bowel bag V45 < 195cc 10% chance grade
3 acute toxicity

Small intestine Small intestine V15 < 120cc 10% chance grade
3 acute toxicity
 Other concomitant therapies: Hormonal therapy
Treatment planning: The planning should be performed by a qualified physicist.
Field arrangement: Add 5 isocentric 15 MV photon beams at gantry angles 0,
80,100, 280 and 260. Adjust the tilt of the lateral beams and shape of MLCs to
conform to the shape of the PTV with uniform margin of 1cm. put appropriate
wedges on the two lateral fields to gate 95% coverage of PTV in 3D.

Dose calculation: AAA algorithm, matrix size of 2mm, homogeneity correction on.
3 Plan pass:
Plan parameter and secondary MU checks:
A qualified physicist other than the one who did the plan should be responsible to check:
Beam position, beam energy, MLC/Wedge, beam weighting, BEV, number of fields,
95% coverage for each slice, hot and cold spots. The MU calculated with the TPS shall
be validated with a different calculation method and the difference shall be within 5%.
Final treatment plan approval: The oncologist shall be responsible for approving the
radiation treatment of the patient accordingly to the treatment plan. He should check the
DVH to see whether all the constraints are met.
4 Quality Management:
Setup Verification: The assigned RTT should check the planning and treatment
isocentre by comparing the EPID image with the DRR weekly. Isocenter shall be moved
if the treatment setup is displaced from the planned setup by more than 10 mm. The
actual treatment fields should be checked daily for the MLC shape and beam position.
In vivo diode checks: Diode measurements should be accomplished at the first fraction
by the RTT on duty. The diode should be placed at the center of the light field projected
on the skin surface. Diode readings should agree with the reported (TPS) dmax doses
within 10 %. In case of >10 % discrepancies, the physicist shall be informed and the
necessary corrective actions shall be taken before the next fraction continues.