Jamie Robinson

University of Wisconsin-La Crosse

Dos 531 – Clinical Oncology

April 21, 2023

Clinical Case Review of a Patient with Prostate Cancer and Lymph Node Involvement

Introduction

In some instances, prostate cancer goes undetected until symptoms arise, especially in its
early stages. Once symptoms are present, men can experience blood in the urine, nocturia and
hesitancy with urination, among others. In this clinical case, a 57 year-old African American
male was experiencing these symptoms which prompted him to see his primary care physician.
Upon work up, the physician conducted an AUA symptom score and a Prostate Specific Antigen
(PSA) screening test as the patient was over the age of 50 and had a family history of prostate
cancer. The patient’s PSA came back as 30.70 and his AUA was 14. The patient was referred to
a urologist who conducted a prostate biopsy. The biopsy demonstrated a Gleason Score of 3+4
(7) and no evidence of extracapsular extension or locoregional disease.

The patient was then referred to our clinic with a diagnosis of an intermediate risk of
adenocarcinoma of the prostate, stage IIC. He was seen in consultation by our physician and was
recommended a curative course of radiation treatment to the prostate, seminal vesicles, and
pelvic lymph nodes. During the consultation, the patient was given several options including
surgery, hormonal therapy, and external beam radiation therapy (EBRT). Due to his elevated risk
of disease, he was not a suitable candidate for brachytherapy. After some consideration, the
patient refused surgery and elected to have EBRT in addition to hormonal therapy. The patient
was then scheduled for a planning computed tomography (CT) simulation.

Simulation

Before returning to the department for his planning CT, a radiation therapist discussed
with him how to achieve a full bladder for his planning CT and treatment. For all patients
receiving EBRT to the prostate, they must have a full bladder. Patients are instructed to urinate
two hours prior to their appointment and then drink 16-24 ounces of water and not urinate until
after their appointment. With a prostate cancer diagnosis, this is not an easy task for most
patients. If the amount of water requested to drink is too much for the patient, it is modified until
they achieve a consistent, comfortably full bladder for twenty minutes. By having a full bladder,
the bladder is filled like a balloon and in theory allows for less of the bladder to be treated
therefore reducing any potential urinary side effects.

When the patient arrived for the planning CT, he changed from the waist on down and
donned a hospital gown. In the CT room, the patient was positioned head first supine on the CT
table. To create a reproducible treatment position, a vac-lok was placed under his legs and
formed around them via vacuum suction. His head was on top of a solid head rest and his hands
were placed high on his chest. He was given a ring to hold onto with the intent to keep his arms
and hands out of what would become the treatment field. Since the prostate is a movable
structure and can change daily with rectal and bladder filling, typically, a SpaceOAR is placed
between the prostate and the rectum and fiducial markers are placed in the prostate prior to a
planning CT for daily localization. However, in this case, the patient refused, and the physician
requested a rectal balloon to be placed into the rectum. The rectal balloon was expanded with
100cc of air on the day of the sim and for daily treatment to aid in prostate immobilization.

A short CT scan was obtained imaging T12 through the bottom of the buttocks with 2
mm axial slice thickness. The physician was present to oversee the CT scan and confirmed the
full area of interest was present in the images. Tattoos were placed on the patient’s pelvis at the
CT zero marks to ensure accuracy and reproducibility in daily positioning. Once this was
completed the CT scan was sent to the Eclipse planning system.

Target Dose

Traditionally prostate cancer that is intermediate risk, has been treated with EBRT to
doses up to 81Gy with standard fractionation of 1.8-2 Gy per fraction over the course of
approximately eight weeks.1 Pelvic lymph nodes would also be included in this treatment
regimen but would receive a lower radiation dose than the prostate equating to 45-50 Gy
combined with hormonal therapy.1 Clinical research trials have found that patients with
intermediate prostate cancer can receive the same results with hypofractionation as they would
with traditional high-dose radiation treatments.2 The hypofractionation dose recommended in
these trials is 60 Gy in 20 fractions with a simultaneous integrated boost (SIB) of 44 Gy in 20
fractions to the pelvic lymph nodes.2

The physician that the patient saw in consultation recommended the hypofractionated
course of EBRT with a total dose of 62 Gy in 20 fractions with a SIB totaling 44 Gy in 20
fractions. Acute and late toxicities were expected to be the same as the traditional high dose
approach. These side effects included fatigue, bowel and bladder irritation that could lead to
urinary frequency, urgency or dysuria, loose bowel movements and the possibility of erectile
dysfunction in coming years.2

Avoidance Structures

Due to the potential side effects that this patient could experience, avoidance structures
were contoured on the planning CT in Eclipse by the dosimetrist. These structures included the
bladder, rectum, penile bulb, small bowel and both the right and left femur. In figure 1, you will
see these avoidance structures contoured.

Figure 1. Avoidance structures

 For each individual critical organ, a Quantitative Analyses of Normal Tissue Effects in
the Clinic (QUANTEC) values have been established.3 Below is a table, figure 2, of the organs at
risk within the treatment plan and their tissue tolerance doses.

Critical Volume Dose/Volume Toxicity Toxicity Endpoint

Structure Rate
Bladder V65 <50% ---Grade 3 Toxicity
V70 <35% ---Grade 3 Toxicity
V75 <25% ---Grade 3 Toxicity
V80 <15% ---Grade 3 Toxicity
Bowel V45 <195 cc <10% Grade 3 Toxicity
Femur R&L V50 <5% --- Necrosis
Penile Bulb Mean dose to <50 Gy <35%
Severe Erectile Dysfunction
95% of the gland
D90 <50 Gy <35% Severe Erectile Dysfunction
D60-70 <70 Gy <35% Severe Erectile Dysfunction
Rectum V50 <50% <10% Grade 3 Toxicity
V60 <35% <10% Grade 3 Toxicity
V65 <25% <10% Grade 3 Toxicity
V70 <20% <10% Grade 3 Toxicity
3
Figure 2. QUANTEC OAR Tolerance Table

Lymph Node Regions

The treatment port shown in figure 3 illustrates the regional lymph nodes involved in
prostate cancer. These nodes include the common iliac nodes, internal iliac nodes, external iliac
nodes, presacral nodes, and the obturator node. The lymph node clinical tumor volume (CTV)
also includes the lymph node’s arteries and veins.5
 Presacral Nodes
Common Iliac Nodes

External Iliac Nodes

Internal Iliac Nodes
Obturator Node

Figure 3. Lymph Node Regions

Anatomical Boundaries

The anatomical boundaries to be treated are defined by the International Commission on

Radiation Units and Measurements (ICRU).4 These guidelines “for treatment planning take into
account extent of gross tumor, microscopic extension, daily variation in treatment setup and
tumor position.”5 Specifically for treatment to the prostate and pelvic lymph nodes, it is
important to ensure that the prostate, seminal vesicles, periprostatic tissue and involved lymph
nodes are included within the field while minimizing exposure to the bladder and rectum.

In figure 4, the blue square outlines the anatomical boundaries to be included in the
treatment field. The superior border includes L5-S1 interspace, extends inferiorly to the bottom
of the obturator foramens, and laterally approximately 1.5 cm-2 cm past the pelvic brim.5 The
anterior border on the lateral field (not shown), should include the pubic symphysis and the
posterior border should include the rectum.5,6 The lateral posterior field border is modified so
that only one-half of the anterior rectum is within the field with the intent to minimize dose to the
rectum.5,6
 Figure 4. Anatomical Boundaries

Radiation Therapy Treatment Technique

Intensity modulated radiation therapy (IMRT) and volumetric arc therapy (VMAT) have
become the standard of care when treating prostate cancer. With this treatment technique, a
uniform dose distribution with dynamic multi-leaf collimators (dMLC) create a sliding window
technique and a sharp fall off dose compared to a traditional 3D conformal, 4 field treatment
plan. Volumetric arc therapy and image guided radiation therapy with daily cone beam CT were
deemed medically necessary to treat this patient to acquire an optimal dose to the target and
spare those adjacent organs at risk (OAR).

The physician contoured the CTV, and the dosimetrist contoured the organs at risk on the
planning CT. Per RTOG 0924, it is recommended that a 0.5 cm-1 cm margin is to be added to
the prostate and seminal vesicles.5 In this case, the physician instructed to have a 0.7 cm margin
around the CTV of the nodal volume. The prostate, on the other hand, was instructed to have a
0.5 cm margin in all directions except for the posterior, where a 0.3 cm margin was placed to aid
in dose minimization to the rectum.

Once the contours were finalized and the specified margins were set, inverse planning
was initiated for the SIB and planned tumor volume (PTV). The Photon Optimizer (Version
15.6.06) was used for the optimization algorithm with a 0.25 dose grid size, algorithm
AAA_15606 and heterogeneity corrections on (shown in figure 5). After the optimization was
completed, a composite plan with dose painting was created and the dose distributions were
evaluated by the dosimetrist and physician. In our clinic, treatments are prescribed to the 100%
isodose line to cover 95% of the PTV. This can typically be achieved in the inverse planning;
however, modifications may need to be made if the dose to the OAR is too high. To do this, the
weighting of the fields can be changed so that critical structures receive less dose and full
coverage remains on the PTV. This plan resulted in a 100% relative dose at the primary
reference point and a global max dose relative to 109.7%. No plan normalization was needed and
an isocenter was established resulting in two shifts from the CT zero marks placed on the patient.
The isocenter shifts were 1 cm to the right and 2 cm inferior.

Figure 5. Plan Properties

This patient’s plan resulted in four 10 MV treatment arcs, alternating clockwise to

counterclockwise shown in figures 6 and 7. The first arc was clockwise with a dose rate of 600
MU/min. The gantry start angle was 181 degrees and stopped at 179 degrees, with the collimator
at 30 degrees and couch rotation of 0 degrees. The field size was asymmetric with X1=7.9 cm,
X2=6.6 cm, Y1=9 cm and Y2=8.5 cm. The second arc was counterclockwise with a dose rate of
600 MU/min. The gantry start angle was 179 degrees and stopped at 181 degrees, with the
collimator at 330 degrees and couch rotation of 0 degrees. The field size was asymmetric with
X1=6.8 cm, X2=7.8 cm, Y1=9 cm and Y2=8.5 cm. The third arc was clockwise with a dose rate
of 600 MU/min. The gantry start angle was 181 degrees and stopped at 179 degrees, with the
collimator at 85 degrees and couch rotation of 0 degrees. The field size was asymmetric with
X1=8.5 cm, X2=6.5 cm, Y1=8.3 cm and Y2=8.0 cm. The fourth and final arc was
counterclockwise with a dose rate of 600 MU/min. The gantry start angle was 179 degrees and
stopped at 181 degrees, with the collimator at 275 degrees and couch rotation of 0 degrees. The
field size was asymmetric with X1=7.3 cm, X2=7.7 cm, Y1=8.3 cm and Y2=8.0 cm.

Figure 6. Treatment Parameters

 Figure 7. Beam’s Eye View of Treatment Arcs 1-4

Dose Volume Histogram

A final dose volume histogram (DVH) of the treatment plan was created to show
“quantitative information with regard to how much dose is absorbed” within each defined
structure.4 In figure 8, the final DVH is shown with each structure of interest, the coverage,
specific volume of the structure, as well as the min, max, mean, modal and median dose. The
ClearCalc data program was also utilized to analyze this data in comparison to the prescription
tolerances. The target and bladder did present challenges when striving to meet the tolerance
guidelines. With nodal involvement it is common to have overlap of the nodal PTV and the
bladder.

Per our ClearCalc report, three different bladder constraints are taken into account and
the CHHiP (1) guidelines are followed. The bladder CTV has a constraint of V100% less than or
equal to 5%. In this plan, despite multiple attempts to correct this, 10.184% was the result. The
second constraint is V48.6 Gy less than or equal to 25%. The V48.6 Gy resulted in 26.1%, just
slightly over the maximum constraint. The final bladder constraint was V40.8 Gy less than or
equal to 50%. This final constraint was met at 38.437%. The physician in this case, did not want
to risk the coverage on the PTV so she allowed a higher dose to the bladder despite the first two
constraints not being met.

Figure 8. Final DVH

Conclusion

In conclusion, the patient completed his prescribed hypofractionated course of EBRT to

the prostate and lymph nodes over the course of four weeks with no delays. He did experience
mild side effects; however, he could manage them with the help of his Oncology team.

Sources:
1. Vann A, Lenards N, Weege M. Prostate Cancer. [SoftChalk]. La Crosse, WI: University
of Wisconsin- La Crosse. Overview (softchalkcloud.com). Last updated March 14, 2023.
Accessed April 21, 2023.
2. Faria S, Ruo R, Perna M, et al. Long-Term Results of Moderate Hypofractionation to
Prostate and Pelvic Nodes Plus Androgen Suppression in High-Risk Prostate Cancer.
Science Diet. Practical Radiation Oncology. 2020;10(6): e514-e520.
https://doi.org/10.1016/j.prro.2020.06.012
3. Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC). WIKI Books.
Radiation Oncology/Toxicity/QUANTEC - Wikibooks, open books for an open world.
Edited September 23, 2015. Accessed April 20, 2023.
4. Lenard N, Vann A, Tobler M, Apinorasethkul O. Tools in Conformal Planning.
[SoftChalk]. La Crosse, WI: University of Wisconsin-La Crosse. Planning Tools
(softchalkcloud.com) Last updated November 7, 2022. Accessed April 21, 2023.
5. Khan F, Gibbons J, Sperduto P. Khan’s Treatment Planning in Radiation Oncology,
fourth edition. Philadelphia, PA: Wolters Kluwer; 2016.
6. Bentel G. Radiation Therapy Planning, 2nd Edition. New York: McGraw-Hill Companies,
Inc; 1996.