Clinical Oncology Assignment

Hieu Tran

UWL Medical Dosimetry

DOS 531-501 Clinical Oncology for Medical Dosimetrists

April 27, 2023

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Introduction

The patient was diagnosed with prostate adenocarcinoma cT1cN0M0 and presented with
Gleason score of 4+3=7 and PSA (Prostate-specific antigen) of 12.9ng/ml. DRE or Digital Rectal
Exam was abnormal (T2b). There’s no metastatic disease as this time. National Comprehensive
Cancer Network (NCCN) classification of unfavorable intermediate risk. Surgery was another
treatment option, but the patient chose radiation therapy.

Patient Setup

The patient was simulated head first supine (HFS) legs on a combifix device @ D with
both hands holding on to blue circular “blue donut”. The patient was asked to come 1 hour
before simulation time to prep, the bladder needed to be full by drinking at least 32oz of water.
Empty rectum by having a bowel movement in the morning before coming in or prior to
simulation. The combination of full bladder and empty rectum kept the bowel superiorly, limit
dose to the empty rectum, and kept the prostate in the same place. The patient was asked to
change to a scrub pant before simulation and was asked to take it off before getting on the
simulation table to avoid the scrunched-up pant underneath the leges leading to extra elevation of
the legs during treatment. The protocol scan for a prostate with lymph nodes involvement is L2
to below the pelvis with 3mm slices.

Target/Prescription/Fractionation

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 The radiation oncologist prescribed 2 prescriptions: the initial prescription with a dose of
4500cGy in 25 fractions to the PTV4500 that included prostate gland and the lymph nodes; and
the boost prescription with a dose of 3420cGy in 19 fractions to only the PTV7920. This
combines to a total dose of 7920cGy. This is a common type of prescription for this type of
prostate cancer with nodal involvement.1

Structures/OAR

The OAR or organs as risk for prostate treatment are femurs, bladder, bowel, rectum,
sigmoid, urethra and the penile bulb.2 The prostate and seminal vesicle are part of the PTV.
Below are the contoured structures, OARs, and PTV.

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Plan Quality Evaluation (PQE)

My clinic utilized the Plan Quality Evaluation (PQE) that was generated by the physician
for each case. Not all PQE for the same treatment area is the same. The constraints and goals
may vary depending on the case and on what the physician wants to focus on. The PQE still
follows very closely to QUANTEC.

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Lymph Nodes

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Anatomy/Field landmarks.

The recommendation landmarks are 3mm surround the prostate-rectal interface and 5mm
for others.

PTV4500

Superior border - L5.3

Inferior border - Inferior border of prostate/ pubic symphysis with margin.3

Anterior border - Most Anterior section of the nodes and prostate with margin.3

Posterior border - Anterior side of spine, sacrum, pelvis and posterior side of
seminal vesicles and prostate with margin.3

Lateral border - cover lymph nodes, pelvic brim, and lateral sections of the
seminal vesicles and prostate with margin.3

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PTV 7920

Superior border - Superior of the seminal vesicles with margin.3

Inferior border - Inferior border of prostate with margin.3

Anterior border - Most Anterior section of the prostate with margin.3

Posterior border - Anterior side of rectum, posterior side of seminal vesicles and
prostate with margin.3

Lateral border - Lateral sections of the seminal vesicles and prostate with margin.3

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Treatment technique

PTV4500

VMAT or Volumetric Modulated Arc Therapy with 2 full arcs. The energy was 6MV.

Arc 1 (1_VMAT_182-178) rotates Clockwise (CW) from 182 to 178 with collimator at
10-degree, 4-degree gantry spacing and 5mm margin around PTV 4500.

Arc 2 (2_VMAT_178-182) rotates Counter-Clockwise (CCW) from 178 to 182 with

collimator at 350-degree, 4-degree gantry spacing and 5mm margin around PTV 4500.

1_VMAT_182-178 2_VMAT_178-182
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 Arc 1 (1_VMAT_182-178) weighed 52.53% with 437.7 MU and arc 2 (2_VMAT_178-
182) weighed at 47.47% with 395.5 MU. We achieved 100% of the dose cover 96.6% PTV4500.

PTV 7920 (Boost 3420cGy only)

VMAT with 2 full arcs. The energy was 6MV.

Arc 1a (1a_VMAT_182-178) rotates Clockwise (CW) from 182 to 178 with collimator at
10-degree, 4-degree gantry spacing and 5mm margin around PTV 7920.

Arc 2a (2a_VMAT_178-182) rotates Counter-Clockwise (CCW) from 178 to 182 with

collimator at 350-degree, 4-degree gantry spacing and 5mm margin around PTV 7920.

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1a_VMAT_182-178 2a_VMAT_178-182

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 Arc 1a (1a_VMAT_182-178) weighed 51.49% with 391.8 MU and arc 2a
(2a_VMAT_178-182) weighed at 48.51% with 369.1 MU. We achieved 100% of the dose
(3420cGy) cover 99.6% PTV7920.

PTV 7920 (Combine initial 4500 and boost 3420)

The final PTV7920 achieved 100% of the dose (7920cGy) cover 99% PTV7920 and the
hotspot was 106.3% (8426cGy). All the constraints and goals were met. I used rings surrounding
the PTVs to conform the dose. For PTV4500 there were 3 rings: Z45Ring1.5 (expand 1.5cm
from PTV4500 with 1mm avoid PTV4500), z45Ring3 (expand 3cm from PTV4500 with 1mm
avoid Z45Ring1.5), zRing6 (expand 6cm from PTV4500 with 1mm avoid z45Ring3). For
PTV7920 there were also 3 rings: zRing1 (expand 1 cm from PTV7920 with 1mm avoid PTV
7920), zRing2 (expand 2 cm from PTV7920 with 1mm avoid zRing1), zRing5 (expand 5cm
from PTV7920 with 1mm avoid zRing2). To reduce dose to the rectum I also created a rectum
void contour. The rings and the rectum avoid contour are shown in the 2 images below.

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Final dose coverage and distribution

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 Final DVH

OAR QUANTEC Objective Objective Met (Y/N) Complication if exceeded

Left Femur V50<5% V50=0 Y Necrosis
Right Femur V50<5% V50=0 Y Necrosis
Penile bulb Mean < 50Gy Mean=19.67Gy Y Erectile dysfunction
Bladder V70 < 30% V70 = 3.91% Y Grade 3+ Toxicity
Rectum V60<30% V60 = 12.48% Y Grade 3 toxicity < 10%
Sigmoid V50<20% V50 = 5.32% Y Grade 1-2 Diarrhea
Sm Bowel V45<200cc V45 = 16.12cc Y Grade 3 toxicity < 6%

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PQE scorecard (Constraints & Goal)

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Conclusion

Currently, the patient is at fraction 11 of the 25 initial 4500cGy. He is doing well,

presented with no symptoms like headaches, fevers, incontinence, diarrhea, rectal bleeding,
nausea, vomiting, abdominal pain, back pain, or bone pain. Pain score is at 0 out of 10. Patient is
set to have weekly on treatment visit (OTV) with the physician.

References

1. Khan FM, Gibbons JP. Khan’s The Physics of Radiation Therapy. 6thed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2020.
2. Khan FM, Gibbons JP, Sperduto PW. Khan’s Treatment Planning in Radiation
Oncology. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2016.
3. Washington C, Leaver D. Principles and Practice of Radiation Therapy. 4thed. St. Louis,
MO: Mosby-Elsevier; 2015: 513-535

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