Ryan Monago

DOS 531
Clinical Oncology Assignment
Introduction:

For this clinical case study, I chose a primary pelvis volume modulated arc therapy (VMAT) case
completed with the guidance of a clinical instructor. The patient included was diagnosed with squamous
cell carcinoma of the anus. This patient received two excisional biopsies before being consulted for
definitive radiation. This patient is unique in that they are not recommending adjuvant chemotherapy
for this case based on the medical oncologist. The tumor has spread locally to include lower levels of the
rectum. The stage for this patient is T3: N1: M0. The following document will explain the process of
clinical decisions utilized to create a dosimetrically acceptable treatment plan according to this patient’s
diagnosis.

Patient Simulation:

The patient was positioned headfirst, supine for their CT simulation. The CT simulator used was
a Canon Celesteion. During simulation a VacLok was positioned underneath the patient’s legs to provide
stability and reproducibility of the lower half of the body. This is important to limit mobility of the
patient’s legs throughout treatment. The VacLok creates a mold surrounding the patient’s legs that
hardens and is specific to their anatomy. Other techniques possibly used would be a prone technique if
the tumor location was more superficial. Prone in that situation would allow us to limit the folding of
gluteal tissue by spreading the folds. In this case, the physician noted that supine would be appropriate
due to tumor location and extent. The top half of the patient’s body is less concretely positioned. We
had a standard pillow underneath the patient’s head. The arms need to be positioned high and out of
the possible treatment field levels, so they are on the chest holding a cushioned ring. This technique
allows the patient to keep arms comfortable and positioned out of the fields. The patient had their legs
flat against the VacLok bag by order of the physician.

Another important aspect of patient simulation, besides patient external positioning is

anatomical positioning. For this case, the physician requested empty rectum and full bladder. This is
important for planning and alignment during registration each fraction. The rectum volume being
reduced by voiding is a tactic to limit the size of our treatment field and thus dose to other areas. When
the bladder is full, it pushed the small bowel/ bowel bag further from the treatment volumes. It can be
difficult for some anal/rectal cancer patients to void completely due to physiological complications.

Physician Dose Prescription:

Target dose and dose fractionation is a complex decision made by each patient’s radiation
oncologist. There are many RTOG protocols and dose constraints for healthy structures developed
through patient research. For this specific case, I asked the physician what protocols they followed
regarding target dose and fractionation. This patient, because of their diagnosis and current clinical
options, is being treated to 4500 cGy and 5400 cGy. This treatment prescription is considered to include
a simultaneously integrated boost. The boost volume is the primary tumor, while the whole volume of
nodal involvement is going to 4500 cGy. The RTOG protocol followed suggests that for patients with anal
canal carcinomas that fall into a certain staging, T3-4: N0-3: M0, elective nodal treatment to 4500 cGy
and primary treatment to 5400 cGy can reduce acute morbidity for these patients. 1 These doses are
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DOS 531
Clinical Oncology Assignment
from a Phase II trial, RTOG 0529 for anal cancers. The fractionation of the dose was 150 cGy/180 cGy for
30 fractions totaling 4500/5400 cGy.1

Organs at Risk and other dose limiting considerations:

The pelvis is an area that has multiple different organs at risk (OAR), and their consideration in planning
is altered based on location of the planning target volumes. This case as mentioned previously, is an anal
and rectal cancer patient. The structures specifically contoured for dose avoidance are: Bladder, Bowel
Bag, Femoral Heads, Genitals, and Transplant Kidney. The rectum was contoured, but due to the
location of the pathology was not optimized for dose constraint. Below are images of contoured targets,
contoured organs at risk and OAR dose tolerances from QUANTEC. The OAR constraint table does show
the preferred Bowel_Bag dose constraint failing. Per our physicians at VCU Health, if the PTV overlaps
with segments of the Bowel_Bag contour the .03 cc max dose constraint has an acceptable variation of
105% PTV prescription dose, which in this case is 5670 cGy. The reliance on this acceptable variation
depends case to case what the physician is more concerned about.

(Screenshot of lower dose PTV_4500 for elective nodal irradiation)

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DOS 531
Clinical Oncology Assignment

(Screenshot of PTV_5400 and GTV of anorectal tumor)

(Screenshot of OAR structures contoured with labeling associated on index)

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DOS 531
Clinical Oncology Assignment
 Ryan Monago
DOS 531
Clinical Oncology Assignment
The above table is site specific dose tolerance values used during plan optimization for this
specific VMAT plan. As mentioned previously, due to the overlap area of Bowel_Bag and PTV_5400, the
acceptable variation dose constraint was met and approved. Below listed are QUANTEC dose constraints
for these organs at risk. Following each QUANTEC constraint is a complication/contraindication from
exceeding those limits.

Within the QUANTEC summary, the whole bladder contour dose constraint is a dose max of
6500 cGy. The complication associated with exceeding that dose is grade 3 toxicities at a 6 percent rate. 2
The bowel bag or small bowel QUANTEC constraint is volume receiving 4500 cGy less than 195 cc. The
associated risk involved with exceeding that dose is grade 3 or worse acute toxicity based on the entire
potential peritoneal location of the bowel. 2 The femoral head dose limit according to RTOG 0529 is as
listed in the site-specific constraints, 50 percent getting less than 3000 cGy. 1 The associated
contraindication is radiation induced necrosis. Also following RTOG 0529, the external genitalia dose
limits are as listed in the chart above. The constraints are 50 percent less than 2000 cGy, 35 percent less
than 3000 cGy, and 5 percent less than 4000 cGy. 1 The final dose limiting structure included in our OAR
list is the transplant kidney. I reached out to the primary physician on this case to understand why we
used this specific value. The limit was 600 cGy to 30 percent of the solitary kidney. The key
nomenclature here is solitary, since this is the only patent kidney this patient has, we utilize stricter
constraint values. QUANTEC has a constraint requirement that if one kidney exceeds 1800 cGy, the
remaining kidney should be kept to 600 cGy less than 30 percent. In this case, a solitary kidney would be
defined as the remaining volume at risk. 2 The contraindication for exceeding this dose is clinically
dysfunction of the kidney.2

Lymph Node Involvement:

Due to patient diagnosis, based on stage and clinical compounding factors, the physician and
patient elected to treat nodal regions within the pelvis. Below are images representing the different
lymph node chains treated in association to this anorectal cancer.
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DOS 531
Clinical Oncology Assignment

The resources used to supply labeling in the above DRRs were previous lecture slides giving
examples of pelvic lymph structure, online contouring guidelines and physician conversations. 3,4 There
are many lymph node chains within the pelvis and different tumors at different stages will include
unique sets of nodal CTVs. Based on this patient’s diagnosis and inability to receive chemotherapy, these
were the lymph node chains included to best treat this specific patient according to their physician.

Anatomical Boundaries of Treated Volume:

There are multiple guiding structures of the pelvis when contouring tumor/treatment volumes.
In this patient’s case, the superior region of the volume is drawn to include the bifurcation of the
common iliac artery/vein and its surrounding nodal involvement. At this level of the axial pelvis, the
posterior border is represented by the anterior border of the sacral bone. Laterally the pelvic brim and
sacral ala encompass the CTV. This represents the boundaries used for the most superior region of the
treatment volume.

As we move inferiorly in the patient new anatomy arises and so do new boundaries. Anteriorly
the volume reaches near the pelvic wall but is contoured to include the external iliac artery/vein. 3
Laterally the anatomic boundary seen at this level is the ischial spine medial border. The tumor volume
does not extend into bone due to the diagnosis and histopathological spread patterns of this squamous
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DOS 531
Clinical Oncology Assignment
cell cancer. Posteriorly at this level the coccyx is set as the boundary, with the contour following the
peritoneum as well.

Inferiorly, the target volume has even more anatomical boundaries. The rectal mass CTV uses
the perianal and perirectal space as a contouring guide. The superficial nodal regions are contoured
using the muscles as borders.3 Around this level of the femoral artery/vein are the sartorius muscle and
pectineus muscle heads.3 Included in the related images is a sagittal view to represent the intergluteal
cleft as the most inferior border, because as one moves further along in the axial plane the contours
would then leave the body.
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DOS 531
Clinical Oncology Assignment
 Ryan Monago
DOS 531
Clinical Oncology Assignment
Treatment Technique:

This plan was insurance approved and prescribed to be treated as a volume modulated arc
therapy plan (VMAT). This method was used in attempt to limit high dose volumes to organs at risk.
When planning this patient, my clinical preceptor and I elected to use 10 MV as our photon energy. This
is a standard for pelvic VMAT plans at our clinical site. Based on patient thickness and location of the
PTVs, this was the best suited energy. There are special considerations when planning a VMAT case that
3DCRT cases do not need to look out for. When we first put on the field and use the arc geometry tool,
we select the PTV total that includes both planning volumes. The treatment planning system will then
recommend an arc set up. The set up recommended may not always be ideal, and it is crucial to
evaluate some other factors before planning. We ended up going against the recommended single
isocenter, 1 full rotation suggestion. Originally, we decided to use 2 full rotations. Once we applied these
features the software gives the planner their arcs. We used a collimator angle of 15 degrees and a
compliment angle of 345 degrees. After fine tuning our fields with a target margin of .5 cm, the X
direction field size was 24 cm. Based on limits of the multileaf collimator (MLC) this could inevitably
provide inadequate coverage to the PTVs. The leaves can only travel so far (roughly 14 cm). To account
for the large field size of this tumor, we added a third arc field. We alternated the gantry for all three
arcs and used a compliment angle in between for the third added arc. The fields then are adjusted so
that the X direction is roughly 14 cm for all three fields with the added arc field covering the gap within
the middle. The arc directions were counterclockwise (CCW), clockwise (CW), and then counterclockwise
(CCW). The final collimator angles were 15 degrees for arc 1, 345 degrees for arc 2, and 5 degrees for arc
3. Images below are included to show field design.

When first opening the optimizer, we made sure the settings were appropriate and used
intermediate dose since this was our first iteration of the planning process. The normal tissue objectives
were set how we wanted, and the MU ratio was adequate for our site (try to keep below 4.0 ratio of
MU/cGy). During optimization we created a multitude of objectives to help shape dose as the optimizer
works its way through MR levels and steps. A chart is included below to show all planning objectives,
upper, lower, and mean limits. During planning we carefully watched maximum dose (Dmax) values and
where there were cold/hot spots in the plan. As the optimizer goes further along in the process, the plan
becomes more fine-tuned. After one iteration within the optimizer, we had a plan that needed to
address certain concerns. The PTV coverage was not adequate, there were multiple regions lacking the
prescription doses. To address this issue, we created planning cold structures labeled accordingly
(z_PTV54cold and z_PTV45cold). The purpose of these structures are to signify in the optimizer that
certain dose should include these entire regions. Using the freehand contour tool, we create these
regions by assessing the prescription isodose level. Once completed we reopened the optimizer to
complete a second iteration and further fine tune this plan. By creating objectives to have lower limits
on the cold structures we hope to increase the PTV coverage. Based on anatomical location these cold
spots most likely came from the small bowel OAR abutting the PTV volumes in these regions or being
near intestinal air.

After adding these structures, we went back to the optimizer to complete the second iteration.
Within the optimizer, we did not restart the entire optimization process. Rather, we continued the
process and utilized the intermediate dose that was already calculated. After this run in the optimizer,
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DOS 531
Clinical Oncology Assignment
our plan was meeting all our expected clinical goals and the PTV coverage was acceptable (99.71% for
the PTV_4500 and 99.11% for the PTV_5400).

(Above: Optimization Objectives and Below: Fields screenshot with specific values highlighted in red)
 Ryan Monago
DOS 531
Clinical Oncology Assignment
 Ryan Monago
DOS 531
Clinical Oncology Assignment

Plan DVH:

The image below contains the final dose volume histogram (DVH) evaluated and approved by
the physician. While discussing the plan, we spoke about the difficulties meeting the preferred bowel
bag dose constraint. The PTV 5500 cGy overlapping with the bowel essentially eliminated the ability for
us to adequately cover the PTV and limit bowel dose. The physician was concerned about the target
dose and elected to accept the variation of the small bowel constraint shown in the clinical goals section
(D.03cc< 5670 cGy). I included in the DVH the rectum. This was not an OAR for this patient since the anal
tumor had been clinically present in this region. I wanted to show the dose to the structure anyways
since we had the information available to us. We met all our target and OAR goals. The target doses
shown represent at least 99% coverage of both planning volumes. The highest PTV encompassing the
tumor bed and margin was covered by 99.11%. The nodal region PTV was covered by 99.71% of the
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DOS 531
Clinical Oncology Assignment
prescription dose. Within the pelvis, dose constricting organs like the bowel bag and rectum can often
prove difficult to meet constraints. As I mentioned, the rectum was the site of interest in this case and
did not require a clinical goal. The bowel bag was the one structure we struggled to meet the preferred
variation on and that was due to overlap with the highest PTV. An image of the final DVH is shown
below, with the dose statistics included as well.

Conclusion:

This plan was completed with the guidance of a clinical preceptor. They helped me to recognize
critical factors necessary for completing this plan specifically. It is important as we continue to grow into
dosimetrists that we continuously are willing to gather new skills. After planning, we discussed the
different ways dosimetrists can plan the same cases. While the end goal remains the same, the way you
get there can differ depending on the persons planning. Working with my preceptor helped me realize
when to create a third arc for this patient, how to assess hot spots, and how to address the cold regions
in this plan. There are endless details that can be put into a descriptive analysis of a plan. My main
takeaway from this assignment is to keep an open mind and pay attention to why we do such things. I
could have planned this case without knowing what lymph nodes were included or why the PTV contour
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DOS 531
Clinical Oncology Assignment
stops at a certain level, but by delving into this case I have a better understanding of physician
reasoning.

Bibliography:

1. Kachnic LA, Winter K, Myerson RJ, et al. RTOG 0529: a phase 2 evaluation of dose-painted intensity
modulated radiation therapy in combination with 5-fluorouracil and mitomycin-C for the reduction of
acute morbidity in carcinoma of the anal canal. Int J Radiat Oncol Biol Phys. 2013;86(1):27-33.
doi:10.1016/j.ijrobp.2012.09.023

2. Bentzen SM, Constine LS, Deasy JO, et al. Quantitative Analyses of Normal Tissue Effects in the Clinic
(QUANTEC): an introduction to the scientific issues. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S3-S9.
doi:10.1016/j.ijrobp.2009.09.040
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DOS 531
Clinical Oncology Assignment
3. Snell RS. Clinical Anatomy for Medical Students. 6th ed. Philadelphia: Lippincott Williams &amp;
Wilkins; 2000.