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Bryn Dahms
DOS 531 – Clinical Oncology
Clinical Oncology Assignment

Introduction

Prostate cancer is the second most commonly diagnosed cancer in men in the United

States, with around 288,300 new patients diagnosed each year. Despite the high incidence of

prostate cancer, most affected individuals do not die from the disease. 1 Improvements in

screening protocols and diagnostic technologies, such as screening for prostate specific antigen

(PSA) and transrectal ultrasonography and biopsies, have allowed for earlier detection of disease

and better treatment outcomes.2 The majority of prostate cancers are histologically

adenocarcinomas, presenting with local to regional spread, and are most commonly seen in men

above the age of 65.3

The patient of interest originally presented with Stage IIB adenocarcinoma of the

prostate. At initial diagnosis, the tumor was graded pathological T2 with no nodal involvement

(N0), and a Gleason score of 4+3=7. Two years prior to treatment with radiation therapy, the

patient underwent a radical prostatectomy and removal of 31 pelvic lymph nodes.

Simulation

During CT simulation, the patient was positioned head first-supine with a vac-loc bag

used to immobilize their legs, a pillow to support their head, and a blue foam ring to hold at chest

level, allowing their arms to relax. Prior to simulation, the patient was marked with radiopaque

markers to set a temporary isocenter. After completion of the simulation, the physician reviewed

the scan and set the treatment isocenter in the treatment planning system. This treatment
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isocenter was then marked on the right and left lateral gluts and on the inferior abdomen with

permanent marker and covered with protective stickers.

Prescription

The patient was treated with photons to deliver 56 Gy to the prostate bed in 28 fractions

at 2 Gy each. A simultaneous integrated boost (SIB) of 12 Gy in 6 fractions was prescribed to the

prostate bed, bringing the total prescribed dose to the prostate bed to 68 Gy. The pelvic lymph

nodes were treated to a dose of 50.4 Gy in 28 fractions with 1.8 Gy administered each fraction.

This patient was negative for nodal metastases; however, after considering other risk factors

including high PSA, extracapsular extensions, and a positive margin, it was determined that

prophylactic treatment of the nodes and their resected margins would be the best approach to

reduce the risk of local recurrence. Treated lymph nodes include the external and internal iliac

nodal chains, sacral nodes, and common iliac nodes (Fig. 1).

A B

C D
Figure 1. Lymph node chains treated during the course of radiation as viewed in the (A) axial,
(C) coronal, and (D) sagittal cross sections. Figure 1B shows the 3D view of the lymph node
PTV structure. The prescribed dose to lymph nodes was 5040 cGy.
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Between the SIB and the standard plan, this patient was treated over the course of 34

fractions. This dose and fractionation regimen to the lymph nodes follows that of the protocols

outlined in the RADICALS-RT (Radiotherapy and androgen deprivation in combination after

local surgery) trial.4,5 This protocol calls for a dose of 66 Gy to the prostate in 33 fractions;

however, the patient being treated was scheduled to receive an additional 2 Gy, beyond what is

outlined in the RADICALS-RT protocol. This dose to the prostate bed and associated coverage

of the CTV and PTV follows that which is outlined in NRG-GU008. 6

Organs At Risk and Planning Objectives

Contoured pelvic OAR include the rectum, bladder, sigmoid colon, bowel space, right

and left femoral heads, and penile bulb. Planning treatment volumes (PTV) and clinical tumor

volumes (CTV) were also contoured separately for the pelvic lymph nodes and prostate bed (Fig.

2). Despite the presence of additional OAR in the pelvic region, the RADICALS-RT trial only

outlines dose constraints for the bladder and rectum (Table 1). Constraints for other OAR in the

pelvic region originate from various RTOG protocols and QUANTEC 7 guidelines (Table 2).

Table 1. Prescribed treatment volume, clinical tumor volume, and OAR constraints outlined in
the RADICALS-RT trial.4,5
Structure Constraint Constraint Met?
CTV (LNs) V5040 cGy ≥ 99-98% Y
PTV (LNs) V5040 cGy ≥ 99-98% Y
CTV (Prostate Bed) V100% ≥ 99-98% Y
PTV (Prostate Bed) Min ≥ 95% Y
Rectum V6600 cGy < 30% Y
V6000 cGy < 50% Y
V5000 cGy < 60% Y
V4000 cGy < 70% Y
V3000 cGy < 80% Y
Bladder V6000 cGy < 50% Y
V5000 cGy < 80% Y
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B
Figure 2. Contoured organs at risk and target volumes for the prostate bed and pelvic lymph
nodes from the (A) anterior and (B) right lateral view.

Table 2. Clinical dose objectives for OAR not related to RADICALs-RT trial and the associated
QUANTEC dose constraints.
Structure Constraint Constraint Source QUANTEC
Met? Constraints7
PTV (Prostate Bed) D95% ≥ 6930-6660 Y NRG-GU0086 N/A
cGy Y
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D0.03cc < 7200-

7550 cGy
Rectum V6600 cGy < 27.5% Y NRG-GU008 V75 Gy < 15%;
V5000 cGy < 57.5% Y V 70 Gy < 20%;
V 65 Gy < 25%;
V 60 Gy < 35%;
V 50 Gy < 50%;
Bladder V6600 cGy < 47.5% Y NRG-GU008 Max < 65 Gy;
V5000 cGy < 80% V80 Gy < 15%;
V3500 cGy < 77% V75 Gy < 25%;
V70 Gy < 35%;
V65 Gy < 50%;
Sigmoid D0.03 cc < 5700 Y (NM quality metric) N/A
cGy
Bowel Space V4500 cGy < 65 cc Y RTOG 08228 V15 Gy < 120
V4000 cGy < 100 cc Y cc;
V3500 cGy < 180 cc Y V45 Gy < 195 cc
Bilateral Femoral D0.03cc < 5000 cGy Y NRG-GU0099 (V50 Gy < 5%
Heads V4500 cGy < 10% Y for each)
Penile Bulb Mean < 5000 cGy Y QUANTEC7 Mean dose to
Mean < 5250 cGy Y RTOG 940610 95% < 50 Gy;
D90 < 50% Gy;
D60-70 < 70%

Exceeding the dose constraints outlined in Tables 1 and 2 can lead to severe side effects

that vary depending on the OAR and the amount of radiation received. Other factors that can

influence normal tissue tolerance include the patient’s age, tobacco use, presence of other health

conditions, and additional treatment including chemotherapy and previous radiation. 11 As it

relates to the current patient, he was considered in good health at the time of treatment and was

free of factors that might influence normal tissue dose tolerances. Considering this, limiting dose

to pelvic OAR was a priority to prevent future radiation induced complications and to maximize

the quality of life for this patient.

Exceeding the recommended dose constraints for the rectum puts the patient at risk for

developing late rectal toxicities including rectal bleeding, fecal incontinences, rectal pain,
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obstruction, and necrosis. Complications of the bladder include obstruction, urethral stricture,

urinary incontinence, and gross hematuria.12 Dose to the sigmoid colon may result in necrosis.

Small bowel radiation in excess may result in diarrhea and late obstructions and/or

perforations.12 Excessive dose to the femoral heads can result in hip pain, femoral head necrosis,

femoral neck fracture, and may increase the likelihood of requiring a hip replacement in the

future. Finally, radiation to the penile bulb may result in mild to severe erectile dysfunction. 11,12

Radiation Treatment Plan

Volumetric modulated arc radiotherapy (VMAT) allows for the precise delivery of

radiation to a specific area of interest while minimizing dose to surrounding OAR. Unlike static

field intensity modulated radiotherapy (IMRT), prostate patients treated using VMAT are subject

to lower OAR dose which may translate to fewer radiation induced side effects. 13 Considering

this, physicians at Northwestern Medicine typically prefer VMAT plans when treating prostate

patients, this patient included.

Separate treatment plans were created for the initial dose to the prostate bed and lymph

nodes, and for the prostate bed boost. After creating the plans separately, a composite plan was

created to determine the total dose administered to both PTVs and OAR. The lymph node and

prostate bed PTVs extended anteriorly to the pubic symphysis, posteriorly to include the anterior

half of the sacrum and vertebral bodies, inferiorly 2 cm beyond the prostate bed, and superiorly

to L4 (Fig 3). Considering the greater width of the patient, it was determined that the use of 10x

megavoltage photon beams would allow for the most optimal plans. This patient was treated on a

Varian TrueBeam linear accelerator, and his plan was created in Eclipse. Prior to treatment, the
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patient’s setup was to be verified with daily 3D imaging via cone beam CT. The therapist then

used a mix of bony anatomy and soft tissue to ensure that the patient was aligned properly.

A B
Figure 3. CTV and PTV borders for lymph node (green and blue, respectively) and prostate bed
treatment (red), as viewed in the (A) coronal, and (B) sagittal cross sections. The green plus sign
in the prostate bed PTV indicates the isocenter.

The initial plan delivered 56 Gy to the prostate bed, and 50.4 Gy to the lymph nodes.

Three full arcs were used to ensure that both PTVs were contained within the treatment area.

These 3 arcs were all weighted relatively equally as they mostly covered different areas of the

PTVs. For all arcs, the couch was set at 0o. The first arc rotated clockwise from 181.0o to 179.0o

and was collimated to 15ᵒ, with a field size extending to 17.5 cm in the x direction, and 25.0 cm

in the y direction. This arc mainly targeted the superior most portion of the lymph node PTV.

This collimation allows multi-leaf collimators (MLCs) to more easily target hotspots on the

lateral portions of the field, while also preventing the appearance of interleaf leakage rings that

are caused by 0o collimators in VMAT plans. The second arc traveled counterclockwise from

179.0o to 181.0o and targeted the lower portion of the lymph node PTV and the prostate bed

PTV. This arc was collimated at 345.0o with a field size set to 18.0 cm in the x direction and 25.0

cm in the y direction. This collimator angle was picked for the same reasons as the first arc. The

final arc for the initial plan traveled clockwise from 181.0 o to 179.0o and was collimated to 90o.

At this angle, the MLCs were able to move superiorly and inferiorly to block dose from the

normal tissues that are present between the arch of the lymph node PTV and the base of the
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prostate bed PTV. This field extended 18.0 cm in the x direction and 22.0 cm in the y direction,

covering the majority of both PTVs.

The plan for the prostate bed SIB maintained the same prostate bed PTV from the initial

plan and consisted of 2 full arc rotations of equal weight. These arcs followed the same direction

and collimation as the first two arcs outlined above. The clockwise arc traveled from 181.0 o to

179.0o, with the collimator set to 15.0o. The field size extended 13.8 cm in the x direction and

10.0 cm in the y direction. The counterclockwise arc traveled from 179.0 o to 181.0o and was

collimated to 345.0o. Similar to the first arc, the field was set in the x direction to 13.8 cm and in

the y direction to 10.0 cm. For both arcs, the field size contained the entirety of the prostate bed

PTV. This plan delivered a total dose of 12 Gy to the prostate bed.

In addition to the OAR and PTV mentioned in Tables 1 and 2, optimization structures

were also used to alter the distribution of dose while the plan was optimizing. Such structures

include rings to either reduce or increase dose to an area, caps on the superior and inferior

portions of the PTVs, general avoid structures, and overlap regions. Caps on the superior and

inferior portions of the PTVs helped prevent early dose fall off to these regions when given a

middle priority in the optimizer. For prostate plans, the general avoid structure mainly includes

the bladder and small bowel that is nearest the PTVs. Prioritizing this structure helped the

optimizer better recognize where to reduce dose in larger structures such as the small bowel.

Rings used for OAR help prevent the placement of excess dose close to the structure. Also

known as a planning organ at risk volume (PRV), this structure can further reduce dose to OAR

by accounting for variations in day-to-day setup and shifts in patient anatomy.

Conclusion
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After summation of the initial plan and the boost plan, dose objectives for both the OAR

and PTVs were assessed. As outlined in Tables 1 and 2, dose constraints for tracked OAR were

met or well below the acceptable limits. Ninety-eight and six tenths of a percent of the lymph

node PTV was covered by the prescribed dose of 50.4 Gy, while 98.6% of the prostate bed PTV

was covered by the prescribed dose of 68 Gy. The final isodose distribution and DVH are

demonstrated in figures 4 and 5, respectively. After plan reviewal with the physician, it was

determined that this plan was acceptable and was approved for administration to the patient.

A B

C D
Figure 4. Isodose distribution of the composite plan which includes the initial 3 arc plan to the
lymph nodes and prostate bed, and the SIB to the prostate bed as displayed in the (A) axial, (C)
coronal, and (D) sagittal cross sections. The magenta isodose line shows the distribution of 50.4
Gy, the prescribed dose to the lymph nodes. The lime green isodose line shows the distribution
of 68 Gy, the prescribed dose to the prostate bed. The orange cloud in Figure 4B shows the
distribution of the 50% isodose line (34 Gy).
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Figure 5. Dose volume histogram demonstrating OAR and PTV coverage.

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References
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Accessed April 18, 2023. https://www.cancer.org/cancer/prostate-cancer/about/key-
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(RADICALS-RT): a randomised, controlled phase 3 trial. Lancet. 2020;396(10260):1413-
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