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Introduction
This patient is an 84-year-old male with high-risk prostate cancer. Patient’s Gleason
score is 4+5=9, making him a Grade 5.1 Patient’s TNM is as follows: cT1c N0 M0. Let's explore
what this means. The first “c” means the patient was clinically staged not pathologically staged.1
All T1 prostate cancers mean there was no evidence of disease, a biopsy is performed, and
confirmed positive, only in the setting of a high prostate specific antigen (PSA) test.2 Patient’s
PSA was 15.4. There was no evidence of extra prostatic extension (EPE) or seminal vesical
invasion (SVI) on MRI. This patient is considered a Stage IIIC simply because of his Grade 5
Gleason score.1

Simulation
At St. Charles Cancer Center all patients receiving radiation to the pelvis for prostate
cancer are positioned the same. For comfort the patients are given a pillow with a wedge for the
head. They hold onto a ring at chest level to relax their arms and keep them out of the treatment
field. An indexed Civco KneeFix (KF) device is used for the legs and an unindexed Civco
FootFix (FF) is used for the feet. The indexed KF is intended so the patient is on the treatment
table in the same position superior-to-inferior daily. The FF is the ensure that the feet are angled
the same daily, this is important because this translates to the hip position which is critical in
pelvic irradiation when treating nodes. The patient is given three tattoos on the pelvis for daily
re-alignment: one AP and a lateral on each hip. They are simulated and treated daily with a full
bladder. All patients with an intact prostate get fiducials placed for daily alignment. This set-up
is denoted as follows in the patient chart: Pillow/wedge, small ring/chest, KF only indexed @
6C, FF not indexed, 3-point to pelvic tattoos, full bladder, align to seeds. A CT scan is acquired
from top of L3 to 10 cm below the perineum using 2 mm slice thickness.

Prescription
Given that this patient is high risk, he received elective nodal treatment even though he
did not present with any positive nodes. The prostate and nodes were treated with a simultaneous
integrated boost (SIB) technique. The prostate prescription was 250 cGy times 28 fractions to a
total dose of 7000 cGy; while the nodes received 180 cGy times 28 fractions to a total dose of
5040 cGy.3 This dose and fractionation pattern comes from the clinical trial RTOG 0415.2 Rather
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than doing an SIB technique another technique would be to treat the whole pelvis to include the
nodal volumes, then cone down on the prostate and/or seminal vesicles.

Targets, OAR & Avoidance Structures

For this plan there were two target volumes, the PTV_5040 and the PTV_7000, refer to
Figure 1.0. Organs included in those target volumes are the prostate, seminal vesicles, and lymph
node chains. Standard OAR for this plan includes the body, rectum, sigmoid colon, small bowel,
bladder, femoral heads, and penile bulb. Refer to Figure 2.0. Other structures contoured were
fiducials for alignment, artifact from the fiducials and an artifact override for the patient’s arm
which was scanned by his side for IV contrast injection but will not be present in that location for
daily treatment. Structures created for scorecard tracking were the small bowel and sigmoid
colon expanded by 10 mm (PRV), refer to Figure 3.0.
Avoidance structures created for plan optimization are as follows: for the rectum there
was a rectal sparing structure, a rectal avoidance structure and a rectal overlap structure (Figure
4.0); for the bladder there was a bladder overlap and an optimization bladder structure (Figure
5.0); for the small bowel and sigmoid colon there was an optimization structure for the respective
PRV’s (Figure 6.0 A); finally, there was an avoidance structure covering the bowel space and
bladder to avoid low dose (Figure 6.0 B). The only objective not met on this scorecard is the
small bowel V40 <5%. The small bowel constraints were difficult to meet on this plan because
of the overlap with the PTV_5040. Because the max dose to the small bowel and the dose to the
PRV were met, the physician accepted this. The scorecard included uses dose constraints from
the RTOG 0415 clinical trial, there are no associated QUANTEC values for 250 cGy per day
fractionation. Refer to Figure 7.0.
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Figure 1.0. Target volumes in A. axial, B. coronal, and C. sagittal views.

A B

C
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Figure 2.0. OAR volumes in A. axial, B. coronal, and C. sagittal views.

B
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Figure 3.0. Small bowel and sigmoid colon PRV structures.

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Figure 4.0. Rectal avoidance structures.

Figure 5.0. Bladder avoidance structures.

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Figure 6.0. A. Small bowel and sigmoid optimization structures. B. Small bowel and bladder
avoid structure.

B
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Figure 7.0. OAR objectives and results.

Lymph Node Involvement

As stated above this patient elected for nodal treatment because of his high-risk
diagnosis. The following nodal groups were included: the obturator nodes, internal and external
iliac nodes, and the common iliac nodes. Please note the following screen captures include the
level of the different nodal groups but this patient did not have any actual involved nodes to
label, refer to Figure 8.0.
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Figure 8.0. Nodal regions treated prophylactically. A. Obturator nodes. B. Internal and external
iliac nodes. C. Common iliac nodes.

B
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Anatomical Boundaries
The physical boundaries of treatment for this patient include, superiorly L4-L5
intervertebral space, inferiorly 0.8 cm beyond the prostate volume (roughly the level of the base
of the pubic symphysis). Anteriorly just behind the pubic symphysis to split the sacrum
posteriorly. Laterally covering the pelvic brim. Refer to Figure 9.0.

Figure 9.0. A. Coronal view displaying superior, inferior and lateral physical boundaries. B.
Sagittal view displaying superior, inferior, anterior and posterior boundaries.

A B
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Treatment Planning Technique

This patient was planned with VMAT technique utilizing two arcs. Our pelvic CBCT
ends at 180 degrees, so the first arc was planned to start at 179 degrees going counterclockwise
to 181 degrees with a collimator angle of 30 degrees. The second arc started at 180.1 degrees
moving clockwise to 178 degrees with a collimator angle of 330 angles. Both arcs were 358
degrees with 2 degree spacing between control points. Beam one delivered 126 cGy in 607 MU
with a delivery time of 110 seconds. Beam two delivered 124 cGy in 600 MU with a delivery
time of 112 seconds. No couch kicks were used. Refer to Figure 10.0 for beam information.
The beam and collimator angles were selected manually, then the optimizer was used to
create the control points, for optimal dose distribution. Structures used in the optimizer that were
not included in the above section of targets, OAR, and avoidance structures include a planning
PTV for each dose zone and control rings for each dose zone. The planning PTV_7000 was
created by carving out the rectum with a margin of 3 mm, this along with the rectal avoidance
structures was how the rectal constraints were met. The planning PTV_5040 was created by
carving out the PTV_7000 with a 5 mm margin, this ensures that they don’t conflict with each
other in the optimizer. The control rings were 5 mm thick and 5 mm away from their respective
planning PTV’s, these help control the conformity of the isodose curves. Using my planning
structures and my avoidance structures, as well as my clinical goals, I started with min and max
dose to my planning PTV’s, uniform doses to my PTV’s, and max doses to my rings and
avoidance structures. As the optimizer starts forming dose distributions, changes were
continually made to the optimizer functions until the desired dose distributions were created.
Refer to Figure 11.0 for the final list of objective functions used in the optimizer.

Figure 10.0. A. Beam information. B. Beam prescription information.

A
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Figure 11.0. Final optimizer objective functions.

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Final DVH, OAR Guidelines and Isodose Distributions

At St. Charles Cancer Center there are standard scorecards for each anatomic site treated
and for different fractionation and dose schemes as well. Within each scorecard there are goal
constraints, which is what is on the virtual scorecard in the TPS. There are also acceptable
variations listed in case the goal constraint is too difficult to achieve. We always start with the
goal constraints. For this plan the following constraints were too difficult to achieve, and I had to
use the acceptable variations: max dose to the small bowel, sigmoid colon, their respective
PRV’s, rectum and femoral heads. I also had to use the acceptable variation for the rectum V60
Gy, and the small bowel V40. There was not only overlap of the PTV_5040 and the small bowel,
but there was just too much low dose spilling into the small bowel. I did have a low dose
avoidance structure in this area to help control this but there was a fine line between controlling
the low dose to the area and losing coverage to the PTV_5040. The final hot spot was 104%
located in the PTV. However, I spent so much time trying to move the hot spot out of the rectal
overlap region that when it finally moved, I failed to realize that it moved right to the bladder
and PTV_7000 interface. Fortunately, I still met all the goal bladder constraints. Refer to Figure
12.0 below for the final plan DVH and scorecard.
Uniform target coverage was almost easier to achieve than meeting the small bowel and
sigmoid constraints. For the PTV_5040 I was able to achieve a conformal dose distribution with
only one small hole in the 5040 cGy and very little hot spots of 5400 cGy. The PTV_7000 had
only a few islands of 103%, mostly around the edges of my PTV, this was probably due to my
control ring being too tight and the dose not being able to fall off. Refer to Figure 13.0 for the
final isodose distributions.
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Figure 12.0. Final plan DVH and scorecard.

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Figure 13.0. A. Isodose key. B. Axial isodose distribution. C. Coronal isodose distribution. D.
Sagittal isodose distribution.

B
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D
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Conclusion
Planning to multiple dose zones when treating a primary target like the prostate and
simultaneously treating lymph nodes is an effective way to deliver the necessary dose to the
patient in the shortest amount of time. As mentioned above, this type of treatment was generally
done sequentially which could take 39 or more fractions to treat. However, for the dosimetrist
this type of planning technique requires skill and critical thinking. You need to keep hot spots
out of two dose zones, get conformal isodose distributions to two dose zones, all while
minimizing dose to the critical OAR. While this plan does a nice job providing conformal dose
to the targets, and it meets all the OAR objectives, there is still room for improvement. The
PTV_7000 has some islands in the 103% isodose lines, which could be eliminated. As seen, on
the axial and sagittal views from Figure 13.0 the low dose regions below 2450 cGy, could be
controlled more to give less dose to the small bowel, bladder, sacrum and cauda equina. Prostate
cancer commonly metastasizes to the bone and if this patient were to need palliative treatment in
the future this would be an area of concern. Overall, prostate cancer is the most common type of
cancer in men and with early detection 5-year survival rates are greater than 99%.4
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References
1. Prostate Cancer Stages. Cancer.org. Published 2018. https://www.cancer.org/cancer/prostate-
cancer/detection-diagnosis-staging/staging.html
2. Whitney Sumner, MD. St Charles Cancer Center. April 21st, 2023.
3. Lee WR, Dignam JJ, Amin MB, et al. Randomized Phase III Noninferiority Study
Comparing Two Radiotherapy Fractionation Schedules in Patients With Low-Risk Prostate
Cancer. Journal of Clinical Oncology. 2016;34(20):2325-2332.
doi:https://doi.org/10.1200/jco.2016.67.0448
4. Cancer.org. Published 2014. https://www.cancer.org/cancer/prostate-cancer/detection-
diagnosis-staging/survival-rates.html