Clinical Oncology Assignment

Madeleine Booth
DOS 531 Clinical Oncology
April 24, 2023

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 Introduction
For this assignment, I would like to discuss a recent treatment plan I did for prostate and
pelvic lymph nodes. The patient, who is 79 years old, was diagnosed with an AJCC 8 th
Edition pT3a N0 M0, Gleason 4+3 prostate cancer. He underwent a robotic assisted
laparoscopic radical prostatectomy in 2019. In January, 2023, he presented to the
radiation oncology clinic with biochemical recurrence with PSA of 0.44 and PSMA PET
concerning for metastasis of a left perirectal lymph node.
Simulation
A CT simulation was performed on an SOMATOM Definition Edge scanner. The patient
in the head-first supine position with his arms on his chest. This is the standard patient
orientation for pelvic treatments at my clinical site. A Vac-Lok bag was created on top of
a leg rest to immobilize the patient’s legs and create a comfortable, reproducible
position for him. A headrest was used with the appropriate height for that patient’s
comfort. He was given a grip ring to hold onto on his chest. This helps keep the patients
arms from moving during treatment. Many patient’s find the grip ring to improve comfort
as well as helping them remain still.
Organs at Risk
The avoidance structures contoured for this plan include bladder, rectum, femurs,
sigmoid colon, penile bulb, cauda equina, and bowel bag. The patient had a right
femoral implant, so that structure was set to the CT value for titanium alloy. The
constraints are based on RTOG reports, QUANTEC, and other journal articles/research.
The constraints for this plan are listed in Figure 1.

Figure 1: Clinical Goals/normal tissue constraints 2

If any of the constraints are exceeded, there is a chance of complication. Some
potential complications from exceeding the tolerance doses for these normal structures
include incontinence, cystitis, impotence, colitis, proctitis, fistula, and necrosis of femoral
heads.1 Screenshots of OAR contours are provided in Figures 2 and 3. Screenshots of
the PTVs are included in Figure 4.

Figure 2: Bladder, rectum, and femur contours

Figure 3: Small bowel, sigmoid, and cauda equina contours

Dose and Fractionation Regimen

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The radiation oncologist prescribed a total dose of 66Gy to the prostate bed in 33
fractions (2Gy per fraction) with the final 8 fractions being a sequential boost to the
prostate bed. For the purpose of this assignment, I will only be discussing the initial
plan. Additionally, the radiation oncologist prescribed a simultaneous integrated boost of
45Gy to the regional pelvic lymphatics in 25 fractions (1.8Gy per fraction), and a 57.5Gy
simultaneous integrated boost to the left perirectal node of concern in 25 fractions
(2.3Gy per fraction). The fractionation pattern for the pelvic lymphatics and prostate bed
is based on the RTOG 0534 protocol. The guidelines for contouring the left perirectal
lymph node were from the NRG atlas on pelvic lymph nodes.
The physician delineated the prostate bed and lymph nodes to be treated. Adequate
margins were added to create CTVs and PTVs. The prostate bed CTV anatomical
borders according to the RTOG are outlined in the Table 1 and Figure 5.

Inferior border Anterior border Lateral border Posterior border Superior border
8-12mm below Below the Above superior edge Above superior Level of cut end
vesicourethral superior edge of of symphysis pubis edge of of vas deferens
anastomosis, symphysis pubis: sacrorectogenitopubic symphysis pubis: or 3-4cm above
may include more Posterior edge of fascia, may extend mesorectal top of symphysis
if concern for pubic bone. below obturator fascia. Below
atypical margins Above the internus. Below superior edge of
superior edge of superior edge of symphysis pubis:
the symphysis symphysis pubis: anterior rectal
pubis: Levatator ani wall
Posterior 1-2cm muscles, obturator
of bladder wall internus muscles
Table 1: RTOG prostate bed CTV anatomical borders2

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Figure 5: Example of prostate bed CTV contours for patients with biochemical recurrence or apical positive margins 2

Lymph Nodes Treated

The lymph node planning target volume encompassed the external iliac, internal iliac,
common iliac, presacral, and perirectal lymph nodes. A simultaneous integrated boost
of 45Gy was used to deliver the prescribed doses to the pelvic lymph node target
volume. The lymph node chains are labeled in Figure 6. The perirectal lymph node
contoured in magenta had a separate SIB with a prescribed dose of 57.5Gy.

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Figure 6: Lymph node chains

Treatment Planning
Volumetric modulated arc therapy (VMAT) was utilized as the planning technique for
this case. This is the standard treatment technique for prostate plans at my clinical site.
This form of inverse planning delivers dose dynamically from a large amount of beam
angles while the gantry rotates in an arc-like fashion. Compared to static field intensity
modulated radiation therapy (IMRT), VMAT is more efficient because treatment delivery
time is shorter. Additionally, VMAT plans yield better dose conformality of the target
volume and improved sparing of normal tissue, such as the rectum, when compared to
static field IMRT plans. When the number of static fields is increased, however, the
dosimetric advantages of VMAT decrease. 3 I used Ecplise as the treatment planning
system and 6MV as the energy. The dose rate was 600MU/min. Two full rotation arcs
were applied and entrance dose was blocked to the right femur because the patient had
an implant. Blocking entrance and/or exit dose to any structure is applied in
optimization. The start angle of the first arc was 178° and the stop angle was 181° with
the gantry direction set to clockwise. The collimator angle was 293° and was
determined by the Arc Geometry Tool. The field size of the first arc was
10.4cmx13.4cm. The second arc traveled counterclockwise from 181° to 178° with a
collimator angle of 23° which was determined by the Arc Geometry Tool to encompass
the entire target volume. The field size of the second arc was 12.9cmx10.6cm. The
couch angle remained at 0° for both arcs. During optimization, I utilized the target
autocrop function to crop the PTVs which were overlapping with each other and create
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a buffer area for dose to drop. I set objectives on each of the OARs and targets to meet
the constraints provided by the physician. For example, I set a dmax dose objective on
the bowel bag to achieve the Dmax<50Gy constraint. If I met the objective, I still
continued to try to achieve the lowest doses to normal tissue while maintaining
coverage of the PTVs. I have included screenshots of the DVH, clinical goals, and the
isodose lines from this plan in the figures below.

Figure 7: Clinical Goals Summary

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Figure 8: Final dose volume histogram

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 Figure 9: Isodose lines - axial and sagittal slices

Conclusion
This VMAT treatment plan was approved by the physician. All of the constraints were
met and the PTVs received optimal coverage. For VMAT/IMRT plans, the physicians
typically require 95% of the PTV to receive 100% of the prescribed dose. Target volume
coverage was more difficult for this plan because of the additional lymph node SIB
within the pelvic nodal volume. The patient is currently under treatment and is tolerating
it well according to the physician’s notes.

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 References
1. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic
irradiation. Int J Radiat Oncol Biol Phys. 1991;21(1):109-122. doi:10.1016/0360-
3016(91)90171-y
2. Michalski JM, Lawton C, El Naqa I, et al. Development of RTOG consensus
guidelines for the definition of the clinical target volume for postoperative
conformal radiation therapy for prostate cancer. Int J Radiat Oncol Biol Phys.
2010;76(2):361-368. doi:10.1016/j.ijrobp.2009.02.006
3. Quan EM, Li X, Li Y, et al. A comprehensive comparison of IMRT and VMAT plan
quality for prostate cancer treatment. Int J Radiat Oncol Biol Phys.
2012;83(4):1169-1178. doi:10.1016/j.ijrobp.2011.09.015

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