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CSB043 Prostate
EBRT
PETER CALDWELL 2016
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 Prostate Cancer

 Radiotherapy

 Volumes and Doses

 Technique: Field Placement etc

 Procedures: CT & Treatment

 QA: Imaging etc

 Side Effects & Patient Care

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 Volumes and Doses
 Single phase: Prostate bed +/- Seminal Vesicle
 60Gy in 33f – 78Gy in 39f
 Two phase (dose escalation):
 Ph 1. Prostate + SV; 56Gy in 28f
 Ph 2. Prostate only; 18Gy in 9f (74Gy in 37f)
 Three phase (pelvic node involvement):
 Ph 1. Prostate, SV + nodes ; 46Gy in 23f
 Ph 2. Prostate + SV; 10Gy in 5f
 Ph 3. Prostate only; 18Gy in 9f (74Gy in 37f)
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EBRT
Volumes and Doses
Two Phase Dose Escalation, Conformal

Ph 1. Prostate + SV; 56Gy in 28f

Ph 2. Prostate only; 18Gy in 9f
(74Gy in 37f)
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 Field Placement:

 4-Field Box or 3-Field standard

 Conformal

 Various Possibilities

 IMRT

 Arc (inc. Vmat)

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 Conformal Sunrise Technique

Ph1 60Gy/30#
Ph2 14Gy/7#
=74Gy/37#

Dose escalation if
OAR’s are within
tolerance to
78Gy/39#
If imaging is
accounted for
this can escalate
up to ~ 81Gy
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 Intensity Modulated
Radiation Therapy
(Step & Shoot)
 High MU
 Long treatment
time
 Max dose <109%
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 Volumetric Modulated
Arc Therapy

 Lower MU

 Faster treatment time

 Higher max dose <115%

 MD Anderson
comparison report
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 CT procedures

 Treatment procedures

 Patient preparation

 Patient set-up
EBRT Prepare for 10

simulation
 Procedures CT
 Pre Appointment
 Check notes and scans
 Prepare room

 Out of room
 Prepare patient
EBRT 11

 Pre Appointment

 Check notes and scans

 Prepare room

 Waiting room

 Prepare patient

 ID

 Check well-being. Establish rapport

 Check details. Explain procedure

EBRT 12

 Pre Appointment

 Check notes and scans

 Prepare room

 Waiting room

 Prepare patient

 ID

 Check well-being. Establish rapport

 Check details. Explain procedure

EBRT patient preparation 13

 Bladder & Rectum

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BOWEL

BLADDER
RECTUM SEMINAL
VESICLE
PROSTATE

URETHRA

PENIS
PUBIC BONE
TESTICLE

SCROTUM
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BOWEL

BLADDER
RECTUM

PROSTATE
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BOWEL

PTV
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BOWEL

EMPTY
BLADDER

Bladder (Quantec):
V65 < 50%
V70 < 35%
V75 < 25%
V80 < 15%
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BOWEL

FULL
BLADDER

Bladder (Quantec):
V65 < 50%
Bladder Prep: V70 < 35%
Empty 30min before and V75 < 25%
drink 2 cups (500 ml) of V80 < 15%
water (liquid), then hold.
(Vary on individual basis)
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RECTUM

Rectum (Quantec):
TD50 = 76.9Gy
V50 <50%
V60 < 35%
V65 < 25%
V70 < 20%
V75 < 15%
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FULL
RECTUM
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EMPTY
RECTUM

Rectal Prep:
Take Metamucil or Fybogel
with water. Ensure bowel
movement within 1 or 2hrs of
treatment.
Avoid gassy foods (soft-drinks,
beer, cabbage etc.)
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RECTUM
FILLED WITH
AIR
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RECTUM FILLED
WITH AIR

Rectal Prep:
Take Metamucil or Fybogel with
water. Ensure bowel movement
within 1 or 2hrs of treatment.
Add ~100ml of air prior to XRT
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SPACER
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 Fill Bladder

 Minimise bladder treated & push bowel sup

 Empty Rectum

 Minimise dose to rectal wall

 Minimise prostate movement

 (keep pressure off prostate)

 OR Fill Rectum with air

EBRT CT 26

 In CT room
 Patient to remove pants and shoes
 Position patient on couch

 How?
EBRT CT 27

 In CT room
 Patient to remove pants and shoes
 Position patient on couch
 Set isocentre and mark for CT

 Where?
EBRT CT 28
 In CT room

 Patient to remove pants and shoes

 Position patient on couch

 Set isocentre and mark for CT

 Scan:

 Scout – check rectal size

 if rectum >4cm, re-prep patient

 Scan ~L3 to below ischium

EBRT CT 29

 In CT room

 Patient to remove pants and shoes

 Position patient on couch

 Set isocentre and mark for CT

 Scan:

 Back in CT room

 Photos, set-up notes, and tattoos

 Anything else?
EBRT Treatment 30

 Waiting room

 Talk to and ID patient

 Prepare patient

 In bunker

 Prepare couch
EBRT Treatment 31

 Waiting room

 Talk to and ID patient

 Prepare patient

 In bunker

 Prepare couch

 Get patient to remove pants and shoes

 Position patient on couch

 Set isocentre (notes, tattoos, lasers)

 And?
EBRT Treatment 32

 Waiting room

 Talk to and ID patient

 Prepare patient

 In bunker

 Prepare couch

 Get patient to remove pants and shoes

 Position patient on couch

 Set isocentre (notes, tattoos, lasers)

 At console

 All QA

 Treat (beam on)

EBRT Treatment 33

 Waiting room
 Talk to and ID patient
 Prepare patient
 In bunker
 Prepare couch
 Get patient to remove pants and shoes
 Position patient on couch
 Set isocentre (notes, tattoos, lasers)
 At console
 All QA
 Treat (beam on)
EBRT Treatment 34

 Access

 Stabilise

 Immobilise

 Reproduce
EBRT Treatment 35

 Access Prone or Supine?

 Stabilise Arms/hands position?
 Immobilise Removal of Clothing?
 Reproduce Stabilisation devices?
EBRT Treatment 36

 Access Prone or Supine?

 Stabilise Arms/hands position?
 Immobilise Removal of Clothing?
 Reproduce Stabilisation devices?

Prone:
Pushes bowel superiorly.
More prostate motion with breathing.
Less comfort and stability, especially for larger men.
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EBRT
Procedures: Patient Position

Access
Standard Position:
Supine, straight & level Stabilise
Arms on chest
Immobilise
Headrest
Knee-bolster (indexed) Reproduce
Foot-stocks (indexed)
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EBRT
Procedures: Patient Position

Access
Standard Position:
Supine, straight & level Stabilise
Arms on chest
Immobilise
Headrest
Knee-bolster (indexed) Reproduce
Foot-stocks (indexed)
Options
Prone; “Belly-board”
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EBRT
Procedures: Patient Position
Knees
Support
Standard Position:
Supine, straight & level FeetFix
Arms on chest Head Rest
Headrest
Knee-bolster (indexed)
Foot-stocks (indexed)
Options
Prone; “Belly-board”
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EBRT
Procedures: Patient Position

Standard Position:
Supine, straight & level
Arms on chest
Headrest
Knee-bolster (indexed)
Foot-stocks (indexed)
Options
Prone; “Belly-board”
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EBRT
Procedures: Patient Position

Standard Position:
Supine, straight & level
Arms on chest
Headrest
Knee-bolster (indexed)
Foot-stocks (indexed)
Options
Prone; “Belly-board”
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EBRT
Procedures: Isocentre

Mid PTV, Midline

~ ½ Sep

Set depth from Post (Post SSD, DOB, Couch height…)

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NOTE
Bladder Fill
EBRT
Instructions
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EBRT
QA Check patient notes and records
- doctors notes
Treat:
- regular card checks
Check patient separations
- regular SSD checks
- IGRT?
Check field positioning
- regular imaging
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EBRT
Field Positioning Images
QA

Treatment Field EPI vs DRRs using EPID

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EBRT
Field Positioning Images
QA

ISO Films

CBCT
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EBRT
AP ISO EPI
QA

EPID:

NOTE: Gold Seeds

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EBRT
QA

EPID:
Traditionally:
Orthogonal EPIs
Considerations: First 3 days,
Size of fields then weekly
Regularity of films
Increasingly:
Dose to patient Daily IGRT -
CBCT
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EBRT
Side Effects and Patient Care
Acute Side-effects
Tiredness
Bladder: irritation, frequency, urgency
Rectum: irritation, soreness, wind, diarrhoea,
bleeding
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EBRT
Get some
Side
rest Effects and Patient Care Advice on
when to
Acute Side-effects drink
Tiredness
Bladder: irritation, frequency, urgency
Rectum: irritation, soreness, wind, diarrhoea,
bleeding

Dietary
advice – Imodium
reduce
fibre intake
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EBRT
Side Effects and Patient Care
Acute Side-effects
Tiredness
Bladder: irritation, frequency, urgency
Rectum: irritation, soreness, wind, diarrhoea,
bleeding
Late Side-effects
Bladder: chronic instability & urinary incontinence
Rectum: radiation proctitis – chronic bleeding &
change in bowel habit
Erectile impotence – common and permanent
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EBRT
Side Effects and Patient Care
Acute Side-effects Keep dose
Tiredness down for Rectal
Bladder: irritation, Wall,
frequency, urgency
Bladder,
Rectum: irritation,and Penile Bulb
soreness, wind, diarrhoea,
bleeding
Late Side-effects
Bladder: chronic instability & urinary incontinence
Rectum: radiation proctitis – chronic bleeding &
change in bowel habit
Erectile impotence – common and permanent
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References
Books:
Levy, L. 2011, Mosby's radiation therapy study guide and exam review, Elsevier
Mosby, St. Louis, Mo; London.
Perez, C.A. 2004, Principles and practice of radiation oncology, Lippincott Williams
& Wilkins, Philadelphia.
Symonds, P., Deehan, C., Mills, J., Meredith, C., Walter, J. & Bomford, C.K. 2012,
Walter and Miller's textbook of radiotherapy: radiation physics, therapy and
oncology, Churchill Livingstone, New York; Edinburgh.
Tobias, J.S., Hochhauser, D. 2015, Cancer and its management, Wiley-Blackwell,
Chichester, West Sussex; Hoboken, NJ.
Washington, C.M. & Leaver, D.T. 2010, Principles and practice of radiation therapy,
Mosby Elsevier, St. Louis.

Articles:
Australian Institute of Health and Welfare (AIHW), 2013. Prostate Cancer in Australia,
Cancer Series Number 79,
http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129545133