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Amanuel Negussie Clinical Practicum I April 22, 2013 Prostate bed Intensity Modulated Radiation Therapy (IMRT) History of Present Illness: DB is a 65-year-old male reported to have elevated prostate specific antigen (PSA) of 12.76 in February 2012. A needle biopsy showed acinar type prostatic adenocarcinoma with perineural invasion. The test presented no seminal vesicle extension, lymph node invasion, and vascular invasion. His Gleason score was 3+4=7. He was staged tumor (T) 3a lymph node (N) 0 metastasis (M) 0. As a result, DB underwent a radical retropubic prostactomy in July 2012. The surgery report indicates that the procedure was uncomplicated and that he tolerated the procedure well. The patient experienced postoperative ileus. However, he was able to tolerate a regular diet without nausea or emesis four days after surgery. His pain was well controlled with oral medications. His post operative (post op) PSA was detectable at 0.14. A few weeks later, he was diagnosed with bilateral inguinal and umbilical hernia. He was treated with bilateral mesh inguinal herniorrhaphies and primary suture repair of midline incisional hernias in October 2012. Past Medical History: DB has a past medical history of hypertension, depression, insomnia, anemia, and pseudophakia. He also had a surgery of the right eye for cataracts removal. The patient has no known allergies. Diagnostic Imaging Studies: DB had a bone scan of the whole body in May 2012 that showed some non-specific uptake in the bilateral acetabulum and ischium. He also had x-ray of the pelvis before and after his prostectomy procedure. Family History: DB has a 24 years old daughter and a 33 years old son. His father died of prostate cancer, and his mother died of breast cancer. Social History: DB is a veteran with a smoking history of 25 packs per year. He quit smoking in 1989. He is a social drinker and does not use drugs. Medication: DB takes Avastin, Citalopram, Hydrobromide, Docusate, Hydrochlorothiazide, Lisinopril, Multivitamin, Sildenafil Citrate, and Zolpide Tartrate. Recommendations: DB was recommended to receive external beam radiation therapy given his detectable PSA and adverse features on pathology. It was explained to him the difficulty of knowing if his disease is confined to the prostate bed, nodal, and distant metastasis. The acute

and long-term effects were briefly discussed. He was notified that during treatment patients typically experience fatigue and urinary symptoms including pain with urination, increased urination, and urgency with urination. There is a long-term risk of urethral stricture, as well as damage to bladder and possible bleeding. Patients may also experience erectile dysfunction, rectal bleeding, increases in bowel movement, and may develop diarrhea. In addition, there is a very small but possible chance of the treatment causing secondary cancer. The Plan (Prescription): After a discussion with the patient, reviewing the chart, and examining the diagnostic study, the radiation oncologist decided to proceed with intensity modulated radiation therapy (IMRT) treatment. The treatment was prescribed to 6660 centigray (cGy) at 180cGy per fraction to the 98% isodose line for 37 fractions. Patient setup/ Immobilization: DB was simulated in a supine position with a customized VacLok under his legs. His pants and belt were moved down away from the pelvic area. His hands were crossed on his chest. A pillow was placed under his head for comfort. A Philips large bore 16-slice computer tomography (CT) machine was used for the simulation. Pelvic images were taken at 0.3 centimeter (cm) slices. Tattoos were applied bilaterally and medially at the end of the simulation process. Anatomic Contouring: After the simulation was completed, the CT scan was imported in the Pinnacle3 9.0 radiation treatment planning system (TPS). The radiation oncologist contoured the prostate fossa and expanded it by 8 millimeter (mm) to make the planning target volume (PTV). He also contoured the penile bulb and the bladder. In addition, I contoured the femurs and rectum. The unspecified tissues were expanded from the external contour excluding the PTV. Beam Isocenter/Arrangement: Varian 21 IX 3501 linear accelerator (Linac) machine was used to treat the patient. During the simulation process, the radiation oncologist placed the isocenter in the tumor. An 8-field beam arrangement at gantry angles of 135o, 100o, 65o, 30o, 330o, 295o, 260o, and 225o was used. The collimator and couch angle were set at 0o for all fields. Treatment Planning: The maximum number of segments was set at 80 and a direct machine parameter optimization (DMPO) was selected. An objective of the PTV was set for a minimum dose volume histogram (min DVH) of 6660cGy and volume of 99%, maximum dose (max dose) of 6993cGy, and uniform dose of 6860cGy. The objective for right and left femurs was set at the maximum dose of 4800cGy. Two bladder max DVHs, three rectum max DVHs, and two penile

bulb max DVHs objectives were created. All the PTV objectives were weighed 5% and all the rest added objectives were weighed 1%. The plan was optimized. Due to the streaking effect of 50% isodose line around the skin surface, two rings were created. The first ring (ring 6660) was made by expanding the PTV by 2cm, and the second ring (ring 3330) was made by expanding the PTV by the 5cm (Figure 1). A 2mm space was left between the two rings and the PTV (Figure 1). In addition, a sphere shaped contour was loaded and adjusted around the posterior aspect of the rectum (Figure 2). The rings were assigned a max dose of 6660cGy for ring 6660, 3330cGy for ring 3330, and 3330cGy for the sphere. All rings were weighted 1%, and the plan was optimized. Multiple weighting arrangements were made on the PTV objectives to create higher dose coverage and minimize the maximum dose. The bladder, rectum, and penile bulb were slowly minimized by adjusting their max DVH. The posterior streaking effect of the 50% dose (3330cGy) was carefully analyzed, and the weighting on ring 3330 was adjusted to push the 50% dose away from the patients posterior external contour. The weight on ring 6660 was also adjusted to constrict the maximum dose within the PTV. The weight on the sphere was adjusted in order to push the 50% dose away from the posterior rectum wall. This is important as it helps minimize rectal toxicity.1 The plan was finalized with a total monitor unit (MU) of 625, maximum dose of 7086cGy, and hot spot of 6% located within the PTV. In addition, the 100% isodose line adequately covered the PTV and the dose to organs at risk (OR) met radiation therapy oncology group (RTOG) 534 protocol (Figure 3 and 4).2 The 50% isodose line did not include the posterior external contour and the posterior edge of the rectum (Figure 3). Each block was checked to ensure that a proper margin was used (Figure 5). After the final plan was carefully analyzed, the dose table created based on RTOG 534 protocol was filled out for the physician to review (Figure 6). Quality Assurance Checks: MU check was performed using the MuCheck 8.2.0. software. At our clinical site, a 5% deviation in MU is the tolerance for any IMRT plans. Anything outside this range needs to be recalculated and fixed by the dosimetrists or physicists prior to treatment. The plan was approved with an individual MU difference less than 5% except the beam angled at 3300(Figure 4 and 5). As a result, a different calculation point was picked for this angle. The MU

was rechecked and passed with less than 5% deviation. The total MU difference was 0.06% (Figure 7 and 8). A plan validation was also performed by ion chamber in solid water and ArcCheck diodes. The chamber plan percentage difference was 0.31% and the average percentage of ArcCheck diodes passed was 99.5%. The summery of the test was printed and double checked by the dosimetrist. The dosimetrist also wrote an IMRT note stating the prescription, the maximum dose, and the quality assurance tests. Conclusions: Through this case, I was able to work closely with my mentors. It was a challenging case that allowed me to learn more about IMRT. During the process, I learned the importance and utilization of rings in IMRT planning. It allowed me to analyze the effects they make on dose distribution and dose avoidance. In addition, I learned about the importance of minimizing dose to patients skin and how it can be achieved. I noted that allowing the 50% dose distribute towards the patient skin will likely enhance skin reaction. This is especially important in the posterior surface since backscatter from the table can increase the skin dose.

Figures

Figure 1: A sagittal, axial, and coronal view of ring6660 and ring 3330. Red represents ring 6660 and orange represents ring 3330

Figure 2: A sagittal, axial, and coral view of the sphere adjusted around the posterior edge of the rectum

Figure 3: Sagittal, axial, and coronal view of dose distribution

Figure 4: DVH of the treatment plan

Figure 5: A beams eye view (BEV) of the DRR

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Figure 6: The dose table of the plan

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Figure 7: MuCheck of the treatment plan

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Figure 8: MuCheck of the treatment plan

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Reference 1. Michalski JM, Gay H, Jackson A, et al. Radiation dose volume effects in radiation induced rectal injury. Int J Radiat Oncol Biol Phys. 76(3): 123-129. 2. Pollack A. RTOG 524. A Phase III Trial of Short Term Androgen Deprivation With Pelvic Lymph Node or Prostate Bed Only Radiotherapy (SPPORT) in Prostate Cancer Patients With a Rising PSA After Radical Prostatectomy. http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0534. Accessed April 22, 2013.