1

Ontida Apinorasethkul
Case Study #2
April 19, 2015
Plan Comparison: Proton Matching Electron Fields and RapidArc (RA) Plans on
Squamous Cell Carcinoma (SCC) of Anal Canal
History of Present Illness: The patient is a 76 year old male with a past medical history of low
risk prostate cancer treated with prostate brachytherapy in July 2004. He was treated with I-125
seeds to a minimum peripheral dose of 145 Gy. His most recent PSAs have been undetectable.
He had done well with regard to toxicity, with the exception of hematuria in 2008, which
prompted cystoscopy showing some urethral scarring, though no intervention was required. He
has normalized urinary function.
He re-presented in September 2013 with hematochezia and a tumor that he was able to feel
within the anal canal. The medical oncologist performed transanal excision of a T2N0 SCC of
the upper anal canal on 10/22/13 with close margins. The patient was felt not to be a candidate
for radiotherapy at that time because of his history of prostate brachytherapy. He underwent
staging work-up post-operatively that revealed no evidence of systemic disease.
In December 2014, the patient developed persistent diarrhea. The examination at the time
revealed recurrent disease at the top of the anal canal, extending into the rectum. Rectal
examination revealed a bulky tumor involving the left superior-most aspect of the anal canal
extending superiorly into the rectum. The inferior extent was palpable approximately 3 cm from
the anal verge, and the superior extent of the mass was difficult to appreciate on examination, but
the tumor appeared to measure greater than 5 cm in the superior-inferior dimension. The mass
was fixed and the anal sphincter tone was intact. The patient indicated he did not want to
undergo abdominoperineal resection (APR) because he was very concerned about quality of life
with a colostomy. Therefore, he was referred for a radiotherapy treatment consultation.
Past Medical History: The patient has a past history of Parkinson disease, GERD, scoliosis,
alcohol abuse, restless legs syndrome (RLS), Barretts esophagus, irregular heartbeat, prostate
cancer and SCC of anal canal. He had a surgical history of an anal lesion excision and cataract
removal. His history of prior radiation was the prostate brachytherapy seeds in 2004. There was
no known allergy reported.

Social History: Patient is married. He was a 30-year tobacco user of half a pack per day and
quit in 1986. He has about 3-4 alcoholic drinks per day and denies any drug use. There was no
known family history of cancer.
Medications: Patient used the following medications: aspirin, Sinemet, Diphenoxylateatropine, Loperamide, Omeprazole, Ondansetron, Prochlorperazine and Azilect.
Diagnostic Imaging: In December 2014, the patient had a CT of the abdomen and pelvis. The
study showed a new mass in the distal sigmoid colon, which did not appear to be associated with
obstruction or associated adenopathy. There was no evidence of metastatic disease. There
appeared to be an invasion of the tumor through the left posterolateral rectal wall, into the
perirectal fat, extending towards the pelvic sidewall and the sacrum, with several adjacent perirectal lymph nodes. The largest bulk of disease was seen at the level of the seminal vesicles,
although there did appear to be tumor adjacent to the prostate gland, which contained multiple
brachytherapy seeds; many of which were visualized directly adjacent to the left anterior rectal
wall.
Radiation Oncologist Recommendations: This diagnosis might represent a secondary
radiation-induced malignancy given the proximity to the prostate brachytherapy seeds, and the
10 year time frame from prior radiation therapy. However, it was unclear whether this would
render the tumor any less sensitive to chemoradiotherapy. Since the patient was opposed to APR
and colostomy, chemoradiation therapy might provide durable palliation and even potentially be
curable given that this was SCC, stage T3N0M0. Given the history of prostate brachytherapy
and very high dose delivered to the anterior rectal wall directly adjacent to the tumor, there was a
high risk of complications with re-irradiation. The potential complications included rectourethral fistula and urethral stricture of the prostatic urethra, potentially resulting in urinary
obstruction and need for dilation or urinary diversion. The use of proton therapy in the reirradiation setting could help reduce the complications and might help spare the prostatic urethra
and reduce the risk of urinary obstruction in the future. The radiation oncologist recommended
treating the tumor directly adjacent to the prostate to 45 Gy, while boosting the bulky portion of
the tumor that is situated more superior to a dose of 59.4 Gy.
The Plan (prescription): The radiation oncologists recommendation to the patient was the use
of proton therapy to reduce toxicity in the re-irradiated high dose previously treated region. The
prescription dose for the initial plan was 45 Gy to the prostate and 50.4 Gy to the inguinal,

internal iliac and perirectal nodes concurrently in 28 fractions. The boost prescription to the
bulky tumor region was 9 Gy in 5 fractions; therefore the total prescription was 59.4 Gy.
Patient Setup/Immobilization: In February 2015, the patient underwent CT simulation for
proton therapy treatment. He was placed in the supine position on the CT simulation couch with
head on #2 sponge and hands on the chest holding a ring (Figure 1), so they were away from
treatment fields. The patient was placed on a knee lock at the index of F4B (Figure 2) and on a
foot lock at the index of F7B (Figure 3) to ensure reproducibility of the hip position. He was
asked to drink 2-8oz. bottles of water 30 minutes prior to CT simulation and daily treatment
sessions for the bladder filling consistency.
Anatomical Contouring: After the CT simulation scan was completed, the radiation oncologist
set the isocenter to the center of the treatment volume. The CT data set was then transferred into
Eclipse treatment planning system (TPS). The medical dosimetrist contoured organs at risk
(ORs) and related structures for planning purposes which included: air, brachytherapy seeds, skin
markers, CT artifacts of the skin markers and seeds, bladder, large bowel, small bowel, and
femoral heads. Since a proton beams stopping power is based on CT number conversion on the
CT scan1, it is essential that all the artifacts and air in the bowels were contoured and corrected
(Figures 4-5). The uncorrected Hounsfield Unit (HU) number could result in undershoot or
overshoot of the proton beam. Artifact from the brachytherapy seeds was overridden to the
neighboring HU number. The skin markers were overridden as air to -1000 HU because they
would not be there at time of treatment. Air was overridden to 0 HU since it might not be at the
same position daily and it could contribute to the range variation in proton beam delivery.2 The
radiation oncologist contoured gross tumor volume (GTV), clinical target volumes (CTVs),
planning target volumes (PTVs), genitalia, perineal skin, prostate and prostatic urethra.
PTV4500 and PTV5040 had a margin of 5 mm from CTV4500 and CTV5040, respectively.
PTV5940 had a margin of 3 mm from CTV5940. After treatment volumes were drawn, the
medical dosimetrist created Pencil Beam Scanning treatment volumes (PBSTVs) as proton
planning volumes to account for any range uncertainty in the direction of the beams distal edge.
This is to account for CT calibration curve error or mass density curve error, which may cause
some dose deviations to the treatment volumes and/or organs at risk.1 The PBSTV margin was
3.5% multiply by the nominal range of the beam plus 3 mm in the beam direction. Both
PBSTV4500 and PBSTV5040 had a margin of 1.2 cm left and right from CTV and match PTV

in all other directions. However, PBSTV5940 had a margin of 1.1 cm left and right from CTV
and match its PTV in all other directions. The PBSTVs were then used as optimizing targets in
the proton treatment plan, however, the PTVs and CTVs were used to evaluate in the dose
volume histogram (DVH). In the photon RA plan, PTVs were used as the optimizing targets.
Beam Isocenter/Arrangement: The medical dosimetrist placed an isocenter in the middle of
the target at midline. There is no aperture or fields to be set in Pencil Beam Scanning (PBS)
planning. Since the patient had previous treatment to the prostate, lateral proton beams were
decided for this plan, so the smallest beam penumbra could be used to spare prostate and
prostatic urethra as much as possible. Beam energies in a PBS plan are delivered by spots and
layers. The spots deposits beyond 7.5 cm water equivalent distance (WED) from the skin
surface. The issue with using lateral beams for this case was that the node volumes did not get
coverage near the surface because WED was less than 7.5 cm (Figure 6). Therefore, electron
beams were used to cover the left and right node volumes matching with lateral proton beams.
The 2 lateral proton beams were arranged at 90 and 270. The 2 electron beams of 16 MeV
were arranged at the gantry of 10 with a couch rotation of 25 and another at 350 with a couch
rotation of 335 to match with the 2 lateral proton beams (Figure 7). The couch rotations were
designed to reduce the dose overlap from the bulging of electron beam isodose curves.3 This
technique was not to perform a perfect match, but to deliver a safe treatment plan to the patient.
The boost plan also consisted of the 2 lateral proton beams to only the bulky tumor volume.
For the photon RA plan, 2 arcs were used on the initial volumes from 113 to 250
counterclockwise with 45 collimator angle and another arc from 250 to 113 clockwise with
315 collimator angle. Partial arcs were designed to not treat through the table rails (Figure 8).
The boost plan used the same field parameters and arc angles as the initial plan. Complimentary
collimator angles were used to decrease the tongue and groove effects of the multileaf
collimators (MLCs).4
Treatment Planning: The usual proton beam arrangement in treating anal cancer is to use 2
posterior oblique fields. With that technique, distal edge of the beams would be pointing directly
into the prostate and prostatic urethra if air in the beam path changes. To reduce range
uncertainty to these 2 dose limiting structures, the recommendation was made from the medical
dosimetrist to the radiation oncologist to use mix modalities of matching electrons with lateral
PBS fields. Both electron plans used 16 MeV, prescribed to 90% isodose line. The objective

was to limit toxicity to the previously high dose irradiated area of prostate and prostatic urethra.
With the proton and electron matching technique, there was a cold match around the nodal area
of 45 Gy in which the nodal area received at least 30 Gy (Figure 9). The cold match was created
to account for set up uncertainties between the 2 treatment set ups of both modalities. The
patient had to switch treatment rooms daily from proton to photon, therefore, it was safer for the
patient to not risk overlapping fields. On every treatment session, a proton therapist would draw
a line at the proton isocenter on patients skin (since the match was at the proton isocenter) and
the photon therapist would ensure that there was at least 0.5 cm gap from the line to the edge of
the electron blocks as seen in Figure 10. In addition to matching the fields on the patients skin,
kV films were imaged daily to align the electron fields to bony anatomy to accompany the same
treatment set up method as the proton beams. All treatment volumes received adequate and
homogenous dose distribution, except for the nodal matching region. Many of the ORs were not
meeting the constraints (Table 1, Figure 11) because they were part of the treatment volumes.
Small bowel received a maximum dose of 58 Gy, while the desired dose objective was 54 Gy.
226cc of the small bowel received 15 Gy or more, though the objective was set for 120 cc.
Prostate received a maximum dose of 52.7 Gy, while the desired objective was 45 Gy. All the
bladder constraints were also not met due to the overlapping of the structures to the treatment
volumes. All PTVs were very well covered except PTV4500 in the nodal area (Figure 12).
PTV5040 and PTV5940 met the target constraints of 95% of volume to receive 100% or more of
dose.
For photon RA plans, 6 MV was used for both arcs and for both initial and boost plans. All
treatment volumes met constraints of 95% of volume receiving at least 100% of dose (Figure
13). All OR doses exceeded the desired objectives focusing on the structures of concerned that
were re-irradiated (Table 1, Figure 14). Prostate received a maximum of 54.2 Gy, while the
constraint was 45 Gy. The prostatic urethra received a maximum of 35.6 Gy, while the desired
objective was 25 Gy. The radiation oncologist was willing to compromise the nodal coverage
with using proton/electron match because there was a clear advantage of using lateral PBS fields
with a small penumbra and lower dose to the prostatic urethra and prostate (Figures 15 and 16).
Quality Assurance/Physics Check: The monitor units (MUs) were reviewed and a second
check was completed using RadCalc program for the electron plans. The proton and photon RA

plans were checked and QAd on a phantom by a medical physicist. The MUs on all the plans
were within tolerance.
Conclusion: Challenges are usually presented when the plan involves matching fields. During
treatment planning, it was given considerable thought of where the cold match would be
acceptable within the treatment volume. Discussions with the radiation oncologist were crucial
to understand the expectations of both oncologist and dosimetrist.
The proton range uncertainties were reviewed with the physicist to ensure that the bowel
movements and the bladder filling would not shift the spread of Bragg peak (SOBP) out of the
acceptable range nor would it affect the treatment volume coverage. Because the patient needed
to be set up at the proton treatment side, then walked over to the photon treatment side for
another treatment, more challenges could be encountered. During the first 5 treatment delivery
sessions, the medical dosimetrist was present at both the proton treatment and the photon
treatment to ensure that the daily match was reproducible. Although the electron fields were not
exactly at the same position as marked, the dose would be smeared out clinically since the proton
isocenter line was drawn as a benchmark to match with electron fields daily.
When comparing the proton/electron matching fields, the photon RA plan was not clinically
acceptable given the dose to prostatic urethra was much higher than the desired objective. Since
the patient received high dose brachytherapy prior to this external beam radiation, it was a
statistically significant increased risk of urethral stricture.5,6 This complication could cause a
blocked or reduced flow of urine.
Another possibility of a planning technique was considered as well. Instead of using photon and
proton match, an anterior proton beam was to replace the electron beams. However, the anterior
beam would need a proton bolus to shift the proton range in order to have the WED equal to at
least 7.5 cm from the skin surface. With the sharp dose fall off of the proton beam, the match
would have to be very precise, since the treatment volume could get double dose in case of the
beam overlap or the volume could get no dose at all from the gap. It seemed to be too risky to
match multiple rapid dose fall off beams on this volume, therefore, mix modalities was the best
option for this patient.

References
1. Jiang H, Seco J, Paganetti H. Effects of hounsfield number conversion on CT based proton
Monte Carlo dose calculations. Med Phys. 2007;34(4):1439-1449.
http://dx.doi.org/10.1118/1.2715481
2. Engelsman M, Schwarz M, Dong L. Physics controversies in proton therapy. Semin Radiat
Oncol. 2013;23(2):88-96. http://dx.doi.org/10.1016/j.semradonc.2012.11.003
3. Sun C, Cheng C, Shimm DS, et al. Dose profiles in the region of abutting photon and
electron fields in the irradiation of head and neck tumors. Med Dosim. 1998;23(1):5-10.
http://dx.doi.org/10.1016/S0958-3947(97)00120-9
4. Xia P, Verhey L. Multileaf collimator leaf sequencing algorithm for intensity modulated
beams with multiple static segments. Med.Phys. 1998;25(8):1424-1434.
http://dx.doi.org/10.1118/1.598315
5. Sullivan L, Williams SG, Tai KH, et al. Urethral stricture following high dose rate
brachytherapy for prostate cancer. Radiother Oncol. 2009;91(2):232-236.
http://dx.doi.org/10.1016/j.radonc.2008.11.013
6. Elliott SP, Meng MV, Elkin EP, et al. Incidence of Urethral Stricture after Primary Treatment
for Prostate Cancer: Data from CaPSURE. J.Urol. 2007;178(2):529-534.
http://dx.doi.org/10.1016/j.juro.2007.03.126

Figures

Figure 1. Patient position holding a ring on CT simulation couch.

Figure 2. Patient placed on a knee lock at F4B position in CT simulation.

Figure 3. Patient placed on a foot lock at F7B position in CT simulation.

Figure 4. Brachytherapy seeds and its artifacts contour.

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Figure 5. Air contour in the bowels.

Figure 6. Water equivalent distance to the node volumes.

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Figure 7. Field entry shape of the 2 electron fields.

Figure 8. Arc angles and its beams-eye-view of not treating through table rails of RA plan.

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Figure 9. The cold match in axial, coronal and sagittal views of proton/electron matching plan.

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Figure 10. A proton isocenter line on patients skin with 0.5 cm gap to the 2 electron fields.

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Organ at Risk

Genitalia

Bowel_small
Prostate
Prostatic urethra
Bladder

Femoral Heads

Achieved

Achieved

Objective

Objective

Proton/Electron

Photon RA

36Gy max

26.7Gy max

26.8Gy max

V20 < 50%

V20 = 0.7%

V20 = 2.3%

V30 < 35%

54Gy max

58Gy max

58.4Gy max

V15 < 120cc

V15 = 226cc

V15 = 337cc

45Gy max

52.7Gy max

54.2Gy max

V30 < 25%

V30 = 27%

V30 = 67%

25Gy max

25.5Gy max

35.6Gy max

V35 < 50%

V35 = 50%

V35 = 68.7%

V40 < 35%

V40 = 41%

V40 = 51.6%

V50 < 5%

V50 = 29%

V50 = 29%

50Gy max

47Gy max

48Gy max

V30 < 50%

V30 = 3%

V30 = 15.2%

V40 < 35%

V40 = 0.2%

V40 = 2.6%

V44 < 5%

V44 = 0.04%

V44 = 0.6%

Desired Objective

Table 1. Organs at risk objectives.

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Bladder

Prostate

Small Bowel

Urethra
Genitalia

Femoral heads

Figure 11. DVH of ORs of proton/electron matching plan.

PTV_5040

PTV_5940


PTV_4500

Figure 12. DVH of the treatment volumes of proton/electron matching plan.

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PTV_5040

PTV_5940


PTV_4500

Figure 13. DVH of the treatment volumes of photon RA plan.

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Bladder

Small Bowel
Urethra
Femoral heads

Prostate

Genitalia

Figure 14. DVH of ORs of photon RA plan.

Figure 15. Dose distribution of lateral proton beams and electron fields of plan sum.

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Figure 16. Dose distribution of photon RA plan sum.