Clinical Oncology Case Study 1

Clinical Oncology Case Study

Katelyn Knoepke
University of Wisconsin- La Crosse
DOS531: Clinical Oncology
Clinical Oncology Case Study 2

Introduction
This case study will detail the treatment planning process for a patient receiving external
beam radiation therapy for the treatment of prostate cancer. The patient is a 73-year-old male
with Stage IIIB (cT4N0M0, Gleason 4+4) adenocarcinoma of the prostate. The staging system
utilized is the American Joint Committee on Cancer (AJCC) TNM system. The staging
indication cT4N0M0 indicates that the cancer has grown outside of the prostate but has not
spread to lymph nodes or other parts of the body.1 Prostate cancer is also assigned a grade based
on the Gleason scoring system. This is based on biopsy results and consists of two individual
scores representing the most common grades within the prostate. These two scores are then
added together for a total score.1 This patient had a Gleason score of 4+4 for a total of 8. Cancers
with a Gleason score of 8-10 are considered poorly differentiated or high grade.1 The patient is
receiving radiation treatment to the prostate, seminal vesicles, and regional lymph nodes.

Simulation
The patient was simulated in the supine position with an indexable knee cushion under
his legs to ensure a reproducible pelvic and leg position. He had a ring held high on his chest to
move the arms out of the treatment area. The patient was instructed to have a comfortably full
bladder for the treatment planning scan as well as for subsequent treatments. The patient
received a treatment planning CT scan in the treatment position and was given set-up marks to
aid in positioning for daily treatment. The patient also received an MRI in the treatment position.
This was registered with the planning CT to aid in target and normal tissue delineation for
treatment planning purposes.

Treatment Volumes
This case involved two treatment volumes to be treated with volumetric modulated arc
therapy (VMAT) utilizing a simultaneous integrated boost (SIB) technique. The high dose
treatment volume included the prostate and seminal vesicles with a margin. This volume had a
dose prescription of 270 cGy per fraction for 26 fractions for a total cumulative dose of 7020
cGy. The low dose volume included the regional pelvic lymph nodes with a margin. This volume
had a dose prescription of 180 cGy per fraction for 26 fractions for a total cumulative dose of
4680 cGy. The images below indicate these treatment volumes.
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Prostate + Seminal Vesicles

PTV7020 (270 cGy x 26)

Lymph Nodes
PTV4680 (180 cGy x 26)

Treatment Volumes

Lymph Nodes
PTV4680 (180 cGy x 26)

Prostate + Seminal Vesicles

PTV7020 (270 cGy x 26)

Treatment Volumes

Lymph Nodes
PTV4680 (180 cGy x 26)

Prostate + Seminal Vesicles

PTV7020 (270 cGy x 26)

Treatment Volumes
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Dose Prescription
Hypofractionation involves delivering a higher daily dose, allows for a shorter treatment
course, and results in similar outcomes compared to standard fractionation. A study by Pollack et
al2 compared a hypofractionated dose delivery (70.2 Gy in 26 fractions) to standard fractionation
(76 Gy in 38 fractions) and found no reduction in biochemical and/or clinical disease failure.
This hypofractionated approach allows the treatment to be delivered in 2.5 fewer weeks than
standard fractionation. The VMAT SIB treatment technique allows for a simultaneous delivery
of a higher dose utilizing hypofractionation to the prostate and a lower dose utilizing
conventional fractionation to the regional lymph nodes for high-risk prostate cancer. 3 In
comparison, conventional fractionation would include a two-phase delivery and result in a longer
treatment course. When compared to this method, the SIB technique was found to result in better
sparing of critical structures, more efficient delivery, shorter treatment duration, and better
biological effectiveness.3 This dose prescription includes both hypofractionation and an SIB
technique resulting in an effective treatment in a reduced amount time in comparison to
conventional fractionation.

Avoidance Structures

Radiation delivery to the prostate and regional lymph nodes must include consideration
of various organs at risk (OAR) within the treatment field in order to limit side effects and other
toxicities. This treatment plan included dose considerations on the following normal tissue
structures: bladder, femoral heads, rectum, penile bulb, large bowel, and small bowel. The
following images depict the location of these structures of interest in relation to the treatment
volumes.
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Bladder

Femoral Head R
Femoral Head L

Organs at risk

Small Bowel
Large Bowel

Bladder
Femoral Head R
Femoral Head L
Penile Bulb

Organs at risk

Large Bowel

Small Bowel

Bladder
Rectum
Penile Bulb

Organs at risk
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Dose Constraints

The physician provided dose constraints with varying priorities in order to communicate
the desired outcome of the treatment planning process. The following chart displays these OAR
structures and the requested dose constraints as well as what was ultimately achieved with this
treatment plan. The listed constraints were provided by the physician to guide treatment
planning.

Structure Dose Constraint Achieved

Bladder V36Gy<60% 44.5%
V57Gy<40% 18%
V61Gy<30% 15%
V66Gy<15% 11.1%
Femoral Head R Mean<44Gy 13.77%
V36Gy<10% 0%
Femoral Head L Mean<44Gy 13.58Gy
V36Gy<10% 0%
Rectum D2cc<75Gy 47.91Gy
V44Gy<50% 29.7%
V53Gy<30% 0%
V57Gy<25% 0%
V61Gy<15% 0%
V66Gy<10% 0%
Penile Bulb D50%<47Gy 7.19Gy
D70%<36Gy 6.22Gy
Large Bowel V50Gy<50% 0%
V60Gy<30% 0%
V65Gy<25% 0%
V70Gy<15% 0%
Small Bowel Max < 52Gy 49.89Gy
V30Gy <300cc 191.12cc
V45Gy <150cc 28.62cc
V50Gy<2cc 0cc

The following chart provides the suggested QUANTEC4 constraints along with
contraindications if these dose limits were to be exceeded.

Structure Dose Constraint Contraindication

Bladder V65Gy <50% Grade 3 + toxicity
V70Gy <35%
Clinical Oncology Case Study 7

V75Gy <25%
V80Gy <15%
Rectum V50Gy <50% Grade 3+ toxicity
V60Gy <35%
V65Gy <25%
V70Gy <20%
V75Gy <15%
Penile Bulb Mean dose to Severe erectile
95%<50Gy dysfunction
D90<50Gy
D60-70<70Gy
Small Bowel V15Gy <120cc Grade 3+toxicity
V45Gy <195cc

Lymph Nodes

This specific treatment plan included the treatment of regional lymph nodes due to the
advanced staging of this case. Pelvic lymph node treatment is required in the case of high-risk or
locally advanced prostate cancer in order to improve outcomes for patients with risk of lymph
node involvement.5 The Radiation Therapy Oncology Group (RTOG) advises the treatment of
the following lymph node volumes: distal common iliac, presacral lymph nodes (S1-S3), external
iliac lymph nodes, internal iliac lymph nodes, and obturator lymph nodes.5 The contour on the
following images was provided by the physician as the pelvic lymph node volume. Labels have
been provided to highlight the included lymph node chains.

Common Iliac

Lymph node volumes

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External Iliac

Internal Iliac

Lymph node volumes

External Iliac

Presacral

Lymph node volumes

Obturator

Lymph node volumes

Clinical Oncology Case Study 9

Field Borders
In order to fully encompass the treatment volume, the boundaries of the treatment field
are as follows. The superior extent of the treatment volume is L4. The inferior extent is through
the obturators. Laterally the field extends approximately 3 cm lateral to the pelvic brim on either
side. Posteriorly the treatment field encompasses the sacrum, and anteriorly approximately 1 cm
anterior to the pubic bone. The following images depict the extent of the treatment volume and
associated anatomical borders.

L4
Approx. 3cm lateral of pelvic brim

Obturator
s
Approx. 1cm anterior of pubic bone

Sacrum

Treatment Borders
Clinical Oncology Case Study 10

Treatment Planning

This treatment plan was completed on the treatment planning scan obtained at the time of
simulation. This plan was created using a VMAT planning technique. The final treatment plan
utilized 3 full rotational arcs around the patient with the following geometries:
o Arc1: Rotated clockwise around the patient from 181-179 degrees utilizing a 10-degree
collimator rotation. The energy utilized for this beam was 6MV. This treatment field
delivered a total of 327 MU.

Arc1 Beams-eye-view

o Arc2: Rotated counterclockwise around the patient from 179-181 degrees utilizing a 350-
degree collimator rotation. The energy utilized for this beam was 6MV. This treatment
field delivered a total of 272 MU.

Arc2 Beams-eye-view
Clinical Oncology Case Study 11

o Arc3: Rotated clockwise around the patient from 181-179 degrees utilizing a 90-degree
collimator rotation. The energy utilized for this beam was 6MV. This treatment field
delivered a total of 277 MU.

Arc3 Beams-eye-view

Three full arcs were chosen due to the large and irregular shape of the treatment volume.
The collimator angles were chosen to allow for optimum MLC shaping around the treatment
volume, taking into consideration the irregular and concave features of the volume as well as the
location of critical OAR structures. Within the treatment planning optimizer dose constraints
were used to limit the dose to the bladder, rectum, femoral heads, large bowel, small bowel, and
penile bulb. The following images display the final isodose distribution that was approved by
the physician.

Final plan isodose distribution

Clinical Oncology Case Study 12

Final plan isodose distribution

Final plan isodose distribution

This treatment plan was able to achieve adequate coverage of the target volumes as well
as meet all of the normal tissue constraints requested by the physician. The use of a VMAT
planning technique allows for a highly conformal dose distribution. This treatment plan achieved
the planning goals of delivering adequate dose to the treatment volume while minimizing dose to
surrounding normal tissues. This technique also allows for maximization of the radiation safety
principle of ALARA (as low as reasonably achievable). The following chart provides the target
coverage objectives provided by the physician as well as the coverage that was achieved.

Target Structure Coverage Objective Coverage Achieved

PTV7020 V98%>=98% 99.9%
V99%>=98% 99.5%
Clinical Oncology Case Study 13

V100%>=95% 98.1%
PTV4680 V98%>=98% 99.9%
V99%>=98% 99.6%
V100%>=95% 98.5%

Plan evaluation with the physician includes evaluating the dose objectives as well as
visually assessing the isodose distribution. Target coverage, OAR dose, dose conformality, and
integral dose are all closely examined and evaluated to ensure optimal plan design. The DVH is
provided here to visualize target coverage and OAR dose statistics.

Final plan DVH

Conclusions
This case study highlighted the treatment planning process for a patient receiving external
beam radiation therapy for prostate cancer. The advanced staging of this patient’s disease
warranted the addition of dose prescribed to the seminal vesicles and the surrounding regional
lymph nodes. A hypofractionated SIB technique allowed for simultaneous dose delivery to these
volumes allowing for a shorter course of treatment compared to standard fractionation. Utilizing
a VMAT treatment planning technique allowed for a highly conformal dose distribution. Care
was taken to ensure adequate treatment volume dose coverage while limiting dose to surrounding
normal tissue structures.
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References

1. Prostate Cancer Stages. American Cancer Society. Updated October 8, 2021. Accessed April
20,2023. www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/staging.html

2. Pollack A, Walker G, Horwitz EM, et al. Randomized trial of hypofractionated external-

beam radiotherapy for prostate cancer. J Clin Oncol. 2013;31(31):3860-8.

3. Li XA, Wang JZ, Jursinic PA, Lawton CA, & Wang D. Dosimetric advantages of IMRT
simultaneous integrated boost for high-risk prostate cancer.
Int J Radiat Oncol Biol Phys. 2005; 61(4): 1251-1257.

4. Marks LB, Yorke ED, Jackson A, et al. Use of normal tissue complication probability models
in the clinic. Int J Radiat Oncol Biol Phys. 2010; 76(3): S10-S19.

5. Lawton CA, Michalski J, El-Naqa I, et al. RTOG GU Radiation oncology specialists reach
consensus on pelvic lymph node volumes for high-risk prostate cancer. Int J Radiat Oncol
Biol Phys. 2009; 74(2): 383-387.