Kearla Bentz Clinical Oncology Assignment 1

Introduction

The patient involved with the treatment plan discussed is a 54-year-old woman who was

diagnosed with stage IIIB (pT3b, N0i+, M0) mixed serous and grade 3 endometrioid

adenocarcinoma. Status post robot-assisted total laparoscopic hysterectomy, bilateral salpingo-

oophorectomy, bilateral pelvic sentinel lymph node biopsy, and omentum biopsy. Her pathology

consisted of 5.7 cm mixed serous carcinoma (75%) and grade 3 endometrioid adenocarcinoma.

Additionally, she had myometrial invasion (100%) with margins negative, cervical stromal

involvement, extensive lymphovascular space invasion, and 1 out of 2 sentinel lymph nodes

were positive.

Patient Positioning for Simulation

The patient was brought to the radiation oncology department and simulated for radiation

treatment. She was positioned supine with a sponge used as a pillow for comfort. A Vac-Loc was

molded under and around her legs and pelvis to maintain her pelvic position and make

positioning reproducible. She was given a rubber hand ring to hold on to, with her hands resting

high on her chest to bring her elbows and hands out of the treatment area. For the scan she was

advised to have a full bladder for the first scan and then to empty her bladder for a second scan.

The bladder full scan was used for planning her external-beam radiation therapy (EBRT)

treatment plan.

Radiation Prescription

This patient was prescribed sandwich therapy of radiation therapy and chemotherapy. Her

EBRT prescription was 45 Gy in 25 fractions, following the RTOG 1203 protocol, to the PTV

which included margin for the vagina and the nodal volume within the pelvis. She also was

prescribed to receive a vaginal cuff HDR boost of 12 Gy in 2 fractions of 6 Gy to the surface of a

Kearla Bentz Clinical Oncology Assignment 2

2.5 cm cylinder to the top 3 cm of the vagina following her EBRT because of the cervical

involvement and extensive lymphovascular invasion.

Contours and Constraints

For this treatment a single PTV was drawn representing the volume prescribed 45 Gy.

Additionally, the physician contoured the CTV for the nodal volume and the CTV of the vagina

parameter. The OAR structures contoured for this plan were organs located in the pelvis and

lower abdomen including the bladder, a bowel bag, bone marrow, both femurs, the sigmoid

colon, and the rectum. The physician constraints for the OAR are referenced from the RTOG

1203 protocol and are listed in Table 1, along with the QUANTEC constraints in Table 2.

All constraints were met from the RTOG 1203 protocol. The only constraint not met was

the QUANTEC small bowel constraint of V15 Gy < 120cc. The measured result for this

constraint was 1295.17cc, but this is an inaccurate measurement because the contour for this

result includes both large and small bowel in a bowel bag. In order to get the actual measurement

for the small bowel constraint there would need to be a contour created that encompassed only

small bowel. If we were to apply this constraint to the bowel bag, it would be understandable that

this constraint would not be able to be met. This is because 275cc of the bowl bag is contained

within the PTV contour and is receiving the prescription dose of 45 Gy.
Kearla Bentz Clinical Oncology Assignment 3

Table 1. Physician Requested Dose Constraints, Referenced from the RTOG 1203 Protocol.1

Structure Constraint Results

Rectum D80% < 4000 cGy 1460.25 cGy
Bladder D35% < 4500 cGy 4387.03 cGy
Bone Marrow D90% < 1000 cGy 945.83 cGy
D37% < 4000 cGy 2871.56 cGy
Bowel Space D30% < 4000 cGy 2782.54 cGy
PTV D95% >= 4500 cGy 4511.30 cGy
Max Dose < 4950 cGy 4854.8 cGy
Femoral Heads & Neck D50% <= 3000 cGy 956.78 cGy
D35% <= 4000 cGy 1267.30 cGy
D5% <= 4400cGy 2437.01 cGy

Table 2. QUANTEC Dose Constraints.2

Structure Constraint Results

Small Bowel V15 Gy < 120cc 1295.17cc
V45 Gy < 195cc 165.45cc
Bladder Dmax < 65 Gy 48.55 Gy
V65 Gy < 50% 0.00%
V70 Gy < 35% 0.00%
V75 Gy < 25% 0.00%
V80 Gy < 15% 0.00%
Femoral Head D100 < 52 Gy 28.95 cGy
V50Gy < 5% 0.00%
Rectum V50 Gy < 50% 0.00%
V60 Gy < 35% 0.00%
V65 Gy < 25% 0.00%
V70 Gy < 20% 0.00%
V75 Gy < 15% 0.00%

Lymph Node Regions

There were many lymph nodes treated within the PTV of this plan. Shown in the pictures

below is an anterior view of the pelvic nodal chains with a screenshot of the PTV volume treated,

Figure 1. Additionally, there is a lateral view of the nodal chains with a screen shot of the nodal

CTV, Figure 2. This shows that many nodal chains were encompassed by the PTV. The major

chains included in this treatment were the common iliac nodes, external iliac nodes, and the

internal iliac nodes shown in orange and blue in the pictures below.3 Also included in the pictures
Kearla Bentz Clinical Oncology Assignment 4

below are axial screenshots of the PTV from superior to inferior within the patient with labels of

the general locations of lymph nodes in the PTV.

Figure 1. Anterior View of the Lymph Node Chains.3

Figure 2. Lateral View of the Lymph Node Chains.3

Kearla Bentz Clinical Oncology Assignment 5

Anatomical Boundaries

This treatment had two different CTVs creating a larger combined PTV and greater

treatment area. Since the plan was created using VMAT technique and the beams went

completely around the patient, the volume being treated encompassed the pelvic and inferior

abdominal region. MLCs were created and used to block out health tissues beyond the PTV

creating a conformal dose around the PTV, which was created with a 1 cm outer margin around

the CTV.

The superior border of the PTV is at the L4-L5 interspace, to include the common iliac

nodes. The inferior border is about the level of the inferior ischium or obturator foramen The

inferoanterior border is the pubic symphysis and bladder, but part of the PTV has margin from

the CTV that covers the posterior aspect of the bladder. The inferoposterior border ends up

following the rectum because of the 1cm margin from the CTV. The superoposterior border

splits L5 and the sacrum, and the superoanterior border follows the nodal chains contoured in the
Kearla Bentz Clinical Oncology Assignment 6

CTV with the 1 cm margin for the PTV. Additionally, the lateral borders of the treatment are 1

cm margin from the PTV. At the superior aspect of the PTV the lateral borders are the psoas

muscles. The middle of the PTV has lateral borders following the ilium and pelvic brim, to

include the external and internal iliac nodes. The middle part of the PTV also had medial borders

to limit dose to the bowel and bladder. The inferior aspect of the PTV has its lateral borders at

the obturator internus muscle. Effort had to made to limit dose to the rectum, bladder, and bowel

since part of the PTV encompassed these radiosensitive organs, without compromising dose to

the PTV. Below are screen shots of the superior and inferior borders along with the lateral,

medial, anterior, and posterior borders of the PTV as the volume changes shape throughout the

patient.

Radiation Treatment Technique

The radiation treatment technique used for this plan was VMAT-ARC therapy. There

were four full arcs utilized in this plan, each arc using 6MV beams. The clockwise (CW) arcs
Kearla Bentz Clinical Oncology Assignment 7

went from 181 to 179 degrees and the counter-clockwise (CCW) arcs went from 179 to 181

degrees, for a total of 358 degrees of beam angles for each arc. The first CW and CCW arcs were

created using the arc geometry tool in the eclipse planning system and fitting the collimator to

the target. This made the first CW arc have the collimator at 30 degrees, and the first CCW arc

collimator was set at 330 degrees. Both of these arcs had the jaws opened wide enough to include

the PTV for the full rotation. Additionally, the second CW and second CCW arcs had their

collimators at 90 degrees. These arcs used the split x-jaw planning technique with each arc

overlapping each other 2 cm. The jaws for these arcs were open wide enough to encompass the

PTV included in that arc (superior or inferior aspect) for the entirety of the arc. There were no

couch rotations or wedges used in this plan. The MLC fluence and weighting for each arc was

created by the computer to try to reach the objectives set in the optimizer.

Conclusion

This treatment plan was able to meet the objectives and constraints requested by the

physician. The desired PTV coverage was 95% of the PTV at 45 Gy (100% dose). This plan

delivered better coverage than what was requested, with 45 Gy to 97.1% of the PTV.
Kearla Bentz Clinical Oncology Assignment 8

Additionally, all dose constraints requested by the physician were met, many OAR doses were

much lower than requested. The bone marrow constraint of D90% < 1000 cGy passed by the

narrowest margin. This is because there are many areas where the PTV covered areas of the bone

marrow, as a result of the 1 cm margin and not wanting to miss nodes that are next to the pelvic

bones. Also, the RTOG 1203 bladder constraint was close because a large volume of the bladder

was inside the PTV. Overall, I would say that this is a homogenous and conformal treatment

plan. The 50% isodose line (2250 cGy) peaks out into the bowel and bladder, but with such a

large PTV and keeping the hot spots to a minimum, it is understandable why this would have

occurred. Included below are the final DVH and dose statistics from this treatment plan.
Kearla Bentz Clinical Oncology Assignment 9

References

1. Knapp P, Eva B, Reseigh G, et al. The role of volumetric modulated arc therapy (VMAT) in

gynaecological radiation therapy: a dosimetric comparison of intensity modulated radiation

therapy versus VMAT. J Med Radiat Sci. 2019;66(1):44-53. https://doi.org/10.1002/jmrs.311.

Accessed April 14, 2023.

2. Marks LB, Yorke ED, Jackson A, et al. Use of normal tissue complication probability models

in the clinic. Int J Radiat Oncol. 2010; 76(3)(suppl 3):S10-S19.

https://doi.org/10.1016/j.ijrobp.2009.07.1754. Accessed April 14, 2023.

3. Micheau M, Hoa D. Atlas of anatomy of the female pelvis and genital system. IMAIOS.

https://www.imaios.com/en/e-anatomy/abdomen-and-pelvis/female-pelvis. Updated March 8,

2023. Accessed April 17, 2023.