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Derek Smith
April 28, 2014
April Case Study
3D Conformal & IMRT Prostate +Proximal Seminal Vesicle Photon Irradiation
History of Present Illness: Patient MC is a pleasant 72 year old white male with a recent
diagnosis of stage IIA prostate adenocarcinoma. MC presented with a rise in his PSA to 4.2
ng/mL. He had 5 out of 8 biopsies positive for prostate adenocarcinoma. Four biopsies showed a
Gleasons score 6 (3+3), however one of the biopsies was Gleasons score 7 (3+4). According to
research conducted by Rasiah et al, patients that have a gleason score 7 prostate carcinoma
provides clinically relevant prognostic information that helps with the management of the
cancer.
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This allowed the radiation oncologist to present a variety of treatment combinations to
the patient. The Radiation oncologist did find however that a mixed treatment of 3D conformal
and Intensity modulated radiation therapy (IMRT) external beam radiation would benefit the
organ at risk (OR) constraints, treatment outcome, and the patients overall wellbeing.
Past Medical History: MC has a past medical history of arthritis, cancer (prostate), hearing loss,
hypercholesterolemia and hypertension. Past surgical history included biopsy, cataract surgery
and ear surgery. MC has reported no known allergies.
Social History: MC lives with his significant other with very supportive family and friends
willing to assist with any needs. MC is active with normal daily routines as well as eating regular
meals. He has never smoked and was a past drinker. His family history shows that his mother
had experienced colon cancer.
Medications: MC is using the following medications: B-12, Lipitor, and Mobic.
Diagnostic Imaging: In 2011 and 2012 MC received PSA screenings that showed PSA levels of
2.8 ng/mL which were considered in range. In late 2013 MC had a PSA screening that conclude
a PSA of 4.2 ng/mL. In early 2014 MC submitted a specimen for the core biopsy of the prostate.
This biopsy alerted a malignant diagnosis with Gleasons score 6 (3+3) in four biopsies and
Gleasons score 7 (3+4) in the right lateral base with focal perineural invasion noted.
Radiation Oncologist Recommendations: After reviewing MCs past surgical history and
pathology reports the Radiation Oncologist discussed a radiation therapy treatment with him.
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The Radiation Oncologist reviewed radiation treatment options including external beam radiation
therapy with IMRT/IGRT, combination of external beam radiation therapy and HDR and
combination of external beam radiation therapy with radioactive seed implant. MC did not wish
to have any invasive procedures and opted for external beam radiation therapy only. The
Radiation Oncologist felt that the value of adding hormonal therapy to radiation for MCs risk
factors and Gleasons score was discussed and participation in clinical trial RTOG 0815 was
offered to the MC, but he was reluctant to participate in the study due to the delay he would have
to start external beam treatment. RTOG 0815 trial enrolls patients with prostate cancer in a study
that treats with a high dose rate (HDR) boost, IMRT high dose boost, or a brachytherapy boost
and randomized them to plus or minus hormonal therapy.
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It was arranged for MC to receive
external beam radiation therapy only outside the study due to his schedule conflicts.
The Plan (Prescription): The Radiation oncologist recommended a 3D conformal plan that
utilized 15MV beams to maintain a conformal dose for a total dose of 18 Gy at 1.8 Gy per
fraction for a total of 10 fractions followed by an arc IMRT plan that utilized 10X-FFF arcs to 63
Gy at 1.8 Gy per fraction for a total of 35 fractions. A 10X-FFF beam is flattening filter free
(FFF) which means that the beam will have a greater forward energy the purpose of a conical
metal absorber, or filter, is to absorb more photons from the central axis while absorbing less
from the periphery of a beam. Attempting to equalize the central and periphery photons allows a
flatter beam that isnt as useful when treating with Arc beam therapy.
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Combined, the total
prescribed dose between the two plans was 81 Gy at 1.8 Gy per fraction for a total of 45 fractions
prescribed to a PTV that included the prostate and the proximal seminal vesicles. For the purpose
of this study, only the 3D conformal plan will be discussed in detail.
Patient Setup/ Immobilization: In early April 2014, MC was simulated for treatment to his
prostate. MC was placed on the simulation table in the supine position, two pillows under his
head, arms on chest, wedge under knees and a foot fix with mount (figure 1). A CT scan was
performed. Images were reviewed and the setup isocenter was selected. Single CAX and lateral
tattoos were given by the radiation therapist.
Anatomical Contouring: After the CT simulation scan was completed, the CT data was
transferred to the Varian Eclipse v.11 treatment planning system (TPS). The medical dosimetrist
imported the CT images and the plan course that consisted of the setup isocenter. The medical
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dosimetrist contoured organs at risk (OR) which included the rectum, bladder, femoral heads,
and pubic symphysis. For IGRT, further research, and setup purposes the spine and sacrum were
also were also contoured. When the dosimetrist finished contouring the radiation oncologist
reviewed the contours and contoured the prostate along with the proximal seminal vesicles. Due
to clinical specific protocols, a stage II prostate adenocarcinoma also includes a CTV margin that
is 3mm symmetrically from the GTV (Prostate+ proximal seminal vesicles) except 0 mm
posteriorly. The PTV margin is 5 mm symmetrically from the GTV except 4 mm posteriorly.
Once these contours and margins were reviewed, the medical dosimetrist completed the
treatment plan.
Beam Isocenter/ Arrangement: The medical dosimetrist used the Varian Eclipse v.11 treatment
planning system (TPS) to place an isocenter in the prostate that was in the exact same location of
the setup isocenter that was selected during the simulation process (figures 2-5). The 3D
conformal plan consisted of seven fields that were chosen by the dosimetrist to administer the
optimum conformal dose while sparing the organs at risk. Each field contained a multi-leaf
collimator (MLC) that was set symmetrically at 8mm around the PTV except for the right
anterior orthogonal (RAO) and left anterior orthogonal (LAO) fields that included a significant
rectum volume (figure 6). In which case, a smaller MLC margin of 0.5 mm was placed at either
the X1 or X2 PTV references to decrease rectal dose (figure 6). For all seven the gantry angle
was set at 0.0. The gantry angles were set at 181.0, 245.0, 275.0, 330.0, 30.0, 85.0, and
115.0 respectively for the posterior to anterior field (PA), right posterior orthogonal (RPO),
right anterior orthogonal (RAO), the second right anterior orthogonal (RAO), left anterior
orthogonal (LAO), the second left anterior orthogonal (LAO), and the left posterior orthogonal
(LPO) field. All seven of the fields were aligned to the prostate isocenter. Each beam was set at
15 MV energy with a dose rate set at 400 MU/min and assigned to the treat at the Truebeam real-
time imaging and treatment system.
Treatment Planning: The treatment objective was to use a 3D conformal technique for the
initial 10 fractions while meeting the best possible OR constraints followed by and IMRT arc
beam technique to administer the remaining 35 fractions to give an overall tighter dose constraint
to spare the rectum, bladder, and femoral head dose. The prescribed dose of 18Gy/ 1.8Gy
Fractions for the 3D conformal plan was prescribed and verified at the isocenter placed by the
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medical dosimetrist. There was no shift from the setup isocenter to the treatment isocenter. When
planning, the dosimetrist placed the seven beams described previously. The MLC margins were
set and the dosimetrist then calculated the isodose distribution with the Varian Eclipse v.11
analytic anisotropic algorithm (AAA). After doing this the medical dosimetrist reviewed the dose
volume histogram (DVH). From the DVH the medical dosimetrist found that the plan didnt
meet sufficient dose constraints that would allow enough flexibility when planning the IMRT
portion. To mitigate this problem, the beam weighting was adjusted to configure the dose
distribution (figure 7). The maximum dose to the rectum was less than 40% the total rectum
volume at 40 Gy (V40) , less than 20% the total rectum volume at 65 Gy (V65), and less than
10% the total rectum at 70 Gy (V70). The Bladder was 60% at 40 Gy (V40), 30% at 65Gy
(V65), and 15% at 70 Gy (V70). The Femoral head constraint was less than 10% of the total
volume at 50 Gy (V50). From these constraints it was difficult to conclude if the 3D plan would
fall within constraints, but the rectal, femoral head, and bladder were brought as low as possible
to allow enough room for dose with the IMRT portion (figure 8). The plan sum DVH (figure 9)
showed that the combined plans met the correct OR constraints. The medical dosimetrist and the
radiation oncologist reviewed both plans together and approved both for treatment approval.
Quality Assurance/ Physics Check: To ensure the Varian Eclipse v.11 treatment planning
system made correct monitor unit (MUs) calculations, the medical dosimetrist exported the
treatment plan to RadCalc. The percent difference between the RadCalc MUs and the TPSs
MUs fell below the required 5% acceptance. A QA diode second check was performed and
approved by the physicists. The actual diode value, read on a Sun Nuclear Corporation diode
system, fell within the expected diode range that was also calculated in RadCalc by the medical
dosimetrist. There was an additional IMRT QA check performed for the IMRT portion. This
IMRT QA displayed that the IMRT plan fell within approved constraints (figure 10).
Conclusion: It is always unfortunate to see a case like MCs that consists of a returning cancer
to the prostate. Prostate Gleasons score 7 prostate cancers tend to be more aggressive.
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However
the use of advanced 3D conformal and IMRT/IGRT radiation therapy can dramatically reduce
the risk of recurrence. The radiation oncologist and the medical dosimetrist worked together to
create a seven field 3D prostate plan. It was interesting to see an advanced combination of
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treatment plans to benefit the patients overall well-being. MCs case was an inspirational and
great example of how crucial patient disease surveillance is to survival rate.

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References
1. Rasiah K, Stricker P, Haynes A, et al. Prognostic significance of gleason pattern in
patients with gleason score 7 prostate carcinoma. Cancer. 2003; 19 (12) 2560-2565.
doi:10.1002/cncr.11850.
2. Moul J, Evans C, Gomella L, Roach M, Dreicer R. Traditional approaches to androgen
deprivation therapy. Urology. 2011; 78 (5) 485-493. doi:
http://libweb.uwlax.edu:2097/10.1016/j.bbr.2011.03.031.
3. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3
rd
ed. St.
Louis, MO: Mosby-Elsevier; 2010.

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Figure 1: Patient setup















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Figure 2: field setup from Anterior to posterior (AP) and right lateral view






















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Figure 3: Isocenter placement Transversal, Sagittal, Frontal as well as isodose distribution
(green=95% isodose line)

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Figure 4: Isocenter placement Sagittal as well as isodose distribution (green=95% isodose line)




















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Figure 5: Isocenter placement Frontal as well as isodose distribution (green=95% isodose line)
















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Figure 6: MLC margins for an RAO field




















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Figure 7: Beam weighting table
Beam name % Beam weight MU Ref. Dose (Gy)
01a PA 6.9 0.494 15 0.178
02A RPO 20.3 1.462 54 0.750
03A RAO 13.3 0.958 36 0.511
04a RAOx 13.3 0.959 29 0.348
05a LAOx 13.4 0.964 29 0.354
06a LAO 12.6 0.904 34 0.476
07a LPO 20.3 1.460 52 0.717













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Figure 8: 3D conformal DVH




















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Figure 9: PlanSum DVH
















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Figure 10: IMRT DVH