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Nick Piotrowski Clinical Practicum 1 March 29, 2013 Prostate Intensity Modulated Radiation Therapy History of Present Illness: GE is 67 year old male that has been recently diagnosed with a malignant prostate neoplasm. After an elevated prostate-specific antigen (PSA) count, the patient presented with a stage of T1 prostatic cancer. After a period of observation, the patient moved forward and had a radical prostatectomy removing the prostate and surrounding organs such as the seminal vesicles and lymph nodes. Following the surgery the patient was to receive post-operation radiation therapy. Past Medical History: GE has a limited previous medical history and no prior experience with radiation therapy. He has a mild case of both hypertension and syncope with the addition of adrenal hyperplasia. Social History: GE is currently single though he was married once from which he has one daughter. He has no history of alcohol or drug abuse but has smoked for over 25 years. He has no family history of cancer, and worked as a high school teacher for many years before retiring. Medications: He is currently taking Metoprolol succinate and Lisinopril for his high blood pressure and has no known allergies. Diagnostic Imaging: The only imaging that GE has had completed is a computed tomography (CT) planning scan prior to receiving his radiation therapy treatments. Radiation Oncologist Recommendations: Following the radical prostatectomy it was recommended that GE receive a course of curative radiation therapy treatments. The Plan (prescription): As is the case in most of our prostate patients, GEs plan was treated as a nine field intensity modulated radiation therapy (IMRT) plan. The plan was to consist of 25 initial fractions at 180 centigray (cGy) per fraction to reach a dose of 4500cGy. Following this prescription is a seven field boost plan of 10 fractions at 180cGy per fraction. The summation of these plans created an overall dosage of 6300cGy over a seven week period. Patient Setup/Immobilization: GE was simulated on a General Electric CT scanner with .5cm thick slices. The upper body did not require much immobilization as an F headrest as shown in Figure 1 was used, and the hands were placed on a blue ring on the patients chest. Starting at

the upper portion of the pelvis, a Vac-Fix was used to immobilize his pelvis and lower extremities. The patient did not receive any contrast as it was already easy to visualize the apex. Anatomical Contouring: I first set a user origin based on the BBs that were set on the day of the simulation. From there I contoured the body, bladder, rectum, both femoral heads, and bowel (large and small combined). Once that was completed the physician went ahead and contoured the planning target volume (PTV), as well as the boost treatment volume (BTV). Beam Isocenter/Arrangement: Using a Varian iX linear accelerator, GE is receiving his treatment over a seven week period of time. The IMRT plan consisted of nine fields, all equally weighted using 6 megavoltage (MV) beams. The beams were equally spaced apart, starting with an anterior posterior (AP) beam and rotating every 40 degrees from there. While the isocenter was placed in the center of the PTV, there were three shifts associated with this plan. The largest shift was a 30.2 centimeter (cm) anterior shift, followed by a 12.8cm superior shift, and finally a 1.9 cm shift to the left. Figure 2 shows the isocenter placement as well as the beam arrangement of the initial IMRT plan. Treatment Planning: By using the planning software Eclipse 8.6, the goal for GEs plan was to reach 100% coverage of the PTV while sparing the surrounding organs such as the bladder and rectum. With the IMRT plan the upper and lower objectives were set to keep the surrounding structures under the dose tolerances set by Emami.1 The PTV was prioritized at 100% and normalized at 105%. Along with the constraints on the rectum and bladder, the best plan was created with 95 percent coverage around the tumor volume. Once the plan was completed, the dose volume histogram (DVH) was analyzed to make sure all of the constraints were met. When the boost plan was created a couple of weeks later, a plan summation was created which included a DVH which can be seen as Figure 3. Quality Assurance/Physics Check: Before printing, the monitor units that were calculated by Eclipse were double checked using RadCalc. Once the numbers were found to be within 2%, the plan was checked and signed off by both the medical physicist, as well as the attending physician. Conclusion: While this plan was not unusual or unique in any way, it held some particular importance to me. As I have progressed in the clinic I have taken on new challenges, one of them being IMRT. With our dosimetrist on vacation and physicist busy working on other plans I was to create my first IMRT plan on my own. While I did end up receiving some suggestions

and helpful hints from our physicist, I was successful in creating this plan. After being educated on the new technologies such as IMRT, it was nice to finally have the opportunity to work with it. Although the ultimate goal of treatment planning remains the same, the way of achieving this result was less complicated than I had expected. Fortunately I didnt have to push the planning system too hard allowing for a relatively easy first plan. After conquering this new technology it has gotten me excited for my treatment planning future. The more I learn and overcome the more I want to push myself to the next level, eventually becoming the best dosimetrist I can be.

Figure 1: F Headrest courtesy of Timo headrests.2

Figure 2: Isocenter placement and beam arrangement.

Figure 3: DVH of plan summation.

References 1. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic radiation. International Journal of Radiation Oncology, Biology, and Physics. 1991;21:109-122 2. Civco medical solutions. Timo headrests. Patient Immobilization. 2013. Available at: http://www.civco.com/ro/products/patient_immobilization/hnpositioning/headrest/timo/. Accessed March 29, 2013.