A.J.

Kressin
February Case Study
February 20, 2014
VMAT Radiation Therapy for Recurrent Prostate Cancer
History of Present Illness: Patient NH is a 79 year old male who was initially diagnosed with
prostate cancer in 1996. He underwent a radical prostatectomy in June, 2006. Final pathology
showed Gleason 7 in both sides with negative margins and no tumor in the apex or base. There
was also no erythropoietin-producing enzyme (EPE), and no systemic viral infection (SVI). His
initial post-operative prostate-specific antigens (PSA) were undetectable and remained that way
for many years. However, his PSA entered a detectable range many years after the procedure
and, therefore, the primary care physician referred him back to the urologist in October 2011. In
August 2012, NH returned to see the urologist and was found to have had an increase in his PSA.
NH was also found to have a small BB sized area just left of midline at the base of the prostate
bed that was thought to be a possible recurrence. The urologist suggested that NH consider local
radiation therapy but NH did not return with a decision. A year later he returned to the urologist
with a substantially increased PSA. It was at this time when NH was referred to radiation
oncology to consider radiation therapy with or without adjuvant hormonal therapy. The radiation
oncologist met with NH and discussed the various treatment options. The radiation oncologist
recommended aggressive radiation treatment to the prostate bed along with hormonal therapy.
NH was informed of the risks and benefits of radiation treatment and agreed to proceed.
Past Medical History: NH has a past medical history of diastolic dysfunction, cellulitis,
obstructive sleep apnea, paroxysmal atrial fibrillation, and gout. He has a surgical history that
includes a colonoscopy and an inguinal hernia repair. NH reports no current allergies.
Social History: NH has no family history on file, but reported his mother, father, and sister have
all had an internal organ cancer and his brother had prostate cancer. The patient is married and
was previously a cigar smoker at 0.8 packs per day. NH has quit smoking since August 3, 2013.
NH denies any drug or smokeless tobacco use and claims to consume 3 alcoholic beverages per
week.
Medications: NH uses the following medications: allopurinol, amlodipine, bumetanide,
lisinopril, metolazone, metoprolol-XL, simvastatin, triamcinolone acetonide, and warfarin.
Diagnostic Imaging: In December 2013, NH had a Computed Tomography (CT) scan with oral
and intravenous (IV) contrast to check for local recurrence of prostate cancer. A 10 mm
asymmetrical soft tissue nodule was discovered in the prostate bed left of midline. Slight
asymmetry was seen in the seminal vesicles but was of unknown significance. No enlarged
lymph node or other mass was detected. NH also underwent a nuclear whole body bone scan in
December 2013. He was injected intravenously with 25.8 millicuries of Technitium 99m. There
was no evidence of radiotracer uptake in a distribution to suggest metastatic disease. In January
2014, NH had a magnetic resonance imaging (MRI) scan that was fused with a CT scan in order
to assist the radiation oncologist with localizing the target volume. A 10mm focus to the left of
midline was confirmed in the posterior inferior junction of the bladder and urethra.
Radiation Oncologist Recommendations: After reviewing the patients surgical history and
pathology reports, the radiation oncologist recommended NH undergo post-operative radiation
therapy to the prostate bed, pelvic lymph nodes, and prostate nodule followed by a boost to the
prostate bed and nodule using a volumetric-modulated arc therapy (VMAT) plan. In a VMAT
treatment, dose rates and field apertures continuously change while the gantry simultaneously
rotates around the patient in order to deliver tightly conformal dose distributions to the target
area.
1
VMAT treatment plans are a cutting edge form of radiation treatment that incorporates
intensity modulation and inverse planning, but can often be more challenging to plan than
intensity-modulated radiotherapy (IMRT) plans.
2
The radiation oncologist also suggested
adjuvant hormonal therapy.
The Plan (prescription): The radiation oncologist recommended NH undergo a VMAT
radiation therapy treatment along with a VMAT boost to the prostate bed and nodule after initial
treatment. The VMAT boost plan incorporated 5 arcs. The initial treatment plan included 2
different prescriptions delivered simultaneously. The prostate bed and lymph nodes were
prescribed a total of 4500 cGy at 180 cGy per fraction for 25 fractions. The nodule within the
tumor bed was prescribed a total of 5000 cGy at 200 cGy per fraction for 25 fractions. The boost
plan also contained 2 different prescriptions. The prostate bed was to receive 2340 cGy total at
180 cGy per fraction for 13 fractions, while the nodule was prescribed 2600 cGy total at 200 cGy
per fraction for 13 fractions. For the evaluation of this case study, only the primary VMAT plan
to the prostate bed, lymph nodes, and nodule will be discussed.
Patient Setup/Immobilization: In February 2014, NH underwent a CT simulation scan for
radiation therapy treatment. He was placed in the supine position on the CT couch and
immobilized using a total body fix Vac-Lok bag with both arms at his sides and hands grasping a
rubber ring on his chest (Figure 1). The radiation oncologist performed a urethrogram and had
NH consume oral contrast. Prior to scanning NH was straightened and aligned with in-room
lasers. Marks were placed on the anterior and lateral skin surfaces of the patient for alignment
and leveling on the treatment couch.
Anatomical Contouring: After the CT simulation scan was completed, the CT data set was
transferred to the Varian Eclipse 11.0 radiation therapy treatment planning system (TPS). The
radiation oncologist contoured the post-operative prostate bed, tumor nodule, lymph nodes,
bladder, rectum, right and left femoral heads, and the small bowel. The medical dosimetrist
contoured the contrast and expanded the prostate bed, nodule, and lymph node contours to form
the planning target volume (PTV). The dosimetrist also constructed a ring around the PTV in
order to constrict dose. A structure was contoured around the rectum to help decrease dose to the
rectum. Structures were also created to form the bladder minus the overlapping PTV and the
rectum minus PTV. The medical dosimetrist was given a prescription objective sheet to begin
treatment planning.
Beam Isocenter/Arrangement: The medical dosimetrist allowed the computer place the
isocenter in the geometrical center of the total PTV (Figures 2-6). The plan consisted of 5 total
VMAT arcs of the gantry, 4 of which were total arcs, and 1 of which was a partial arc. Each arc
utilized a 6 megavoltage (MV) energy photon beam. The first arc was in the clockwise direction
and the arcs that followed alternated between counterclockwise and clockwise directions. For
arcs 1, 2, 3, 4, and 5 the gantry rotated from 180.1 to 179.9, 179.9 to 180.1, 180.1 to 179.9, 179.9
to 180.1, and 215.0 to 145.0 degrees respectively. Collimator rotations were 330, 340, 30, 20,
and 20 degrees for VMAT arcs 1, 2, 3, 4, and 5 respectively. The medical dosimetrist assigned
one prescription to the prostate bed and lymph node PTV and a second prescription to the nodule
PTV. The TPS automatically determined the optimal field size apertures and field weightings for
each arc to meet the treatment objectives (Figures 7-11).
Treatment Planning: The radiation oncologist outlined the dose prescription objectives for the
VMAT plan. The objective was to reduce radiation toxicity in the bladder and rectum while still
achieving homogeneous dose coverage of the prostate bed, nodule, and pelvic lymph nodes
(Figure 12-14). Both prescriptions were prescribed to the appropriate PTVs. The patient received
a total of 180 cGy to the prostate bed and pelvic lymph nodes and 200 cGy to the prostate nodule
per day for 25 fractions. The objectives for the prostate bed, nodule, and pelvic lymph nodes that
were entered into the VMAT module of the TPS were uniform, minimum, and maximum doses
corresponding to the prescribed doses. The organs at risk (OR) dose constraints included: the
volume of rectum receiving 4276 cGy (V
4276
) was to be less than or equal to 25%, the volume at
2632 cGy (V
2632
) was to be less than 45% (radiation oncologist would accept 50% but volume at
2961 cGy (V
2961
) must be less than 50%), the bladder volume receiving 4276 cGy (V
4276
) was to
be 40%, and the volume at 2632 cGy (V
2632
) had to be less than or equal to 60%, the volume of
the femoral heads receiving 3289 cGy (V
3289
) was to be less than 10%, and the bowel space
volume receiving 2961 cGy (V
2961
) was to be less than 150 cc. In order to get adequate dose
coverage the medical dosimetrist normalized both prescriptions to 97.4%. When there was
sufficient prescription dose coverage to the indicated PTVs the dosimetrist referred to the OR
dose constraints along with the isodose lines, and dose volume histogram (DVH) (Figure 15).
Quality Assurance/Physics Checks: Quality assurance (QA) was carried out using the
ArcCHECK program. The planned treatment was delivered on the linear accelerator aimed at the
cylindrical ArcCHECK diode array system made by Sun Nuclear. Our department tolerance is
based on the International Commission of Radiological Units and Measurements (ICRU)
guidelines of a 90% pass rate of the gamma criteria. The gamma criteria are numerous point
comparisons of the actual delivered dose compared to the planned dose from the TPS.
3
The
gamma criteria fell within the tolerance level and the complete VMAT treatment plan was
reviewed by the physicist as a final check prior to the start of treatment.
Conclusion: One of the major challenges for the medical dosimetrist was getting the rectal dose
within an acceptable range. Extra contours were constructed and priorities had to be reordered
several times in order for the rectal dose to become acceptable. The reason the rectum dose
posed such a challenge was because the PTV actually extended into part of the rectum.
Therefore, tighter margins had to be used in order to further constrict the dose to the PTV.
Having no previous experience with the Varian Eclipse TPS and no prior exposure to VMAT
treatment planning, watching the medical dosimetrist manipulate the TPS to achieve desired
objectives was very interesting. I picked up on some details of the treatment planning process.
For instance, the gantry cannot start at 180 degrees and end at 180 degrees. That is why when a
complete arc is planned in our department the medical dosimetrist will start at 180.1 degrees and
stop at 179.9 degrees for a clockwise rotation and vice versa for a counterclockwise rotation.
Also, creating additional contours in regions that need more assistance with increasing or
decreasing the amount of dose delivered can be effective.


References
1. Sale C and Moloney P. Dose comparisons for conformal, IMRT and VMAT prostate plans. J
Med Imag and Radiat Oncol. 2011;55:611-621. http://dx.doi.org/10.1111/j.1754-
9485.2011.02310.x
2. Chen H, Craft DL, Gierga DP. Multicriteria optimization informed VMAT planning. Med
Dosim. 2014;39:64-73. http://dx.doi.org/10.1016/j.meddos.2013.10.001
3. Low DA, Harms WB, Mutic S,Purdy JA. Evaluation of the gamma dose distribution
comparison method. Med Phys. 2013;30(9):2455-2464. http://dx.doi.org/10.1118/1.1598711


Figures

Figure 1. Patient position in a total body fix Vac-Lok bag at CT simulation.

Figure 2. Anterior/posterior view of isocenter placement.


Figure 3. Right lateral view of isocenter placement.

Figure 4. Axial view of isocenter placement.


Figure 5. Sagittal view of isocenter placement.

Figure 6. Coronal view of isocenter placement.


Figure 7. VMAT field size for arc 1 automatically determined by TPS.

Figure 8. VMAT field size for arc 2 automatically determined by TPS.


Figure 9. VMAT field size for arc 3 automatically determined by TPS.

Figure 10. VMAT field size for arc 4 automatically determined by TPS.


Figure 11. VMAT field size for arc 5 automatically determined by TPS.

Figure 12. VMAT dose distribution of PTV.


Figure 13. VMAT dose distribution of PTV.

Figure 14. VMAT dose distribution of PTV.


Figure 15. Dose volume histogram (DVH).