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Heather Tlougan
Clinical Practicum I
April Case Study
April 17, 2014
Rapid Arc IMRT for Pelvis
History of Present Illness: The patient is a 78-year-old male who presented to the
hospital with rectal bleeding. A colonoscopy in April of 2014 showed a circumferential
ulcerated partially firm and friable mass with the distal ends 1 cm from the anal verge and
the proximal end 13 cm from the anal verge. Biopsies were obtained, and showed
moderately differentiated adenocarcinoma. The patient had a CT scan of the chest,
abdomen and pelvis in April 2014. A rectal mass was not identified. A MRI of the
rectum was done a few days later and showed near circumferential tumor in the rectum 9
cm in length and starting 2.75 cm from the anal verge. This appeared to be T3 based on
MRI findings. There was no evidence of extension to the mesorectal fascia or invasion of
the adjacent organs. There were no suspicious nodes. The referring physician feels that
the patient would be a high-risk surgical candidate.
Past Medical History: Patient has diabetes mellitus type 2, obstructive sleep apnea with
pulmonary hypertension and left sided heart failure with diastolic dysfunction. He also
suffers from chronic obstructive pulmonary disease, atrial fibrillation, essential
hypertension, morbid obesity and chronic venous stasis in the lower extremities with
ulcer.
Social and Family History: The patient is a former smoker. He is married and his wife
is still living. There is a family history of diabetes and heart disease.
Current Medications: The patient is currently taking the following medications:
Insulin, Toprol-XL, Furosemide, and Lisinopril. Medications on admission include:
Albuterol inhaler, Diltiazem, Sodium docusate, Acetaminophen, Ipratropium, Nebulizer
solution, Zaroxolyn, Metolazone, multivitamin, Prednisone, and Warfarin.
Radiation Oncologist Recommendation: The radiation oncologist stated that the
staging of the distal rectal cancer was T3NOMO. The radiation oncologist pointed out
that the patient has multiple comorbid conditions including COPD, heart failure, diabetes
as well as morbid obesity. Taking that into account, the patient would be a high-risk
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candidate for surgery. He stated if surgery were planned, he would give neoadjuvant
radiation. When the patient first presented, he was not a candidate for chemotherapy.
The patient now has improved renal function and he is off Coumadin. The patient's
chemotherapy eligibility would impact the treatment recommendations from the radiation
oncologist. The physician would prescribe the target area to receive a dose of 5040
cGy (180 cGy in 28 fractions), if eligible for chemotherapy treatment. However,
if ineligible for chemotherapy treatment, the patient would be prescribed 2500 cGy over 5
fractions." Neither one of these approaches is curative without surgery.
Treatment Plan Prescription: The radiation oncologist prescribed 2500 cGy at 500
cGy per fraction over 5 fractions total. The prescription in conjunction with surgery is a
curative approach. The radiation oncologist prescribed rapid arc IMRT technique. The
plan consisted of two full arcs, one clockwise and the other counter clockwise. There
was no boost planned at this time.
Set Up/Immobilization: In April of 2014, the patient had a CT simulation scan to image
the area that needed to receive radiation. The patient was placed supine on top of a vac
loc bag on the simulation table. The immobilization device was then constructed in this
position. Upon completion of the scan, the images were sent to the Advantage Work
Station. At this station the images from the CT scan were uploaded. The physician
decided where to place the central axis for the radiation beams. Upon completion of
setting the central axis, the coordinates were sent back to the CT simulation for
coordinate shifts. The patient was given tattoos for setup purposes.
Anatomical Contouring: After completion of the CT simulation scan, importing the
images to the Advantage Work Station was completed. The radiation oncologist set the
central axis for the treatment plan. The images were transferred into the Varian Eclipse
Treatment Planning System. The radiation oncologist then contoured the Gross Tumor
Volume (GTV) and the Planning Target Volume (PTV). The medical dosimetrist then
contoured the bladder and femoral heads. The last step was to add the couch into the
contouring portion and set appropriate Hounsfield units to match the machine. The
medical dosimetrist also needed to decide what anatomical structures needed to be
avoided in the VMAT optimization. The medical dosimetrist created a structure called
bladder avoid, it consisted of the bladder subtracting the overlap with the PTV. One
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other useful tool is to create a ring around the PTV, giving the optimizer a bulls eye and
making the dose more conformal.
Beam Isocenter/Arrangement: A Varian 2100 IX Linear Accelerator was used for this
treatment. The machine has the capability of treating with dual energies of 6MV or
10MV. The central axis placed by the physician is evaluated by the medical dosimetrist
at this time. There were no shifts made for this patient. The medical dosimetrist is ready
to start planning. See figure 1 for the central axis placement and the PTV. This also
shows that two arcs were used. Figures 2 and 3 show the isodose lines on the coronal and
sagittal planes. Figure 4 and 5 show the anterior and lateral reference fields showing the
PTV contour and the central axis.
Treatment Planning: The dosimetrist imports the patient information into the Varian
Eclipse treatment planning system. The radiation oncologist has prescribed 500 cGy per
fraction to the PTV for a total of 5 fractions totaling 2500 cGy. Next, the medical
dosimetrist decides what arcs are going to be used for treatment. Many institutions only
use a single arc, while others have a standard practice of using two arcs. The main
objective is to avoid going through unnecessary tissue and at the same time avoid critical
structures. Arc treatment fields can be started and stopped at the discression of the
medical dosimetrist. You can also have the arc not deliver radiation during certain parts
of the arc. In this case, two full arcs were used, one clock wise and the other counter
clock wise. Each arc had a 15-degree collimator rotation to decrease any radiation
leakage between the leaves. The medical dosimetrist then set the appropriate field size
for each arc taking into consideration how the PTV was projected while the arc was in
motion. The next step is setting the constraints in the optimizer. The medical dosimetrist
wanted to give 100 % of the dose to the PTV. The dosimetrist also wants the optimizer
to deliver dose away from the bladder and femoral heads. A high priority was set for
these two structures telling the optimizer to put the dose elsewhere. This plan was not
very hard; both arcs distributed the dose beautifully. There were not a lot of critical
structures to avoid making this plan easier. The plan ended with a 108.3 % hot spot in
the PTV, with the mean dose being at 102%. The dose volume histogram, Figure 6,
shows very low dose to critical structures. In the end, the radiation oncologist ended up
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treating 2500 cGy with ten fractions. Depending upon the fractionation the radiation
oncologist chooses, depends upon the dose limit to each structure.
Quality Assurance/Physics Check: The monitor units for the plan were double-checked
using the Rad Calc program. Our department tolerance between the TPS MU and the
RadCalc MU is 3 %. This plan fell within those parameters. Physics would check the
plan and also do quality assurance on the treatment machine before treating this plan.
Conclusion: This was an easier rapid arc plan. It allowed the medical dosimetry student
to easily understand the step-by-step approach needed for this type of planning. The
medical dosimetrist is able to get the radiation dose very conformal to the PTV. By
creating your avoidance structures and really thinking hard up front establishing the arcs
and treatment field makes the plan go quite smoothly.



























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References
1. Bentel GC. Radiation Therapy Planning. 2
nd
Ed. New York, NY: McGraw-Hill; 1996.
2. Khan,F. Gerbi, B. Treatment Planning in Radiation Oncology. 3
rd
ed. Philadelphia, PA.
Lippincott Williams and Wilkins; 2012.




























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Figures

Figure 1. The transverse view showing the central axis and two arcs along with the
isodose distribution. The hot spot in the plan is 108%.


Figure 2. This picture shows the coronal view of the treatment area.

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Figure 3. This picture shows the sagittal view of the treatment area.


Figure 4. The picture is showing the anterior reference field with the PTV in blue.

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Figure 5. The picture is showing the Rt Lateral reference field with the PTV in blue.



Figure 6. Dose Volume Histogram.