Tsai 1 Kevin Tsai January Case Study January 22, 2013 IMRT for Prostatic Adenocarcinoma History of Present

Illness: The patient is an 83 year-old male that recorded an elevated Prostate Specific Antigen (P.S.A) of 30.54 nanograms per milliliter ng/ml on January 5, 2012. Prostate Specific Antigen blood levels are often tested in men older than 50 years old and normal PSA value is said to be less than 4 ng/ml.1 The patient had another prostate screening 6 months later on June 2, 2012 and the results still showed abnormally high PSA of 28.19 ng/ml. On August 3, a microscopic needle biopsy was performed on the right and left side of the prostate. The right prostatic tissue showed negative signs of carcinoma. The biopsy on the left side of the prostate indicated prostatic adenocarcinoma with a Gleason grade of 9 (4+5) in 3 cores. It involved 14% of the needle core tissues and measured 8 millimeters (mm) in length (59 mm of total tissue). The Gleason score is a histologic grading system from 2-10 based on the tumors characteristics.1 The patient tested a high Gleason score meaning a more invasive and metastatic disease. On August 31, the patient was referred to a radiation oncologist to discuss various treatments to his prostate. Past Medical History: The 83 year-old patient has a past medical history of benign prostatic hyperplasia (BPH), allergic rhinitis, diverticulosis, spinal stenosis, disc herniation, childhood asthma, psoriasis, and colitis. The patient had a tonsillectomy when he was 10 years old and a hemorrhoidectomy in 1970. He has had no previous radiation treatments or chemotherapy. No allergic reactions to foods or latex. Social History: The patient lives at home with his wife and daughter. The wife has Alzheimers disease and the daughter stays at home to take care of her. The patient is a retired concrete construction consultant. His father passed away from metastatic disease when he was 56 years old and mother died of natural causes. The patient claims he smoked for 40 years and has quit for the last 35 years. During the 40 years, the patient smoked more than half a pack per day. The patient now drinks 1-2 drinks per day and denies any drug use in the past. Medications: The patient is using the following outpatient medications (including supplies): Artificial tears polyvinyl alcohol, barium SO4, Capsacin cream, Flunisolide nasal spray, Leuprolide, Loratadine, Meloxicam, Mesalamine, Aspirin, and Tamsulosin.

Tsai 2 Diagnostic Imaging: On August 27, the patient went through computed tomography (CT) scan of the abdomen and pelvis with contrast as well as a bone scan. The CT scan showed bilateral renal calculi and multiple hepatic cysts. The bone scan had no evidence of metastatic bone disease. Radiation Oncologist Recommendations: The radiation oncologist had a long discussion with the patient about the diagnosis of his prostate cancer. The doctor explained what the Gleason Grade meant and discussed all treatment options best for him. The options given to the patient included observation / active surveillance, radiation therapy, endocrine therapy, and radical surgical extirpation. Observation is often the general management for patients older than 75 years old for well-differentiated tumors.1 This is not the case for this patient because of his high Gleason score. The natural course of high-risk prostate cancers includes metastases to the bone if tumor is left untreated. Surgical therapy is also not a good option for him because of the many complications including blood loss, infections, bowel injuries, and age. Hormone ablative therapy would slow down the tumor but not stop cancer progression. Radiation therapy by external beam or interstitial seeds was also discussed during the consultation. Radiation therapy may not be curative and may cause more damage such as cystitis, proctitis, urinary incontinence and erectile dysfunction; however, the benefits of radiation therapy would include the lack of anesthesia and the good results with past patients. After the consultation, the patient opted for external beam radiation treatment. The Plan/Prescription: External beam to the pelvis/prostate is often given by intensitymodulated radiation therapy (IMRT) technique. Intensity-modulated radiation therapy is a technique in which nonuniform fluences are delivered to the patient in any position.2 It uses multiple angles to avoid high doses to critical structures and conforms the treatment volume very well. For this patient, the radiation oncologist prescribed a dose of 5040 centigray (cGy) at 180 cGy per fraction for 28 fractions to the entire pelvis. The large fields will include the whole prostate as well as certain pelvic lymph nodes. After the pelvis treatment is completed, another 540 cGy will be deliver to the prostate and seminal vesicles at 180 cGy per fraction for 3 fractions. The last 1980 cGy will be delivered to only the prostate at 180 cGy per fraction for 11 fractions. The total dose given will add up to 7,560 cGy. The IMRT technique gives us extremely conformal fields and tight margins allowing us to go to high doses such as in this case.

Tsai 3 Patient Setup and Simulation: After the consultation, the patient came back in September for a CT scan, which is used to make his treatment plan. This CT scan was different than other CT scans because it uses a hard flat table similar to the treatment table. The patient was scanned exactly in the same position he will be treated in every day so patient setup is vital during this process. The patient is scanned headfirst supine with his arms on his chest. His head was on a soft pillow for comfort. An alpha-cradle was conformed around the patients legs to minimize movement as well as setup reproducibility. A small knee wedge was also inserted underneath the patients knee for comfort (Figure 1). Right before the scan, the simulation technician drew crosses and put BBs on each side of his pelvis and one on the anterior surface using the lasers in the room (Figure 1). The crosses and BBs will be used to reproduce the patients setup for his radiation treatment. The patient was also told to have a full bladder, which assist in pushing the small bowel out of the treatment field. The CT scan was given without any problems and the CT images were exported to treatment planning system. Anatomical Contouring: When the CT scan was complete, the simulation technician exported all the CT images to the Eclipse Version 8.9 TPS. The dosimetrist used Eclipse complete the treatment plan according to the doctors prescription. First he contoured all the critical structures that may be affected during treatment. The organs at risk (OR) in prostate cancer treatments include the rectum, bladder, small bowel, and femoral heads. These contoured structures will let the doctor know how much dose is delivered to these structures. Once the contouring is complete, the dosimetrist or medical physicist created treatment fields to fulfill the radiation oncologists prescription. Beam Isocenter and Arrangement: The isocenter is a fixed point that the linear accelerator rotates around. It is the intersection point of the gantry, collimator, and base of couch.1 Isocentric techniques are often used in more complex treatments like prostate cancer because of the multiple beams it uses. Isocentric techniques will redirect treatment beams so that the patient will not have to be moved. The isocenter is set during the simulation by the simulation technician where the BBs are located. The dosimetrist will create an isocenter if one was not created during simulation. For pelvic treatments, it is best to have the isocenter towards the middle of the patient shown in Figure 2. There were 7 beam angles used in this treatment plan to minimize dose to the critical structures (Figure 3). The 7 gantry angles were 180, 250, 284, 336, 28, 80,and 110. All of the IMRT beams used were 6 Megavoltage (MV) energies to conform around the tumor volume

Tsai 4 because 18 MV IMRT would cause too much radiation scatter. In each field, the MLC setting changes and shields areas that doctors dont want treated such as the femoral heads, bladder, rectum, and small bowel. This allows higher dose to the tumor volume and less to the organs. When the dosimetrist was satisfied with the dose distribution to the target volume, they called the doctor to approve the treatment plan. Treatment Planning: The treatment plan for this patient was completed on the Eclipse version 10 TPS. The dosimetrist received a prescription from the radiation oncologist after the CT simulation. They used the TPS to create a plan that achieved the constraints set by the physician. In this case, the dosimetrist decided that IMRT technique was best to give maximum dose to the treatment volume while minimizing dose to organs. This plan had 7 beam angles created with MLCs to treat the whole pelvis including the prostate and seminal vesicles. When the plan was completed, the doctor analyzed the Dose Volume Histogram (DVH) to see how much dose each organ was receiving (Figure 4). The total dose given to the whole bladder must be under 6500 cGy and only 3730 cGy was delivered.3 The whole rectum can only receive 6000 cGy or the patient may suffer proctitis, necrosis, stenosis, and fistula.3 In this case, an average of 3786.5 cGy was delivered to the rectum. The entire femoral head and neck can only receive a max dose 5200 cGy.3 The average dose of 3166.1 cGy was delivered to the left femoral head and 3710.3 cGy to the right femoral head. The max dose to the small bowl is 4500 cGy and 4295.9 cGy was delivered.3 In this plan, none of the critical structures surpassed the max limit dose. The doctor approved the DVH and set the plan normalization value to 97.8%. The treatment plan was completed and sent off to physics. Quality Assurance and Physics Check: After the plan is complete, it was exported to the RadCalc software to double-check the monitor units (MU). The MUs did not have more than a 3% difference than the treatment plan. The plan was tested on a phantom before the patient to ensure the correct dose is being delivered. All the numbers tested were within tolerance so the plan was submitted to physics for a final check before actual treatment began. There are many Quality Assurance (QA) checks before any dose was delivered to the patient to minimize treatment errors. Conclusion: The patient completed his treatment without many problems. He is a very old man with vision problems and walked around with a walker. At first, I was wondering why they would treat this patient because of his old age. I found out later that his tumor was very

Tsai 5 aggressive and that he would live longer if he got treatment instead of observation. Throughout his treatments the patient experienced fatigue, pain, acceptable continence, and loss of erections. These are all side effects commonly seen in prostate patients. Approximately 95% of patients have socially acceptable continence, which will return within 3-6 months. Regarding impotence, it could take from 12-24 months before erections return. The patient completed his radiation treatment in December of 2012 and the doctor will follow up with him in 3 months. In this case study, I was able to learn how a patient flowed through a radiation oncology department. I learned about patient setup, treatment options, contouring, treatment planning, and QA. This case has helped me get a better understanding of my department.

Tsai 6 FIGURES

Figure 1: Patient Setup

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Figure 2: Isocenter

Figure 3: Treatment plan

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Figure 4: Dose Volume Histogram (DVH)

Tsai 9 Reference 1. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsvier; 2010:164-164, 823-850. 2. Khan FM. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams and Wilkins; 2010:430. 3. Vann A, Dasher B, Chestnut S, Wiggers N. Portal Design in Radiation Therapy, 2nd ed. Columbia, S.C: The R.L. Bryan Company; 2006:150-158.