1 Eyob Mathias April Case Study April 22, 2011 Adenocarcinoma of the prostate - Intensity Modulated Radiation Therapy

History of Present Illness: NP is a 69-year-old white male who has been treated for multiple prostate infections with antibiotics over the last couple of months, and has had a persistent mild elevation of his PSA. His primary care physician (PCP) noticed an elevated area on the left side of the prostate gland that was suspicious. He was referred to a urologist and underwent a prostate biopsy on 12/14/2012. This showed multiple areas of involvement in the left side of the gland, with Gleason score 7, stage IIa adenocarcinoma of the prostate with a serum prostate specific antigen (PSA) level of 4.24 nanogram/milliliter (ng/mL). The urologist reviewed the results with Mr. NP and the treatment options were discussed. Mr. NP opted to get radiation treatment and he was referred to my clinical site. In terms of urinary symptoms, he has some mild nocturia maybe once nightly and occasional episodes of weak urinary stream or urinary frequency. His American Urological Association (AUA) symptom score is 4 which falls within the mild category of severity. His overall nocturia score is between 2 and 3. 2. In terms of erectile issues, he stated that he had well-maintained erectile function, but he is not sexually active at this time. Other than skin cancer, prostate cancer is the most common cancer in American men.1 The American Cancer Society estimates about 238,590 new cases of prostate cancer and about 29,720 men will die of prostate cancer in the United States for 2013.1 Some of the risk factors for prostate cancer are vasectomy, sexually transmitted disease (STD), obesity, diet, gene, race and age.1 Past Medical History: Mr. NP has had kidney stones in 2000 and he had right low back pain radiating to the right lower quadrant (RLQ) and testes. NP had a history of lower testosterone for years and this has been associated with erectile dysfunction. He also had a history of insomnia and dyslipidemia. Other than the indicated medical history, patient has been relatively healthy most of his life with no serious medical or surgical issues. Diagnostic Studies: On January 01, 2013 NP underwent abdominopelvic computed tomography (CT) scan with and without contrast. The result showed tiny granuloma at the left lung base and

2 mild fatty infiltration of the liver. A normal bladder is seen and the prostate demonstrates a few calcifications. Social History: Mr. NP was a former cigarette smoker. He used to smoke 1-2 packs per day for about 40 years. He stopped smoking on January 1st, 2003. He drinks alcohol occasionally. He is single and retired. Patients mother died due to ovarian cancer. Current Medications: Mr. NP is currently taking alprazolam as needed. He also takes Zofran 4 milligram (mg) tablet per day and Lansoprazole 30 mg every 30 minutes before the first meal of the day. Recommendations: Mr. NP has an intermediate to high-risk prostate carcinoma based on his Gleason 7 morphology and bulky left-sided disease. He was at a higher risk of having extension and pelvic nodal involvement. The oncologist discussed with the patient regarding radiotherapy options for this stage disease. The doctor indicated that patient is not a good candidate for seed implantation. Rather, external beam radiotherapy was recommended so the treatment fields can be customized to include the prostate, periprostatic tissues, seminal vesicles, and proximal pelvic lymph nodes. Given the bulkiness of his disease, NP was also recommended to receive 6 months of hormonal therapy using Lupron or Eligard. He was reffered to another clinical facility to start his hormonal therapy and have the gold seed fiducial placement for his external beam radiation. The Plan (prescription): The radiation oncologists plan was for NP to receive a definitive dose of radiation therapy with concurrent hormonal therapy. The dose prescribed to NP was 4500 cGy at 180 cGy per fraction for 25 fractions to the prostate and pelvic lymph nodes followed by 1620 cGy per fraction to the prostate and seminal vesicles in 9 fractions and finally boosting the prostate only to 1620 cGy in 9 fraction. The total dose prescribed was 7740 cGy to be given 180cGy per day in 43 fractions. IMRT plan was requested over 3D plan in order to reduce the dose to critical structures. IMRT will also help reduce radiation toxicity around the treatment volume. Patient Setup / Immobilization: Mr. NP was simulated in the supine position with a pillow behind the head for comfort, both arms were on his chest holding a blue ring, and a knee cushion was provided for the patients comfort and to help him maintain the setup position throughout his treatment. Patient was instructed to have a full bladder at the time of simulation and every day before his treatment. A CT scan was performed for radiation therapy treatment planning. The scanned images were sent to digital imaging and communications in medicine (DICOM) server

3 where the dosimetrist will have access to download all images into the treatment planning system (TPS). Anatomical Contouring: There was no image fusion required so only the CT simulation images were downloaded into the TPS. The physician contoured the gross tumor volume (GTV) and the dosimetrist contoured all the critical structures surrounding the treatment volume. The critical structures included bladder, rectum, small bowel and femoral heads. For the first 4500 centi-gray (cGy) prostate, seminal vesicle, pelvic nodes were included in the PTV with the following expansion margins; anteriorly 0.7 (centimeter) cm, posteriorly 0.5 cm, laterally 0.7 cm, superiorly 0.7 cm, and inferiorly 0.7 cm . These margins are somehow constant for all prostate IMRT cases according to our physician recommendation. Beam Isocenter / Arrangement: The dosimetrist utilized nine beams IMRT arrangement for this treatment plan. The gantry angles were 220, 260, 300, 340, 20, 60, 100, 140 and 1800. The collimator angles were adjusted for each beam to avoid the bladder, rectum and sigmoid colon. The treatment couch angle remained at 00 for all treatment beams. A 6MV photon energy were used for all the 9 beams. The dosimetrist put objectives into the IMRT module of the TPS and allowed the computer to determine the appropriate field sizes to achieve the desired objectives. Treatment Planning: The physician treated the pelvic lymph node chain to 45gray (Gy) at 1.8gray (Gy) per fraction for 25 fractions, cone down to the prostate and seminal vesicles and final boost for only the prostate to a total dose of 7740 cGy for 43 fractions. Each plan was normalized to the 98% isodose line. The visualized hot spot were 103%. All critical structures received a dose that was acceptable and it was approved by the physician. Quality assurance: After the plan was approved by the radiation oncologist, the dosimetrist transferred the IMRT plan to Mozaiq where the physicist can have direct access to the treatment plan and perform quality assurance (QA) procedure. The dosimetrist also generated a separate Matrixx plan that can be used to perform QA on a phantom. The physicist compared the computer calculated monitor unit with another QA software calculated monitor units. The second check QA monitor unit calculator software used for this plan is known as Radcalc. Each IMRT field dose was measured on a water phantom and Matrixx QA device was utilized. The QA software records the dose readings from all beams. The result should reveal an error percent of

4 only less than 5%. The treatment plan passed the IMRT QA test with only 2% error and the plan was approved by the medical physicist. Conclusion: This plan was slightly labor intensive because the dosimetrist had to create 3 plans and create a composite plan that consisted of all the plans together. Other than that the objective dose constraints set for the organs at risk (OR) were not difficult for the TPS to achieve. The fact that the patient had a full bladder before going through the simulation process definitely helped to easily delineate the GTV and critical structures. It also helped the optimization process, since the critical structures are out of the treatment field. NP started his treatment on April 15, 2013. According to his treatment plan schedule, he will complete his radiation therapy treatment on June 13, 2013.

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

7 References 1. American Cancer Society. Prostate Cancer. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-key-statistics. Accessed April, 28, 2013.