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Titus Kyenzeh
February Case Study
March 3, 2014
VMAT for a bladder cancer patient with a hip prosthesis
History of Present Illness: Patient BA is an 84-year old male who initially presented with
hematuria and a bladder infection in September of 2011. He was found to have T1 urothelial cell
carcinoma with multifocal carcinoma in situ. Several cycles of Bacille Calmette-Guerin (BCG)
were administered. Upon further evaluation, a right-sided high-grade ureteral obstruction with
cystoscopy revealed a muscle-invasive tumor. A right-sided ureteral stent was placed. Patient
BA received a cystoprostatectomy with ileal conduit and lymph node dissection in late
November 2013 which revealed pT4aN2M0 disease. There was extensive involvement of the
prostate with focal areas of positive prostatic surgical excisional margins on both right and left
sides of the prostate.
Past Medical History: The patient has a past medical history of hypertension, open
appendectomy 30 years ago, exploratory laparoscopy with lysis of adhesions, left nephrectomy,
right ankle surgery, left knee and hip replacements, and bilateral cataract surgery.
Social History: BA lives by himself. He smoked for 30 years but quit about 20 years ago. He
denied any history of alcohol or illicit drug use. A sister was diagnosed with stomach cancer at
the age of 40 years.
Medications: The patient takes Amlodipine and Sodium Bicarbonate.
Allergies: The patient is allergic to the following medications: Reglan, Morphine, Benadryl, and
Lovenox.
Diagnostic Imaging: A chest x-ray in November 2013 showed no evidence of metastatic disease
in the chest.
Radiation Oncologist Recommendations: Due to the patients locally advanced bladder
cancer, the radiation oncologist recommended a course of adjuvant radiation therapy. The
radiation oncologist recommended the use of volumetric modulated arc therapy (VMAT)
technique to deliver the treatment. This was medically necessary in order to deliver adequate
dose to areas of interest while avoiding surrounding normal sensitive structures of interest to
include the small bowel, sigmoid, rectum, and right femoral head. Volumetric modulated arc
therapy has been increasingly used for the treatment of patients with prostate cancer because it is
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associated with fewer monitor units and higher patient throughput than those in step-and-shoot
intensity modulated radiotherapy.
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The use of daily image guided radiation therapy (IGRT) was also recommended as medically
necessary in order to optimally replicate daily setup thereby minimizing the margins required
and increasing accuracy. Image-guided radiation therapy not only provides accurate information
on patient and tumor position on a quantitative scale, it also gives an opportunity to verify
consistency of planned and actual treatment geometry including adaptation to daily variations
resulting in improved dose delivery.
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The risks and benefits of radiation were reviewed with the
patient. Possible early effects included loose bowel movements, abdominal cramping, rectal
pain, erythema, and fatigue. Possible late effects included fistula formation, stricture formation,
small bowel obstruction, small bowel necrosis, proctitis, permanent skin changes, permanent
loose stools, and intractable fatigue. The patient expressed understanding and a written consent
was obtained.
The Plan (Prescription): The radiation oncologists prescription was a VMAT plan that
consisted of 4 arcs defined at appropriate arc lengths. The prescription was 54 Gy at 1.8 Gy per
fraction for 30 fractions. There was no boost to be planned. The patient was not receiving
chemotherapy.
Patient Setup/Immobilization: The patient was placed in the supine position on the computed
tomography (CT) simulation table. Immobilization was achieved with a full-body Vac-Lok/
BodyFIX bag. The arms were placed on the chest holding a blue ring for comfort (Figure 1).
The legs were placed in extension with a foot block secured between his feet for improved
immobilization. A pillow was also used for comfort. A red rubber tube was inserted into the
rectum for decompression of the organ of interest. Once appropriate immobilization was
achieved, the patient was aligned with anterior-posterior (AP) and lateral room lasers using tattoo
marks placed on the skin as reference points (Figure 2). High-resolution 0.25 CT images of the
pelvis were obtained.
Anatomical Contouring: The CT images were transferred from the scanner into the Philips
Pinnacle 9.6 radiation treatment planning system (TPS). The radiation oncologist contoured the
target volumes. The clinical target volume (CTV) consisted of the entire bladder and prostatic
fossae, the pelvic lymph nodes, and partial seminal vesicles, as visualized on the CT axial
images. A planning target volume (PTV) was obtained by adding a margin of 5 mm in the
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posterior direction and a margin of 8 mm in the other directions to the CTV. The medical
dosimetrist contoured the following structures: the rectum, sigmoid, right femoral head, small
bowel and prosthesis. In addition, the artifact regions on the left hip due to the prosthesis were
outlined and assigned a density of 1.0 (Figures 4 and 5). The critical structure contours were
reviewed by the radiation oncologist.
Beam Isocenter /Arrangement: The patient had a left hip replacement. Perturbations in the
dose distribution caused by a hip prosthesis can result in unacceptable dose inhomogeneities
within the target volume and in regions where tissues interface with implant. Great
consideration was given not to administrator radiation to the target through the prosthesis. The
medical dosimetrist placed the beam isocenter at the geometrical center of the target (Figure 3).
The VMAT plan consisted of 4 arcs. The 1
st
arc rotated clockwise direction (arc angle: 358-
146) and the 2
nd
arc in counterclockwise direction (arc angle: 146-358). The 3
rd
arc was in
clockwise direction (arc angle: 52-0). The 4
th
arc was identical to the 3
rd
arc but was in the
counterclockwise direction (Figure 6). The angle between 146 and 52 was avoided so as not to
directly treat through the prosthesis. In addition, the beams eye-view (BEV) in the TPS was used
to determine the left avoidance sector thereby averting beam angles that directly went through
the left femur. The collimator angle for the 1
st
and 3
rd
arcs was set at 170. The collimator angle
for the 2
nd
and the 4
th
arcs was set at 90. The couch angle was set at 180. The energy used for
each arc was 6 megavolts (MV). A multileaf collimator (MLC) margin of 10 mm was applied to
compensate for the beam penumbra.
Treatment Planning: To commence the planning process, the radiation oncologist wrote a
prescription with a set of objectives and constraints (Table 1). The medical dosimetrist entered
the prescription dose to the mean of the planning treatment volume and generated the necessary
objectives and constraints in the treatment planning system (TPS). A 6MV (Varian 2300EX)
linear accelerator equipped with a 120-leaf multileaf collimator (MLC) was used to implement
the treatment plan. Heterogeneity correction was applied, and a 3 mm grid was utilized. The
patient received a total of 54 Gy at 1.8 Gy in 30 fractions. The TPS utilized Smart Arc
optimization type with final gantry spacing of 4. The plan was optimized enough times to
ensure adequate coverage to the target. The organs at risk (OR) objectives were manipulated
during treatment planning to reduce the respective doses to tolerable limits. The medical
dosimetrist reviewed the isodose lines, OR doses and the dose volume histogram (DVH) (Figure
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7). The resulting plan satisfied 96% of the constraints for the OR as given in Table 1. The
volume of rectum receiving more than 55 Gy (V55) was 3.8%, while the volume receiving more
than 20 Gy was 70%. The small bowel received a maximum dose of 57.0Gy to 0.02 cubic
centimeters (cc) of the volume, and 180.00 cc received 45Gy. The right femoral head received
a maximum dose of 39 Gy. The PTV maximum dose was 59 Gy and D95 (dose covering 95% of
the PTV) was 52.4 Gy. The radiation oncologist reviewed the plan and approved a
normalization of 98% to the PTV mean.
Quality Assurance/Physics Check: The monitor units were reviewed first by sending the plan
to 2nd check software. Radcalc uses independently measured beam data [Sc, Sp, TPR,
(D/MU)
ref
] and includes effects from multi-leaf collimator transmission and radiation field offset
(difference in size between the light field and the radiation field due to transmission through the
rounded ends of the multi-leaf collimator).
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The monitor units of all the arcs were within the
institutional tolerance of maximum deviation of no more than 5%. Fluence patterns for each
individual arc were measured using the Delta4 QA phantom and compared against the calculated
fluence patterns from the treatment planning system. All the measurements agreed within 2% of
deviation (Figure 8). As a final check, the treatment plan and QA measurements were reviewed
and approved by a medical physicist before the first day of treatment.
Conclusion: One of the challenges of VMAT planning for prosthesis patients is the inability to
place the primary beams through the prosthesis, therefore limiting the available beam angles.
Another challenge is the difficulty in visualizing the organs due to the presence of large amount
of streak artifacts coming from the prosthesis.
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The case study was chosen to illustrate how the
PTV challenges can be resolved using a VMAT technique. The use of 4 arcs in this case study
demonstrated that the technique has potential of improving dose homogeneity across the PTV
and reduce the dose to the critical structures. However, it is important to note that the prosthesis
still received a maximum dose of 48 Gy largely attributed to the exit dose from the 1
st
and 2
nd

arcs. It was enjoyable to overcome the challenges of this plan. In the future, it would be
beneficial to evaluate two plans; one with inhomogeneity correction and the other without. The
goal would be to document the clinical significance of ignored inhomogeneity correction to the
artifact.


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References
1. Kunishima N, Naoi y, Yoda K. Anatomy-based volumetric modulated arc therapy for a
prostate cancer patient with a hip prosthesis. J Radiat Res. 2013;54(2):398-400.
http://dx.doi.org/10.1093/jrr/rrs101
2. Haslam J, Bonta D, Lujan A, et al. Comparison of dose calculated by an intensity modulated
radiotherapy treatment planning system and an independent monitor unit verification
program. J Appl Clin Med Phys. 2003;4(3):224-230. doi: 10.1120/1.1590611
3. Gupta T, Narayan C. Image-guided radiation therapy: Physician's perspectives. J Med Phys.
2012;37(4):174-182. http://dx.doi.org/10.4103/0971-6203.103602
4. Rana S, Pokharel S. A dosimetric study of volumetric modulated arc therapy planning
techniques for treatment of low-risk prostate cancer in patients with bilateral hip prosthesis.
South Asian J Cancer. 2014;3(1):18-21. http://dx.doi.org/10.4103/2278-330X.126506



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Figures

Figure 1. Patient position on CT table with arms placed on the chest holding a blue
ring for comfort.

Figure 2. Tattoo marks on the skin as reference points.
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Figure 3. Isocenter placement.

Figure 4. A transverse view of computed tomography slice showing hip prosthesis
and artifacts.
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Figure 5. A transverse view of computed tomography slice showing hip prosthesis,
corrected artifacts, clinical target volume, planning target volume, small bowel, right
femoral head, rectum and sigmoid.

Figure 6. A rooms eye view (REV) showing (a) the path and length of 1
st
and 2
nd
arcs
and (b) 3
rd
and 4
th
arcs.
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Figure 7. Resulting dose volume histogram (DVH) for the PTV, CTV, small bowel,
sigmoid, rectum, and right femoral head.


Figure 8. QA comparison of calculated fluence patterns from the treatment planning
system planar dose.



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Tables

Table 1. Objectives and constraints.