Case 1: General Description

 50 yo s/p prostatectomy 5 mo ago

 Mild stress incontinence, no pads
 Pretreatment PSA 4.13 ng/mL
 Postop PSA <0.1 ng/mL
 Surgical Path: Gleason 4+3 Tertiary 5
 Bilateral and Apex
 Extraprostatic extension, extensive
 Margin+ on right
 0/12 LN+
 Plan 64 Gy in 32 Fx to bed
 52 Gy to clips above bed 1
 Case 1: Target Anatomy

 CTV1: Prostate bed

 Anteriorly: pubic symphysis
 Posteriorly: rectum
 Laterally: obturator internus m
 Inferiorly: bulb of penis
 Superior-anteriorly: top of symphysis
 Superior-posteriorly: clips & SVs if present
 CTV2: Superior-posterior bed
 Distal clips if present
2
 Case 1: Normal Tissue

 Rectum:
 Sim empty, entire contents
 Maybe rectal wall is better
 Tucker SL: IJROBP 60:1589, 2004
 Inferiorly: Anal- bottom of ischial tuberosities
 Maybe anal canal should be separate

 Peeters ST: IJROBP 64:1151, 2006

 Superiorly: to sigmoid flexure

3
 Case 1: Normal Tissue

 Bladder:
 Sim moderately full, entire contents

 Femoral Heads:
 To between the greater and lesser trochanters

4
 Case 1: Margins

 PTV1: Prostate bed

8 mm everywhere
 Posteriorly 6-8 mm
 PTV2: Superior-posterior bed
8 mm everywhere
Posteriorly 6-8 mm

5
 Case 1: Constraints
 PTV1: >95% 68 Gy
 PTV2: >95% receives 52 Gy
 Rectum: <17% >65 Gy; <35% >40 Gy
 In the postop setting these constraints are more
difficult to achieve and many times are violated
 <25% >65 Gy; <45% >40 Gy

 Bladder: <25% >65 Gy; <50% >40 Gy

 In the postop setting these constraints are more
difficult to achieve and many times are violated
 Femoral Heads: <10% >50 Gy 6
 Case 1: Post-operative
Image-Guidance
 Preferable: CT localization on clips
 3 clusters of clips outlined
 Calcifications
may be used alternatively
 CT-alignment to clip clusters
 Secondary: CT/ultrasound localization
 Ultrasound inaccurate as a stand-alone
 Setultrasound by CT, then use ultrasound
 Daily CT/Cone beam CT
 Anatomical alignment if no clips

7
 Case 1

100%
90% 6MV
80%
70%
60%
50%

8
 Case 1

100%
90%
80% 6MV
70%
60%
50%

9
100%
90% Case 1 6MV
80%
70%
60%
50%
10%

10
 Case 1

PTV295 = 53.1 Gy

PTV195 = 64.3 Gy

B40 = 47.8%

B65 = 11.4%

R40 = 37.8%

R65 = 13.4%
11
 Case 2

 57 yo, excellent health

 PSA: 1.3 2004; 2.5 2005; 4.9 2006
 PSA velocity >2 ng/mL
 Bx: 12 Cores
 Gleason 4+3 (predominantly)
 8/12 cores positive

 DRE: Nothing palpable- T1c

 ER-MRI: No extracapsular extension
12
 Case 2-Biopsy Results

Left Right
3+4 3+4 4+3
Base 1/1 0/1 1/1
1/1
<5% 5% 20%

4+3 4+3
Mid 0/1 0/1 1/1 1/1
30% 70%

4+3 3+4
Apex 0/1 0/1 1/1 1/1
50% 50%

 TZ- Left: 0/0

 TZ-Right: 0/0 13
 Case 2- Plan

 Prostate and Proximal SV: 80 Gy 40 Fx

 Distal SVs: 56 Gy 40 Fx
 Pelvic Lymph Nodes: 56 Gy 40 Fx
 To bifurcation of common iliacs
 Androgen deprivation x2 yr

14
Case 2: Anatomical Landmarks

 CTV1: Prostate and Proximal SVs

 Prostate defined on MR & CT
 Proximal SVs (≥9 mm over 3 cuts)
 CTV2: Distal SVs
 CTV3: Pelvic lymph nodes
 Peri-seminal vesicle
 External iliac
 Obturator
 Internal iliac
15
 Case 2: Normal Tissue

 Rectum:
 Sim empty, entire contents
 Maybe rectal wall is better
 Tucker SL: IJROBP 60:1589, 2004
 Inferiorly: Anal- bottom of ischial tuberosities
 Maybe anal canal should be separate

 Peeters ST: IJROBP 64:1151, 2006

 Superiorly: to sigmoid flexure

16
 Case 2: Normal Tissue

 Bladder:
 Sim moderately full, entire contents

 Femoral Heads:
 To between the greater and lesser trochanters

17
 Case 2: Margins

 PTV1: Prostate & proximal SVs

 8 mm everywhere, except
 Posteriorly 5 mm
 PTV2: Distal SVs
 8 mm everywhere, except
 Posteriorly 5 mm
 PTV3: Lymph nodes
 8 mm Ant, Sup, Inf
 5 mm Post, Lat
18
 Case 2: Constraints
 PTV1: >95% 80 Gy
 PTV2: >95% receives 56 Gy
 PTV3: >95% receives 56 Gy
 Rectum: <17% >65 Gy; <35% >40 Gy
 Bladder: <25% >65 Gy; <50% >40 Gy
 Bowel (potential space): <150 cc >40 Gy
 Femoral Heads: <10% >50 Gy 19
 Case 2: Image Guidance

 MRI/CT used in planning

 Ultrasound prostate localization daily during
treatment

20
 Case 2

100%
10MV 90%
80%
70%
60%
50%

21
 Case 2
100%
10MV 90%
80%
70%
60%
50%

22
 100%
10MV Case 2 90%
80%
70%
60%
50%

23
 Case 2

LN95 = 60.8 Gy
SV95 = 73.8 Gy

PTV195 = 81.1 Gy

B40 = 49%

B65 = 17.8%

Bowel40Gy = 145cc

R40 = 28.9%
R65 = 13.5%
24
 Case 3

 66 yo
 Excellent health, 45 cc Prostate
 PSA: 2.8 2000; 3.5 2001; 2.9 2002; 3.2
2003; 3.5 2004; 4.3 2005 (Bx-), 5.0 2006
 Bx: 11 Cores
 Gleason 3+3
 4/11 cores positive

 DRE: Nothing palpable- T1c

25
 Case 3

Left Right
3+3
Base 0/1 0/1
0/1 0/1
<5%

3+3
Mid
1/1 0/1 0/1 0/1
<5%

3+3 3+3
Apex 1/1 1/1 0/1
10% 60%

 TZ- Left: 0/0

 TZ-Right: 0/0 26
 Case 3- Plan

 Prostate and Proximal SV: 78 Gy 39 Fx

Now giving 80 Gy for this case

 Androgen deprivation for 4-6 months

Indications weak for AD

27
 Case 3: Normal Tissue

 Rectum:
 Sim empty, entire contents
 Maybe rectal wall is better
 Tucker SL: IJROBP 60:1589, 2004
 Inferiorly: Anal- bottom of ischial tuberosities
 Maybe anal canal should be separate

 Peeters ST: IJROBP 64:1151, 2006

 Superiorly: to sigmoid flexure

28
 Case 3: Normal Tissue

 Bladder:
 Sim moderately full, entire contents

 Femoral Heads:
 To between the greater and lesser trochanters

29
Case 3: Margins & Constraints

 PTV1: Prostate & proximal SVs

 Margins
8 mm everywhere, except
 Posteriorly 5 mm

 Constraints
 PTV1: >95% 80 Gy

 Rectum: <17% >65 Gy; <35% >40 Gy

 Bladder: <25% >65 Gy; <50% >40 Gy
Femoral Heads: <10% >50 Gy
30

 Case 3: Image Guidance

 MRI/CT used in planning

 Fiducial Markers
 4 placed 1 week prior to sim
 Daily orthogonal films for localization

31
 Case 3

100%
90% 6MV
80%
70%
60%
50%

32
 Case 3

100%
90% 6MV
80%
70%
60%
50%

33
100%
90%
80% Case 3 6MV
70%
60%
50%

34
 Case 3

PTV95 = 78.6 Gy

B40 = 73.8%
B65 = 35.8%

R40 = 27.5%

R65 = 14.0%

35
 Case 4: Extra

 62 yo s/p prostatectomy 9 mo ago

 Urinary incontinence, 1 pad/d
 Pretreatment PSA 5.5 ng/mL
 PSA velocity >2 ng/mL
 Postop PSA = 0.4 ng/mL at 1.5 mo, 0.5 at 6
mo and 0.7 at 9 mo
 Surgical Path: Gleason 4+5
 Bilateral, 20% of tissue
 Extraprostatic extension on left
 Left SV Involvement
 Margin-
 0/3 Right LN+; 0/6 Left LN+
 Plan 68 Gy in 34 Fx to bed
 52 Gy to clips above bed 36
 Case 4: Extra

100%
6MV 90%
80%
70%
60%
50%

37
 Case 4: Extra

100%
90%
80%
6MV 70%
60%
50%

38
 100%
6MV Case 4: Extra 90%
80%
70%
60%
50%

39
 Case 4: Extra
Clips95 = 52.8 Gy

PTV95 = 68 Gy

B40 = 94.2%

Bowel40Gy = 49.4cc
B65 = 56.4%

R40 = 52.6%

R65 = 19%

40
 Case 5: Extra

 65 yo
 Good Health
 PSA: 0.5 ng/mL 2004, 6.9 ng/mL 2006
 PSA velocity >2 ng/mL
 Bx: 12 Cores
 Gleason 4+4 on left
 5/12 cores positive

 DRE: T2B, Left mid to apex

41
 Case 5: Extra

Left Right
4+4 4+4
Base 0/1 0/1
1/1 0/1
95% 90%
4+4 4+4
Mid 1/1 1/1 0/1 0/1
95% 90%

4+4
Apex 0/1 1/1 0/1 0/1
95%

 TZ- Left: 0/0

 TZ-Right: 0/0 42
 Case 5- Plan: extra

 Prostate and Proximal SV: 80 Gy 40 Fx

 Distal SVs: 58 Gy 40 Fx
 Pelvic Lymph Nodes: 58 Gy 40 Fx
 To bifurcation of common iliacs
 Androgen deprivation x2 yr

43
 Case 5: Extra

100%
90% 10MV
80%
70%
60%
50%

44
 Case 5: Extra

100%
90%
80% 10MV
70%
60%
50%

45
 Case 5: Extra
100%
90% 10MV
80%
70%
60%
50%

46
 Case 5: Extra

LN95 = 57 Gy
SV95 = 61.7 Gy PTV95 = 80 Gy

B40 = 44.7%

B65 = 23.5%

Bowel40Gy = 144cc

R40 = 29.1%
R65 = 15.5%
47