1

Susan Hunt
Final Clinical Project
Prostate IMRT Plan
For this project, I chose to do an entire prostate plan, which involved three separate
prescriptions. The radiation oncologist prescribed an initial dose of 4500 cGy to Pelvis, which
included the prostate, seminal vesicles (SVs) and pelvic lymph nodes. The dose was to be
delivered in 25 fractions (fx) of 180 cGy/fx. The first cone down (and 2nd prescription) included
the prostate and SVs to an additional 1440 cGy (8 additional fractions of 180 cGy/fx) and the
final cone down (3rd prescription) involved just the prostate to 1800 cGy (10 more fractions of
180 cGy/fx). This provided a total dose of over 7900 cGy to the prostate (after normalization).
Such a plan would be used in cases of high risk prostate carcinoma (with higher Gleason and/or
PSA scores or in cases where lymph nodes were known or suspected to be involved). This
particular patient was a 76-year old white male who was diagnosed with Stage II (T2aN0M0),
Gleason 9 (4+5) adenocarcinoma of the prostate. His pretreatment PSA was 5.52. As such, the
oncology team recommended combined modality treatment with androgen deprivation therapy
for about a year and a half along with external beam radiation to the pelvis, prostate, and seminal
vesicles. An IMRT plan was favored because of the ability to protect the other important
structures in the region including the femoral heads, rectum, and bladder. Dose distribution is
better with an IMRT plan and side effects and long-term complications are improved as well.
Therefore, I chose IMRT using 9 beams as my technique.
The patient was simulated in the supine position, head first, on the IGRT tabletop with 3
yellow block type pillows under his head, a specialized leg holder under his legs designed for
immobilizing the pelvis, and gold markers that were surgically implanted in his prostate prior to
the simulation. I contoured the femoral heads, small intestine, sigmoid, rectum, bladder and
penile bulb, since these are all dose-limiting structures. Reference Table 8 for tolerance doses of
these critical structures. The prostate gross tumor volume (GTV), SV GTV and Nodal GTV
were contoured seperately. The overall GTV for the first plan consisted of all three separate
GTVs and the PTV was simply the GTV with a 3mm margin. The oncologist determined the
margins based on stage and grade of disease and other factors (Gleason score, general health of
the patient, etc). I contoured the fiducial markers in the prostate and overrode the density of the

markers to 1 (the same as tissue). If there is a lot of air in the rectum, its density can also be
overridden to 1.
I then added 9 beam angles using a hotscript for 9 field IMRT (PA). This script uses a
straight 180 degree beam and then scatters the remaining 8 beams at 40 degree increments. I
rotated the 2 posterior beams (on either side of the 180 beam) in toward 180 to avoid the bars on
the treatment table. This left me with a final beam arrangement as follows (in degrees): 213,
260, 300, 340, 20, 60, 100, 147 and 180. I adjusted collimator angles on each beam such that the
dimension in the x-direction was smallest, thus allowing the multi-leaf collimators (MLCs) to
move easily to block the bladder and rectum. This left me with collimator angles of 90, 25, 40,
90, 90, 320, 325, 270 and 270 degrees, respectively.
I started with very basic IMRT objectives such as a uniform dose of 4500 cGy to the PTV, a
maximum dose of 4950 cGy (110%) to the PTV and a minimum DVH of 4365 cGy (97%) to
97% of the PTV volume. I also gave Maximum DVH restrictions to the rectum (3500 cGy),
bladder (4000 cGy) and femoral heads (4000 cGy). I weighed these objectives 90, 10, 10, 20, 20
and 20, respectively. This plan resulted in a hotspot of 4707 cGy and the plan took 524 monitor
units (MUs) to deliver, but was not very conformal to the PTV. This original plan took 524 MUs
to deliver. The hotspot was 4707 cGy and was located just medial to the right femoral head.
Reference Table 1 for a summary of the original plan.

Structure

Objective

Weight

PTV

Uniform dose of 4500 cGy (Rx)

90

PTV

Maximum dose of 4950 cGy (110% of Rx)

10

PTV

Minimum DVH of 4365 cGy (97% of Rx) to 97% of Vol 10

Rectum

Maximum DVH of 3500 cGy

20

Bladder

Maximum DVH of 4000 cGy

20

Femoral Heads Maximum DVH of 4000 cGy

20

Table 1. Summary of Original plan

I then revised the objectives as follows (Rev 1): The uniform dose to the PTV remained at
4500 cGy (the prescription dose), but I changed the maximum dose to the PTV to 4680 cGy
(104%) and the minimum DVH to the PTV to 4500 cGy (97%) to 97% of the PTV volume. I

also changed the Max DVH values to critical organs. Rev 1 took 564 MUs to deliver and had a
small hotspot of 4787 (105%), located just lateral of the Nodal GTV. After completion of dose
calculations for Rev 1, I compared the Dose Volume Histograms (DVHs) for the 2 plans. Rev 1
provided better coverage of the PTV and the 80% and 50% isodose lines were much more
conformal. Doses to the bladder and rectum were much lower but the dose to the femoral heads
was larger. This was acceptable, as the femoral heads can tolerate more dose than the bladder
and rectum. See Table 2 for a summary of Revision 1.

Structure

Objective

Weight

PTV

Uniform dose of 4500 cGy (Rx)

90

PTV

Maximum dose of 4680 cGy (104% of Rx)

10

PTV

Minimum DVH of 4500 cGy (97% of Rx) to 97% Vol 10

Rectum

Maximum DVH of 4400 cGy to 3% Vol

20

Rectum

Maximum DVH of 3370 cGy to 20% Vol

Rectum

Maximum DVH of 1740 cGy to 66% Vol

Bladder

Maximum DVH of 4000 cGy to 14% Vol

20

Bladder

Maximum DVH of 2320 cGy to 55% Vol

Femoral Heads Maximum DVH of 4000 cGy

20

Table 2. Summary of Rev 1 plan

For my final revision of the objectives, (Rev 2), I added the following regions of interest
(ROIs) to help steer the dose for more a more conformal plan: a ring structure, Bladder PTV,
50% Rectum & Avoid. These ROIs were created as follows:

The Ring structure was created around the PTV. It is used to help make the dose more
conformal. It will ultimately be used to allow dose inside the ring and limit dose outside
the ring. The margins were customized to the patient (dictated by the radiation
oncologist).

Bladder PTV: This structure was created by using the bladder as the source and
avoiding the interior of the PTV. There were no margins on this structure. I deleted the
axial slices above and below the field.

50% Rectum: First I created ROI1 by expanding the PTV by about 7mm. Then, on the
axial CT slices, I contoured an oblong structure starting at the posterior edge of ROI1 and
extending posteriorly to the tailbone, about 17mm wide. ROI1 was deleted after the
creation of 50% rectum.

Avoid: This structure was created to help steer dose away from the rectum and center of
the field. I contoured between the nodes in the center of the field.

Reference Table 3 for a summary of the objectives and weights for Rev 2.

Structure

Objective

Weight

PTV

Uniform dose of 4500 cGy (Rx dose)

90

PTV

Maximum dose of 4680 cGy (104% of Rx)

40

PTV

Minimum DVH of 4432 cGy (98% of Rx) to 98% Vol

90

50% Rectum

Maximum DVH of 2250 cGy (50% of Rx) to 5% Vol

15

50% Rectum

Maximum DVH of 2000 cGy (45% of Rx) to 50% Vol 10

Bladder - PTV

Maximum DVH of 3375 cGy (75% of Rx) to 20% Vol 7

Bladder - PTV

Maximum DVH of 2025 cGy (45% of Rx) to 55% Vol 7

Femoral Heads Maximum DVH of 2700 cGy (60% of Rx) to 6% Vol

Femoral Heads Maximum DVH of 2000 cGy (45% of Rx) to 45% Vol 1
Avoid

Maximum DVH of 3375 cGy (75% of Rx) to 7% Vol

Avoid

Maximum DVH of 2700 cGy (60% of Rx) to 30% Vol 9

Avoid

Maximum DVH of 2000 cGy (45% of Rx) to 60% Vol 9

Ring

Maximum DVH of 4275 cGy (95% of Rx) to 4% Vol

Ring

Maximum DVH of 3600 cGy (80% of Rx) to 45% Vol 4

Ring

Maximum DVH of 3000 cGy (67% of Rx) to 88% Vol 4

Table 3. Summary of Rev 2 plan. These were the final objectives for the Pelvis plan

For the first cone down (CD1), I moved the beam angles to prevent hot spots due to MLC
leakage. The new PTV was defined as the Prostate GTV + SV GTV with 3mm margins.
For the final cone down (CD2), I again adjusted the beam angles, and in some cases, the
collimator angles. The final PTV was the prostate GTV with a 3mm margin. The original plan

(Pelvis) was normalized to the 97% isodose line; CD1 and CD2 were normalized to the 98%
isodose lines. The absolute max dose for the composite plan was 8085.7 cGy.

Pros of using IMRT:

The incidence of both acute and late rectal toxicities are much less frequent with IMRT when
compared to three-dimensional conformal techniques. Therefore, the use of high-dose IMRT to
treat prostate cancer is now the standard over 3D conformal radiation.1

Studies that support IMRT:

A study involving 1571 patients comparing the long-term (median 10 years) effects of
IMRT vs 3D-CRT for prostate cancer found that gastro-intestinal (GI) toxicities were
significantly fewer (5% vs 13%) in the IMRT patients. Similar results were found for
urinary toxicities.2

In a study to determine the long-term outcomes (5-9 years) among 561 patients treated
for prostate cancer using IMRT, less than 2% of patients experienced rectal bleeding after
8 years and long-term tumor control was found to be excellent.3

When comparing IMRT to 3D-CRT in a study involving a total of 232 patients, IMRT
improved tumor coverage while reducing volumes of rectal and bladder walls taken to the
high dose levels. Urinary toxicities (both early and late) were not significantly different
between the two methods, but acute rectal toxicities were much lower in the IMRT
patients.4

Cons of using IMRT:

In spite of its superior tumor coverage and excellent normal tissue sparing, since IMRT delivers
higher doses, special care needs to be taken when defining margins. The prostate is an organ that
moves from day to day depending on the fullness of the bladder and rectum, so defining careful
margins will assure adequate coverage of the prostate without overdosing nearby critical
structures. Markers embedded in the prostate are invaluable in helping to create reproducible
setups.5

In recent years, there have been numerous studies involving the use of simultaneous
integrated boosts (SIB) in the treatment of many different types of cancer, including prostate
cancer. These plans differ from traditional boost plans because the boost doses (or conedowns) are delivered at the same time as the original plan.6 So in this case, the entire composite
plan would be delivered to the patient in the amount of time it took to deliver the Pelvis
portion of the plan. The benefits of this type of plan is that you can actually achieve a higher
dose to the prostate itself (up to 8200 cGy) in 41 fractions of 200 cGy/fx without increasing the
risk of serious damage to outlying structures. In this case, I could use the exact same beams and
collimator arrangements, but instead of delivering the dose in subsequent fractions, it would be
delivered in shrinking fields in the same fractions. The actual treatment time (for a single
fraction) would increase significantly (by up to 2.5 times as long), but the length of the total
treatment time would be reduced, depending on the dose. This would mean less trips the patient
has to make to the treatment facility. The advantages of this type plan is that it enables dose
escalation with a lower rate of gastrointestinal (GI) toxicity.6 A study comparing 3 different
techniques for the treatment of prostate cancer showed the following promising results:

3D-CRT

IMRT to

IMRT to

To 74 Gy

78 Gy

82 Gy

(subsequent

Using SIB

Cone-downs)
Acute GI toxicity
(>/= grade 2)

35.1%

16%

7.7%

26.6%

33%

30.7%

14%

5%

2%

9%

7%

6%

Acute GU toxicity
(>/= grade 2)
Late GI toxicity
(Late = 3 yrs)
(>/= grade 3)
Late GU toxicity
(Late = 3 yrs)
(>/= grade 3)

Table 4. Summary of Dolezel study results.

Additionally, the same study showed better coverage of the PTV: at least 95% of the PTV was
covered by 95% of the prescribed dose. The difference between these studies and the plan I
prepared was that I also included a nodal volume, while the study only covered the prostate and
the base of the seminal vesicles.

References
1. Zelefsky MJ, Fuks Z, Hunt M, et al. High-dose intensity modulated radiation therapy for
prostate toxicity and biochemical outcome in 772 patients. Int J Radiat
Oncol*Biol*Phys. 2002;53(5):1111-1116.
2. Zelefsky MJ, Levin EJ, Hunt M, et al. Incidence of late rectal and urinary toxicities after
three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for
localized prostate cancer. Int J Radiat Oncol*Biol*Phys. 2008;70(4):1124-1129.
3. Zelefsky MJ, Chan H, Hunt M, et al. Long-term outcome of high dose intensity
modulated radiation therapy for patients with clinically localized prostate cancer. J of
Urology. 2006;176:1415-1419.
4. Zelefsky MJ, Fuks Z, Happersett L, et al. Clinical experience with intensity modulated
radiation therapy (IMRT) in prostate cancer. Radiotherapy and Oncol. 2000;55(3):241249.
5. Teh BS, Bastasch MD, Wheeler TM, et al. IMRT for prostate cancer: Defining target
volume based on correlated pathologic volume of disease. Int J Radiat Oncol*Biol*Phys.
2003;56(1):184-191.
6. Dolezel M, Odrazka K, Vaculikova M, et al. Dose escalation in prostate radiotherapy up
to 82 Gy using simultaneous integrated boost: direct comparison of acute and late toxicity
with 3D-CRT 74 Gy and IMRT 78 Gy. Strahlentherapie und Onkologie. 2010;186:197202.

Figures

Figure 1. Axial view of isodose lines of original plan (Pelvis). This field included the
prostate, seminal vesicles and surrounding lymph nodes. Reference Table 5 below for color key.

Color

Isodose line

Absolute dose

(% of normalized Rx dose 4500 cGy) Equivalent (cGy)

Cyan

101%

4545

Pink

97%

4365

Green

95%

4275

Blue

90%

4050

Yellow

80%

3600

Orange

50%

2250

Forest

20%

900

Table 5. Colors for isodose lines in Pelvis plan (Figure 1).

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Figure 2. Axial view of isodose lines of first cone down (CD1). This field included the
prostate and seminal vesicles. Reference Table 6 below for color key.

Color

Isodose line

CD1 Absolute dose CD2 Absolute dose

(% of normalized Rx dose)

(cGy)

(cGy)

Cyan

102%

1468.8

1836

Pink

97%

1396.8

1746

Green

95%

1368

1710

Blue

90%

1296

1620

Yellow

80%

1152

1440

Orange

50%

720

900

Forest

20%

288

360

Table 6. Colors for isodose lines in CD1 (Figure 2) and CD2 (Figure 3).

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Figure 3. Axial view of isodose lines of second and final cone down (CD2). This field
included the prostate only. Reference Table 6 (previous page) for color key.

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Figure 4. Axial view of isodose lines of Composite plan (all 3 plans combined). Reference
Table 7 below for color key.

Color

Isodose line

% of total prescribed dose

(absolute dose in cGy)

(7740 cGy)

Cyan

7972

103%

Red

7740

100%

Pink

7585

98%

Green

7353

95%

Blue

6966

90%

Yellow

5940

Pelvis + CD1

Orange

4500

Pelvis

Forest

1548

20%

Table 7. Colors for isodose lines in Composite plan (Figures 4, 5 and 6).

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Figure 5. Sagittal view of isodose lines of Composite plan (all 3 plans combined). Reference
Table 7 (previous page) for color key.

Figure 6. Coronal view of Isodose lines of Composite plan (all 3 plans combined). Reference
Table 7 (previous page) for color key.

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Figure 7. Dose Volume Histogram (DVH) of Composite plan. Reference Figure 8 (below) for
color key.

Figure 8. Key to colors in Composite DVH (Figure 7).

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Structure

Max Tolerance

Comments

Femoral Heads 5000 cGy

25% Vol < 45 Gy and 40% Vol < 40 Gy per RTOG 0822

Small intestine 5000 cGy

<100cc<40Gy, 180cc<35Gy and 65cc<45 Gy per 0822

Sigmoid

TD 5/5: 1/3 Vol < 55 Gy and 3/3 Vol < 45Gy

See Comments

TD 50/5: 1/3 Vol < 65 Gy and 3/3 Vol < 55 Gy

Rectum

See Comments

15% Vol< 75Gy, 25% Vol< 70Gy,

35% Vol< 65Gy and 50% Vol< 60Gy per RTOG 0126

Bladder

See Comments

15% Vol< 80Gy, 25% Vol< 75Gy,

35% Vol< 70Gy and 50% Vol< 65Gy per RTOG 0126

Penile Bulb

Mean dose<52.5 Gy

Table 8. List of dose limiting organs and their tolerances

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After reviewing actual doses received (from the Composite DVH) and comparing these values to
the objectives and tolerances, the following table summarizes the plan.
Structure

Dose(s) recieved

Objective met?

Lt femoral head Max dose 3019 cGy

Yes

25% Vol: 1500 cGy

Yes

40% Vol: 1200 cGy

Yes

Rt femoral head Max dose 3229 cGy

Yes

25% Vol: 2020 cGy

Yes

40% Vol: 1800 cGy

Yes

Small intestine

Max dose 2179 cGy

Yes

Sigmoid

Max dose 3219 cGy

Yes

1/3 Vol: 1235 cGy

Yes

3/3 Vol: 291 cGy

Yes

Rectum

Bladder

Penile Bulb

Max dose 7967 cGy

15% Vol: 6500 cGy

Yes

25% Vol: 4800 cGy

Yes

35% Vol: 3900 cGy

Yes

50% Vol: 3100 cGy

Yes

Max dose 7991 cGy

15% Vol: 6900 cGy

Yes

25% Vol: 6200 cGy

Yes

35% Vol: 5400 cGy

Yes

50% Vol: 4200 cGy

Yes

Mean dose 6827 cGy

No

Table 9. Actual doses vs objectives

The only objective that was not met was the mean dose to the penile bulb. This objective
could not be met and still adequately cover the target volume. The possible consequence of
exceeding this tolerance dose is erectile dysfunction and impotence. The patient has suffered
from chronic erectile dysfunction for years and has no intention of parenting any more children,

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so these side effects were discussed with him and it was decided that the excessive dose to his
penile bulb was acceptable.