ROSE PROSTATE SBRT.pptx

1. PROSTATE SBRT
ROSE CASE
RADIATION ONCOLOGY SIMULATION TO EXECUTION
DR KANHU CHARAN PATRO
MD,DNB(RADIATION ONCOLOGY),MBA,FICRO,FAROI,PDCR,CEPC
HOD,RADIATION ONCOLOGY
Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam
drkcpatro@gmail.com /M+91-9160470564

2. General history
• 66 , male
• No co morbidity
• h/o BHP
• On regular f/up
• p/w urinary retention
• Needed catheterization
• Evaluated

3. SHORT HISTORY
• 66 year old male
• No comorbidities
• Presented with Lower Urinary Tract symptoms
(LUTS) – Obstructive symptoms: acute retention
of urine since 4 months in jan 2022
• BPH for 3 years
• PSA: 36 ng/dl
• Biopsy: Adenocarcinoma
• Gleason score: 3+4 (7), Gleason group: 2, core:
4/8 positive

4. MRI PELVIS PRE HT
• CEMRI pelvis: Prostate volume: 78.5cc.
• Well defined T2W Hypointense 3*1cm lesion at peripheral
zone at right side; at apical region and few hypointense
lesions in right half of the prostate.
• Rt peripheral zone hypo intense area
• Restricted diffusion
• Abnormal contrast enhancement
• Lower signal in ADC
• No seminal vesicle involvement
• Rt External iliac node
• Hypertrophy of glandular zone and transitional zone – BPH

5. MRI PELVIS PRE HT

6. PSMA PET PRE HT

7. TUMOR BOARD
• 6 months of Neoadjuvant Hormonal therapy
followed by EBRT then Adjuvant Hormonal
therapy

8. POST HT MRI
• Prostate volume: 64cc
• T2W Hyperintense lesion with peripheral hypo
intensity at posterolateral aspect peripheral
zone – reduced in size

9. POST HT PSMA

10. IPSS-PRE HT

11. IPSS-PRE RT

12. RADIATION TUMOR BOARD
• SBRT based on PRIME protocol
• 36.25Gy in 5# to the prostate
• 25Gy in 5# to the nodal region
• Alternate days treatment over 2 weeks
• Morning treatment

13. PATIENT COUNSELLING
• PROCEDURE
• BLADDER AND RECTUM PROTOCOL
• TOXICTY

15. PRIME TRIAL

16. DOSE SELECTION
DOSE :
36.25Gy in 5# to the Prostate
30Gy in 5# to the Gross node
25Gy in 5# to the Elective nodal region

17. PLANNING CT
• 3mm slice
• Contrast enhanced CT and delayed scan CT
• Nipple to mid thigh
• With VAC-LOK + KNEE REST

18. PLANNING MRI
• 3mm slice
• T2 MRI
• True Axial
• L5 to mid thigh
• With VAC-LOK + KNEE REST

19. Bladder protocol
• Empty bladder
• Drink 750 ml water
• Wait half an hour
• CT/TREATMENT

20. RECTUM protocol
• Soap water enema
• Enema Before planning CT
• Enema Before each treatment

21. FRAME LESS SBRT
IMMOBILIZED THE VAC-LOK WITH INDEXER

23. TARGET
PROSTATE
SEMINAL VESICLES
NODES SOS

24. IMAGING
• CECT PELVIS
• MULTIPARAMETRIC MRI
• PSMA
DIAGNOSTIC
• CECT PELVIS
• T2 MRI
FOR TARGET

25. IMMOBILIZATION
SUPINE
• NIL/
• VACLOCK/
• SBRT BOARD
WITH OR WITHOUT KNEE REST
HANDS ABOVE HEAD

26. IMAGING
PROTOCOL
SUPINE WITH KNEE REST
DESIRABLE FULL COMFORTABLE BLADDER
EMPTY RECTUM
AXIAL CECT [Arterial and delayed phase-10 min]
T2 MRI 3 PLANE [A/C/S]
2-3 mm slice
UPPER BORDER OF KIDNEY TO MID THIGH
ANAL VERGE MARKER

27. OAR
BOTHERING BOWEL
FARLY PLACED FEMORAL HEAD
BUBBLING BLADDER
IRRITAING ANAL RECTUM
UNKNOWN URETHRA

28. DOSE
PROSTATE
• 36.25 IN 5 #
NEGATIVE NODE
• 25Gy IN 5 #
POSITIVE NODES
• 30-35GY IN 5 #

29. Target delineation

30. ESTRO ACROP Guidelines

31. ESTRO ACROP Guidelines

32. TARGET DELINEATION
• CTV P: according to ESTRO ACROP guidelines
• CTV N:
– Contoured by giving a radial margin of 5 to 7mm around
the common iliac, external iliac, internal iliac, presacral and
the obturator vessels and editing from muscles and bones
– Cranial extent of CTV nodes: at the level of L5–S1 vertebra
– Caudal extent: at the level obturator nodes
• Seminal vesicle: 1.5cm when no involvement; entire SV
if involved
• PTV P & PTV N:
– 5mm to the CTV P (including SV) and CTV N.

33. OAR DELINEATION
• Bladder
• Rectum
• Bowel bag
• Penile bulb
• Head of femur

34. ABCDEF OF PROSTATE CONTOURING
A
• ANI-LEVATOR ANI
B
• BULB-PENILE BULB,
• BLADDER BASE
C
• CANAL-ANO RECTAL
CANAL
D
• DIAPHRAGM-
GENITOURINARY
DIAPHRAGM
• DEFERENT DUCT
E-EXTRA
STRUCTURES LIKE
• NEUROVASCULAR
BUNDLE
• URETHRA
• VENOUS PLEXUS
OF SANTORINI
F-FIBROMUSCULAR
STROMA
• NEUROVASCULAR
BUNDLE
• URETHRA
• VENOUS PLEXUS
OF SANTORINI

35. A-ANI-LEVATOR ANI

37. B-BLADDER BASE

38. B-BASE-BLADDER BASE

39. SEPARATING FROM BLADDER BASE
• Distinction between the base of the
prostate and the bladder lumen . Also,
protrusion of the prostate into the bladder
due to benign prostate hypertrophy can be
considered.
• We therefore recommend the routine use
of contrast on planning-CT, unless contra-
indicated.
• CT and MRI based. Protrusion of prostatic
hyperplasia into the bladder base can be
easily visualized on T2-weighted MRI and
adds to a correct delineation of the prostate
especially when no contrast is administered
prior to CT
• DELAYED PHASE CT-10 min

40. C-CANAL-ANO RECTAL CANAL

42. Contouring help-structure- Boolean

43. D-DIAPHRAGM- GENITOURINARY
DIAPHRAGM

47. Cranial

48. middle

49. Tringle

50. D-DUCT- VAS DEFERNS

51. Identification of
vas deferens and
exclusion
The yellow arrows indicate the deferens
ducts
The deferent duct, consisting of a thin tubular structure
that can be recognized cranial and medial to each SV,
should not be included in this delineation

52. E-EXTRA-NUROVASCULAR BUNDLE

53. E-EXTRA-URETHRA

54. DELINEATING URETHRA
The lower part of the urethra, where it can
be excluded from the clinical target
volume
Whenever visible, the urethra should be excluded from the apex, creating
a butterfly shaped structure, except in cases where the urethra cannot be
discriminated from the apex or when urethral involvement is suspected

55. E-EXTRA-VENOUS PLEXUS OF
SANTORINI

56. Exclude
venous
plexus of
Santorini
ARTERIAL
PHASE

57. F-FIBROMUSCULAR STROMA

58. Anterior fibromuscular stroma

59. DELINEATION OF ISCHIOPUBIS FOR FUSION
FUSE AROUND ONLY PROSTATE AREA

60. CT MR FUSION

61. CAPSULE IS BLACK ON MRI

62. CTV PROSTATE

63. Exclusion from vessels anteriorly

64. Prostate rectum differentiation

65. Tracking and delineating urethra

66. BUTTERFLY PROSTATE APEX AROUND URETHRA

67. APEX-UGD-BULB COMPLEX- AUB CT

68. APEX-UGD-BULB COMPLEX- AUB MRI

69. Delineating seminal vesicles

70. Sagittal view

71. Delineating iliac vessels

72. PRESACRAL NODE

73. Delineating obturator nodes

74. NODAL CORONAL VIEW

75. PTV PRIMARY_36.25Gy

76. PTV NODE_25Gy

77. FEMORAL HEAD DELINEATION

78. BOWEL BAG

79. Bladder as OAR

80. Empty rectum

81. PENILE BULB in MRI/CT

82. PLANNING
• VMAT
• DCARC
• 3DCRT
• IMRT

83. BEAM ARRANGEMENT

84. DVH
PTV 36.25
PTV 25
RECTUM
BLADDER
BULB
BOWEL
FEMURS

85. DOSE CLOUD (98% coverage)

86. PTV COVERAGE
PRIME
PROTOCOL
TARGET Prime Ours
CTV PRIMARY
D98 98% 100
PTV PRIMARY
D98 95% 98
CTV NODE
D98 98% 99
PTV NODE
D98 95% 98.71

88. OAR DOSE CONSTRAINTS
OAR PACE Ours
RECTUM
D50% 18.1Gy 19Gy
D20% 29Gy 28Gy
D1cc 36Gy 36.3Gy
BLADDER
D40% 18.1Gy 16.7Gy
V37Gy 10cc 14cc

89. OAR DOSE CONSTRAINTS
OAR PACE Ours
Femoral head left
D5% 14.5Gy 14.2Gy
Femoral head right
D5% 14.5Gy 14.1Gy
BOWEL
D5cc 18.1Gy 25.8Gy
D1cc 30Gy 26.1Gy
BULB
D50% 29.5Gy 9.33Gy

90. DOSE CONSTRAINT – PRIME PROTOCOL

91. OAR DOSE CONSTRAINTS
OAR PRIME OURS
Bladder
V14 <40% 47%
V17.5 <27% 37.95%
V28 <20% 15.12%
V35 <3% 5.77%
Rectum
V14 <50% 90.7%
V17.5 <40% 60.3%
V28 <15% 20.15%
V31.5 <8% 12.69%
V35 <3% 4.94%

92. OAR DOSE CONSTRAINTS
OAR PRIME OURS
Femoral head left
V14 <5% 5.63%
Femoral head right
V14 <5% 5.63%
BOWEL
V28 80 cc 0cc

93. DRY RUN

94. SET-UP VERIFICATION
• CBCT CORRECTIONS
• HEXAPOD CORRECTIONS

95. SET-UP VERIFICATION
• HEXAPOD CORRECTIONS

96. D1

97. D2

98. D3

99. D4

100. D5

101. PREMEDICATION
TAB. DEXAMETHASONE
8MG THRICE DAILY
STARTING DAY BEFORE
TAB. PAN 4O ONCE
DAILY STARTING DAY
BEFORE
DIABETES CARE IF

102. IPSS-POST RT

103. POST MEDICATION
Taper the
steroid over a
week
Proton pump
inhibitor
Tab
Toluteredine
4mg BD

104. ACKNOWLEDGMENTS
DOCTORS
• DR P S BHATTACHARYA
• DR C R KUNDU
• DR V K REDDY
• DR MJR
PHYSICISTS
• MR A C PRABU
• MR A SRINU
• DR ANIL KUMAR
• MR BHOOPATI
• MR KARUNAKARAN
TECHNOLOGIST TEAM