1. Treatment Techniques for the Pelvis Region - Prostate - (- Cervix Ca -) Uwe Götz, Bernd Schicker Institute of Radiation Oncology Limburg, Germany Treatment Techniques for the Pelvis Region - Prostate

2. Textbook Techniques Treatment Techniques for the Pelvis Region - Prostate Perez & Prady – Principles and Practice of Radiation Oncology... A variety of techniques have been used, raging from parallel anteroposterior portals with perineal appositional field to lateral portals (box techniques) or rotational fields to supplement the dose to the prostate. In recent years, three-dimesional conformal radiotherapy (3-D CRT) and intensity modulated irradiation techniques have been used increasingly in selected centers. My Opinion: - Treatment Planing based on Radiograph should be history ! - CT based Treatment Planning should be standard – 3-D CRT!

3. 3-D Conformal Treatment Planning Treatment Techniques for the Pelvis Region - Prostate Definition of 3-D CRT: - CT Dataset for Treatment Planning, Spaceing 1-0.5 cm. - Delination and Definition of the Organs at Risk (OR) and Target Volume in each CT slice. - Definition of the field (gantry and collimator angle and field borders) under the Beams Eye View (BEV) of the Treatment Planning System (TPS) - Planning and optimisation of the Dose distribution in each CT slice. - Dose Distribution conformal to TV and OR; ICRU Recomondations

4. Target Volume Treatment Techniques for the Pelvis Region - Prostate - CT Dataset with 22 CT Slices - Spaceing 0.5 cm.

16. Treatmen Planning – AP / PA Fields Treatment Techniques for the Pelvis Region - Prostate

17. Treatmen Planning – AP / PA Treatment Techniques for the Pelvis Region - Prostate

18. DVH – AP / PA Fields Treatment Techniques for the Pelvis Region - Prostate

19. Treatmen Planning – Box Fields Treatment Techniques for the Pelvis Region - Prostate

21. DVH – Box Fields Treatment Techniques for the Pelvis Region - Prostate

22. DVH – AP / PA Fieds vs Box Fields Treatment Techniques for the Pelvis Region - Prostate

23. Improvement – Box Fields Treatment Techniques for the Pelvis Region - Prostate Homegneous Dose Distribution the Target Volume Quality Index of 94 OK High Dose to the Oragn at Risk (Rectum) NOT OK !!!

24. Improvement – Box Fields Treatment Techniques for the Pelvis Region - Prostate High Dose to the Organ at Risk (Rectum) NOT OK !!! Solution: Find the area at the OR with high dose level

25. Find the Area at the OR with a high dose level

26. Modification of the AP / PA Fields Treatment Techniques for the Pelvis Region - Prostate Area that should be protected to reduce the dose dowards the OR Solution: Shielding by a satelite or Multi Leaf Collimator

27. Field Setup of the Box Technique Treatment Techniques for the Pelvis Region - Prostate

28. 180° Field / Collimator Rotation to 270°

37. Dose Volume Histohgram Treatment Techniques for the Pelvis Region - Prostate

38. DVH – Box vs Improved Box Treatment Techniques for the Pelvis Region - Prostate

39. Advanced Techniques - Crossfire Technique - Treatment Techniques for the Pelvis Region - Prostate Clinical Case: 70-year old patient Diagnosis: Adenocarcinoma of the prostate. PSA- Increase to 8.22 ng/ml. Histology: Medium- to low graded differentiated adenocarcinoma of the prostate; tumor stadium pT3a, N0, M0, G2, R1 (Gleason-Grading: 7). Therapy: Status after radical perineal prostaticovesiculectomy. For a better tolerance, at an aimed total dose of 76.4 Gy, the therapy starts with the boost series applied to the tumor bed (Dose per fraction: 2.0 Gy; total dose: 26.0 Gy). The main series provides the box of the prostate and the loco regional lymphatic drainage area with a dose per fraction of 1.8 Gy at an total dose of 50.4 Gy.

40. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Target Volume Definition: The target volume of the primary series contains the primary tumor and the lymph nodes. Normally the target volume contains the primary tumor which means the prostate and the seminal vesicles. In the case of smaller tumors the seminal vesicles could be excluded from the target volume. In the cranial area the target volume begins at the bifurcation of the A. iliaca communis in the A. Iliaca interna and externa.

41. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Target Volume:

42. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Patient Modell: Room View Target Volume (red) Urinary Bladder (blue) Tectum (green)

43. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Beam Setup: A monoisocenter technique composed by eight fixed fields with individual absorbers and wedges are arranged around the patient in a nearly equidistant angle was developed. The lateral fields only cover the whole target volume. The fields with a diagonal beam direction respectively limit to one side of the target volume and enable in this way an adaption to its biconcave shape.

44. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Physical Treatment Planning: The common isocenter of all fields is located in the center of the body, in this case 6 cm in the dorsal direction of the cranial edge of the symphysis. Here the eight fields are divided into three groups. The first two groups form a self- contained functional unit in which the field- and absorber borders as well as the weighting have to be reconciled with each other.

45. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Group I - Field 1 to 3: Dose adaption to the concave part in the direction to the urinary bladder and the cranial divided area of the target volume. For the beam direction of the field 2 and 3 in the beam´s eye view a gantry position is searched in which the tangent to the ventral tip of the target volume coincides with the center of the “bottom” of the target volume.

46. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate An individual absorber in field 2 (in field 3 correspondingly symmetrical) protects in the complete cranial part of the target volume the contra lateral side of the target volume (arrow). Caudalward both fields cover the target volume at its complete width. Because of the half sided absorbing in the cranial part a symmetrical underdosage is the result, which is compensated through a separate field (field 1). Its beam direction is at gantry position 0° and enables with the central absorber, especially in the bipartite area of the target volume, a maximum protection of the healthy tissue. The caudal field boundary of field 1 geometrically coincides with the caudal edge of the absorber of field 2 (and 3) what can be seen in the beam’s eye view.

47. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate The caudal field boundary of field 1 geo- metrically coincides with the caudal edge of the absorber of field 2 (and 3) what can be seen in the beam’s eye view.

48. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Group II - Field 4 to 6 Dose adaption to the concave area to the rectum and in the cranial divided part of the target volume. The interplay of the field 4 to 6 is similar. Here the absorber (arrow) is shown which enables to adapt the course of the isodoses to the concave shape of the target volume in the area of the rectum. Cranialward the field ends near the bifurcation of the target volume. Cranialward field 4 from 180° links up to the fields 5 and 6.

49. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Group II - Field 4 to 6 Cranialward field 4 from 180° links up to the fields 5 and 6.

50. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Group III - Field 7 and 8 Relief of the normal tissue ventral- and dorsalward of the target volume. The fields 7 and 8 are a variation of the conventional “Box”-Technique. But they are inclined dorsalward in that way (here 2°), that the dorsal field boundaries coincides in the relevant area of the rectum.

51. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate All fields with a diagonal beam direction are equipped with a 60° wedge (with the tip in the lateral direction), to relieve the area which is covered by all the fields and is situated in the center of the target volume (yellow area). Field configuration in the middle section of the target volume.

52. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Beam Parameter:

53. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Dose Distribition

54. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Dose Distribution

55. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Dose Distribution

56. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Dose Distribution

57. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Dose Distribution

58. Advanced Techniques Treatment Techniques for the Pelvis Region - Prostate Dose Volume Histogram

59. 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002 Conformal Technique for CERVIX CARCINOMA Short Overview Bernd Schicker Uwe Götz and I. Chr. Kiricuta ISRO-Limburg - Germany

60. TARGET VOLUME DEFINITION 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

61. LIMBURG-TECHNIQUE 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

62. Field set up in the „V“-shape area of the PTV 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

63. Field set up in the cranial and caudal part of the PTV

64. 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002 How to use the marker in the „V“-shaped area of the PTV

65. FIELD PARAMETER 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

66. How to use a MLC 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

67. DOSE DISTRIBUTION in sagittal reconstructed slices 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002 A B C BC A

68. DOSE DISTRIBUTION in CT-slices 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

69. DOSE DISTRIBUTION in CT-slices 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

70. DOSE DISTRIBUTION in CT-slices 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

71. DOSE DISTRIBUTION in CT-slices 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

72. DOSE VOLUME HISTOGRAM 2nd International Symposium on Target Volume Definition - Limburg - May 30 - June 01 2002

73. Treatment Techniques for the Pelvis Region - Prostate Thank You Very Much