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Protocol of Radiotherapy for Prostate Cancer

Indication of radiotherapy
Indications of RT:
(1) very low risk, life expectancy 20 years
(2) low risk, life expectancy 10 years
Indications of RT+ADT:
(1) Intermediate risk
(2) high risk
(3) very high risk
(4) LN positive
Indications of adjuvant RT after radical prostatectomy
(1) positive margin
(2) seminal vesicle invasion
(3) extracapsular extension
(4) detectable PSA, or > 0.2 ng/ml on consecutive 2 measurement
(5) Gleason score 8-10
(6)Positive pelvis LN

Simulation and Treatment Planning

1. Use of CT simulation and 3D treatment planning is required to ensure adequate
target volume coverage and avoid normal tissue irradiation.
2. When CT simulation shows that rectum is distended with gas or stuff or thebladder
is not distended with water, a repeated CT simulation with good boweland bladder
preparation is necessary
3. Before CT simulation and each treatment, the rectum must be emptied to reduce
the anterior displacement for prostate. Patients will be educated to take 250-500 ml
water 30 minutes (more water and/or waiting time, if necessary) before treatment
or CT simulation.
4. To improve the treatment quality, insertion of fiducial marker and image-guided
radiotherapy is strongly recommended.

Radiation Treatment Fields
1. CTV for pelvic lymph node (CTVn): the anatomical component of pelvic nodes.
The upper margin is higher than the junction of ext. and int. iliac vessels, but not
higher than the junction of common iliac vessels.

2. CTV for distal seminal vesicles (CTVsv): above bifurcation of SV shown in CT.
3. CTV for prostate (CTVp): visible prostate with or without proximal SV.
4. Rules for creating PTV by expanding each CTV: since fiducial markers are
inserted into prostate and the position and shape of seminal vesicle will change
with the distension of bladder and rectum, the margin between CTV and PTV is
larger for SV than prostate in patients with fiducial markers.
A. PTVn: (0.5-1) 0.7cm expansion in 3 axis from CTVn
B. When fiducial marker is inserted for image guidance (PTV with i prefix):
i. iPTVsv: 5-7 mm in dorsal direction and 1-0.8 cm for the rest from CTVsv
ii. iPTVp: 5-8 mm in 3 axis from CTVp
C. Without fiducial marker
i. PTVsv: 7 mm expansion in dorsal direction and 1 cm for rest from CTVsv.
ii.

PTVp: 5-7 mm in dorsal direction and 1-0.8cm for rest from CTVp.
D. For SBRT
i. PTVp: 5mm in all direction, 3-5 mm in dorsal direction

Radiation dose
1. The dose escalation (78 Gy) will be only given to patients who are inserted with
fiducial marker and treated with image-guided RT (IGRT) because these techniques
improve the positional precision.
2. The reduction of RT dose is allowed if the dose constraints for rectal and bladder
can not meet the safety criteria, especially for patients with multiple co-morbidity
or taking anti-coagulant.
3. Radiation dose to primary tumors by external beam:
RT dose to prostate: 75.6 -81Gy in 1.8-2Gy/fractions.
RT dose to SV: 50.4-59.4 Gy/28-33 fx for T1-2, 75.6 78.4 Gy for T3.
RT dose to pelvic node: 45 Gy 50.4 Gy. Boost dose to gross LN is allowed.
4. SBRT dose
Low/intermediate risk: 700-750cGy x 5fractions, QD or QOD
High risk: after whole pelvis 45-50.4Gy, boost by SBRT with 700cGy x 3 fxs.
Boost dose to gross LN is allowed.
5. Radiation dose to primary tumors by external beam for adjuvant treatment:
RT dose to prostate and SV tumor bed: 64-72Gy in 1.8-2Gy/fractions.
RT dose to pelvic node: 45 Gy50.4 Gy. Boost dose to gross LN is allowed.
6. Radiation dose to primary tumors by external beam for salvage treatment:
RT dose to prostate and SV tumor bed: 64-72Gy in 1.8-2Gy/fractions.
Biopsy-proven gross recurrence may require higher doses.
RT dose to pelvic node: 45 Gy50.4 Gy. Boost dose to gross LN is allowed.

Dose constraints

Conventional dose fraction

Rectum

V65 < 17% or V75<15%, V70<20%, V65<25%, V60<35%, V50<50%
V40 < 35% or V4 <50%
Bladder

V65 < 25% or V80<15%, V75<20% or V80<15%, V75<25%,
V70<35%, V65<50%, V50<50%, V40 < 50% or V50 <50%
Small bowel
 Maximum dose < 5200cGy or V15<120cc, V45<195cc
 Mean dose < 23.5 Gy
Femoral head

V50 < 5-10%
SBRT dose fraction(monotherapy or combined EBRT)
Rectum

Monotherapy : 100 < 5%, D90 <10%, D80 <20%, D50<50% or


V36Gy< 1c.c.
Combined EBRT: V14.5<17%, V20< 1c.c.

Bladder

Monotherapy: 100 < 5%, D90 <10%, D80 <20%, D50<50% or V37.5<


5.c.c.
Combined EBRT: V14.5<25%, V21< 5c.c.

Penile bulb

Monotherapy: V29.5 < 50%


Combined EBRT: V16.5 < 50%

Femoral head: V50 < 5-10%

References
1. Prostate cancer. NCCN practice guidelines in oncology v.1.2015. Available online
at: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp
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suppression and external irradiation in patients with locally advanced prostate
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randomized doseescalation trial for prostate cancer. Int J Radiat Oncol Biol Phys
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4. Roach M III, DeSilvio M, Valicenti R, et al. Whole-pelvis, mini-pelvis, or

prostate-only external beam radiotherapy after neoadjuvant and concurrent

hormonal therapy in patients treated in the Radiation Therapy Oncology Group
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randomised phase III trial. Lancet 2009;373(9660):301-308.
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8. Roach M 3rd, DeSilvio M, Lawton C, et al. Phase III trial comparing whole-pelvic
versus prostate-only radiotherapy and neoadjuvant versus adjuvant combined
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