Radiation Therapy Treatment Planning: CT/Simulation and Field Design

2. What Happens in the days before treatment ? CT/Simulation Contouring images Treatment planning Radiation Field Design Quality Assurance Iso-center check

3. CT/Simulation A series of detailed images taken of areas within the body to precisely locate and mark the target (cancer) area that is receiving the radiation.

4. CT/Simulation • To Ensure that the patient will be in the same position everyday, the patient’s legs and hips are immobilized. • A Vac Lock bag is used to immobilize the patient. It is a bean bag like material that hardens when the air is sucked out of the bag.

5. Contouring Images The images from your CT/Simulation are downloaded into a treatment planning program. Then, the important anatomy in and/or around the radiation therapy field are outlined.

6. C O N T O U R I N g • 3-D Contouring at the Dosimetry work station. • These contours are used to determine how the radiation will be delivered. • Every person’s anatomy is unique. Seminal Vesicles Bladder Femoral Head Femoral Head Prostate Rectum Penile Bulb Rectum

7. Treatment Planning This is a process in which the Physician, Physicist, and Dosimetry staff work together to optimize delivering the highest prescription dose to the target area while minimizing radiation to the normal anatomy.

8. Treatment Planning Collaborative effort of Physician, Physicist, and Dosimetry Staff

9. Radiation Field/Beam Design The radiation fields will be designed according to the Physician’s prescription with the aid of the treatment planning system. This 3-D shaping (modulation) helps prevent/minimize radiation dose to the surrounding healthy anatomy.

10. Radiation Field DesignMLC (Multi Leaf Collimation) • The Radiation Beam is Shaped (modulated) internally; inside the Treatment Machine. • There are hundreds of interlocking lead ‘leaves’ working together to create one unique dynamic shape altering the 3-D effect of the radiation beam.

11. Radiation Field/Beam ManipulationbyDesigning the MLC Pattern The design of the MLC pattern is based solely upon the patients unique anatomy in correlation to the physician’s prescription. As the radiation beam travels through the MLC pattern the intensity of the beam is shaped (modulated) as it enters the target area (cancer). Meaning, the target area (cancer) is receiving the highest prescription radiation dose and the surrounding healthy anatomy is receiving the absolute minimum amount of radiation.

12. Isocenter Check Isocenter Check (Verification CT Simulation)

13. Quality Assurance Testing When the radiation therapy plan is completed, our physicist will perform a series of QA testing to ensure that the radiation dose we are delivering to the patient is exactly what the prescription calls for prior to the start of treatment.

14. Isocenter Check This is a process in which we verify the center of the radiation field that correlates with the center of the target (cancer) area receiving radiation. In addition this confirms that the patient’s position is accurate. This procedure produces the final markings of the radiation field. (3 points) Note: Patient will get 3 permanent tattoo marks the size of a small freckle. (One on each hip and the third Under the belly button.)

15. Bladder Fill Instructions • All Patients undergoing Radiation Therapy for Prostate cancer will be asked to drink 20-24 oz of water 45-60 minutes prior to their appointment time. • All water is to be consumed within 10 minutes of beginning to drink. This allows for optimal bladder filling. • The first week of treatment will determine how well your body processes the water and the therapists may need to alter these instructions to better fit the needs of the patient. Everyone is different. Hydration and kidney function can also affect the rate of bladder fill.

16. Importance of the Full Bladder When the bladder is full it is pushed up and away from the prostate. Since the prostate is the structure receiving 100% of the radiation dose, it is important to limit the dose to the Bladder by filling it up. FULL BLADDER Prostate Radiation Dose Cloud around Prostate

17. Importance of the Full Bladder • If the Bladder is empty or not full enough it will lay over the prostate like a deflated balloon and receive unnecessary amounts of radiation dose. The therapy team will evaluate bladder fill everyday before treatment using ultrasound technology. The therapists will give feedback on the bladder volume. Unfortunately, if you are not full enough, you may be asked to drink more water before treatment occurs.

18. Clarity Patient Positioning System The Ultrasound probe is gently pressed over the abdomen near the bladder to obtain the images needed for patient positioning.

19. Ultrasound Technology • Is a procedure in which high-energy sound waves are bounced off internal tissues or organs and make echoes. The echo patterns are shown on the screen of an ultrasound machine, forming a picture of body tissues called a sonogram. • The full bladder acts as a window to let us see the Prostate. • If the bladder is not full enough, it may be difficult to image the Prostate.

20. Clarity Ultrasound System In this image, the Bladder is nice and full. It gives the Ultrasound picture a great deal of contrast. If it was empty, everything would appear as gray. Bladder Bladder Prostate P Prostate

21. Ultrasound IGRT IGRT (Image Guided Radiation Therapy) The daily Ultrasound is compared with the original Ultrasound that was fused with the CT images and contours acquired with the initial simulation procedure. The images and contours are then manipulated until they are perfectly aligned. This whole process takes only minutes; however, it is very precise and the reason why we are able to deliver radiation so accurately.

22. The Yellow and Red lines are the contours taken from the original CT scan. As you can see, they are aligned perfectly over the Ultrasound image.

23. IGRT Process This alignment is reproduced daily by the therapists with much accuracy and then reviewed by the physician. The Clarity System will calculate any shifts required based on the alignment of the images for the final table coordinates. The therapists will then move the table to within the sub-millimeter tolerance that the Clarity System is calibrated for. Once these shifts are applied, the patient is now perfectly aligned and ready for treatment.

24. Treatment Day Treatment Machine Radiation Therapist work station

25. What to Expect during Treatment • You will not feel anything during the treatment delivery just like when you have an X-ray. • The therapists can see and hear the patient all the time they are out of the room. • We do ask that you lay as still as possible during your treatment. *** Note: The Treatment table can be elevated 5 feet off the ground so never attempt to dismount the table without the help and direction from a therapist.

26. Things to Make note of while undergoing Radiation Therapy

27. Nutrition While Undergoing Radiation • Please eat well balanced meals, and stay well hydrated. • Do not try to diet or lose weight during treatment. • It is important that patients try and maintain the same weight throughout the course of treatment. • Excessive weight gain or loss may result in re-planning.

28. Urinary Side Effects • Frequency ~ going to the restroom more often than normal. • Urgency ~ finding it difficult to postpone urination. • Incomplete Emptying of the Bladder ~ a sensation of not emptying your bladder completely after you finished urination. • Intermittency ~ when your stream of urine has stopped and started again several times. • Weak Stream ~ when your stream of urine is weaker than normal. • Nocturia ~ getting up to urinate frequently during the night. • Urinary Irritation ~ burning with urination. • Note: Some may experience these side effects within 4 weeks of starting Radiation Therapy. Please tell staff members ASAP if any these occur.

29. What to do when experiencing urinary side effects? • Avoid caffeine and alcohol, these will further irritate you bladder • Avoid carbonated beverages • Drink Cranberry Juice • Flomax/Uroxatral/Detrol LA may be prescribed for urinary frequency • Pyridium my be prescribed for urinary burning

30. Bowel Side Effects • Rectal irritation • Loose stools or diarrhea more frequently • Hemorrhoid irritation • Note: Some may experience these side effects within the first 4 weeks of treatment. Please report this symptoms to the Staff.

31. What to do when I experience Bowel side effects? • Diet modifications or restrictions: Do not eat fresh fruits or vegetables. Stay away from high fiber foods • Daily use of Metamucil or Citrucel • Use Imodium AD on an as needed basis for loose stools or diarrhea • Anusul HC may be prescribed for hemorrhoid and rectal irritation

32. Sexual Side Effects • Temporary decrease in Sexual interest may occur • Temporary decrease in erectile function is not unusual • Permanent decrease in ejaculate or dry ejaculate • Viagra/Cialis/Levitra may be prescribed to help with these side effects. • Sexual activity may be pursued • Note: Some may experience these side effects within the first 4 weeks of treatment. Please report these symptoms to Dr. Beat or Heather.

33. General Side Effects • Fatigue may occur when nearing the end of treatment • Irritation/Redness to the treatment area may occur but is not likely • Note: Please report these Symptoms to the Staff.

34. Scheduling the Treatment Course • Treatment days are Monday-Friday, no weekends. • In the event we are closed for a holiday or for an unexpected circumstance, we will take the days missed and add them to the end of your treatment. • It is preferred to have the same appointment time daily, but arrangements can be made when it is necessary to accommodate other appointments. Time availability will be determined by patient volume. • If you are scheduling travel plans, please let us know ASAP so that we can anticipate any breaks in your treatment schedule and plan accordingly.

35. Thank You