Variant 1.
67-year-old man diagnosed from PSA screening program. PSA 5.2 ng/mL, prostate within normal limits on examination. Multiple needle biopsies of the prostate showed adenocarcinoma. Gleason score 3 + 3 = 6.
| Treatment | Rating | Comments |
|---|---|---|
| Presimulation | This option is not required if performing image guidance but is an option that is not wrong for planning purposes. | |
| Bowel prep | 7 | Microenema is recommended.81 Oral stool softener and antiflatulent agents are also options.21, 82 |
| Supine position | 8 | See references.83, 84, 85, 86 |
| Prone position | 5 | See reference.87 |
| Custom immobilization (eg, with custom thermoplastic cast) | 8 | This option is per previously published reports.88, 89 |
| Bladder | This treatment is dependent on institution. | |
| Full | 7 | |
| Comfortably full | 8 | |
| Empty | 4 | |
| Simulation Tools | ||
| CT simulation | 8 | CT alone is possible in the hands of an experienced clinician.90 |
| MRI simulation and fusion to CT | 7 | This procedure may be most helpful if the prostate contour is uncertain or in instances of unusual anatomy. See references.118, 119, 120, 91, 92, 93 |
| Treatment Planning | ||
| IMRT (non-arc) | 8 | |
| IMRT (arc) | 8 | |
| Proton beam | 6 | This reflects recognized controversy in the field. This procedure is unlikely to have worse outcomes than IMRT. Treatment on protocol is encouraged. |
| 3D-CRT | 5 | This procedure is acceptable if dose-volume histogram constraints are met or if IMRT is not available. |
| Image Guidance | ||
| Use of radiofrequency transponders | 7 | See references.16, 18, 26, 28, 39, 40, 41, 42, 43, 44, 45, 49, 50, 51, 52 |
| CBCT with fiducial markers, aligned to PTV | 8 | |
| CBCT without fiducial markers, aligned to PTV | 7 | |
| CBCT, aligned to bony anatomy | 3 | The prostate gland is recognized to move independently of bony anatomy, so alignment based on the prostate PTV is recommended. |
| 2-D imaging with fiducial markers | 7 | |
| Ultrasound | 7 | |
| None | 3 | |
| RT Fractionation | ||
| CFRT (ie, 1.8–2.0 Gy/fraction) | 8 | |
| HFRT (ie, 2.1–3.5 Gy/fraction) | 6 | This procedure is per previous protocol (eg, RTOG 0415 121). |
| Stereotactic RT (ie, >3.5 Gy/fraction) | 6 | This procedure is probably acceptable, but head-to-head comparisons are limited currently. This procedure is per previous protocol (eg, RTOG 0938 77). |
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate