48 y/o M with cT3N2 intrahepatic cholangiocarcinoma involving the duodenum, status-post progression on gemcitabine/cisplatin and gemcitabine/cisplatin/nab-paclitaxel, planned for concurrent chemoradiation with capecitabine and proton therapy (50.4 Gy to primary tumor with motion management and 45 Gy to regional lymph nodes).
Rx: 45 Gy in 25 fractions to regional lymph nodes, followed by sequential boost (of 1.8 Gy x 3 fractions) to 50.4 Gy in 28 fractions to primary tumor.
Chemotherapy: Capecitabine PO 1500 mg BID concurrently with radiation.
Sim/Planning:
Contours per Bisello Oncol Lett 2019
GTV: primary tumor defined on MRI fused with 4D-CT on each phase of the respiratory cycle.
ITV: union of GTVs across respiratory cycle phases.
CTV_5040: ITV + 1 cm, anatomically adapted.
CTV_4500: CTV_5040 + elective nodes (portal, peri-pancreatic, hepatoduodenal, para-aortic (including covering para-aortic down to the IMA, as defined in the atlas above), anatomically adapted.
This specific patient was treated using proton therapy, so no additional PTVs were generated. If photon therapy is used, 5 mm isometric expansions of the CTVs to PTVs may be considered.
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