Pelvic irradiation of the obese patient: a treatment strategy involving megavoltage simulation and intratreatment setup corrections.

This study involves a fractionated course of external radiation therapy for a 42 year old female weighing 150 kg, diagnosed with stage IIb cancer of the cervix. The patient could not be simulated in the conventional sense due to weight restrictions on the simulator couch, and body casts or molds were impractical. Using an on-line portal imaging device, treatment fields were established during the first session, and intratreatment verification was used before every subsequent treatment to measure and, when necessary, to correct the patient setup. Two courses of treatment were prescribed with a total dose of 60 Gy delivered by a four field box technique (A/P, P/A, and two lateral fields). Out of a total of 108 treatment fields monitored, 12 anterior fields and 1 posterior field were corrected (exclusive of the first, or simulation fraction). Without corrections, 10% of the initial setup displacements would have had displacements greater than 10 mm, 21% greater than 7 mm, and 41% greater than 5 mm. With the application of intratreatment corrections, only 2% of the displacements were greater than 10 mm, 11% were greater than 7 mm, and 32% were greater than 5 mm. It was also found that the second field treated in a parallel opposed pair (i.e., anterior/posterior or left/right lateral) had lower setup displacements and did not require verification or correction.