Ashley Walsh

Clinical Lab #2
RTOG 0418
Target Volumes: patient TP had two CT scans performed; the first was 45 minutes after the
patient drank 32 ounces of water and the second was immediately after the patient had voided.
The medical dosimetrist utilized the MIM workstation to fuse the two scans and start a workflow
so the physician could delineate the gross tumor volume (GTV). Once the GTV is contoured, the
medical dosimetrist continued the workflow so MIM could propagate the internal target volume
(ITV). This contour along with the CT data set was sent to Pinnacle where the expansion of 5mm
in all directions was added to create the planning target volume (PTV). Once the physician
reviewed the PTV and ensured it was expanded appropriately the medical dosimetrist started the
planning process. Treatment planning was performed on the CT data set with a full bladder.
Organs at Risk: The dosimetrist began by contouring all the normal tissue, the current standard
for normal tissue followed is from the Radiation Therapy Oncology Group (RTOG) published
atlases. This included contouring the bladder and rectum on every slice. The small and large
bowels were contoured on every slice starting 2 cm above the planning target volume moving
inferiorly. Both femoral heads were added, the last slice added inferiorly was the same slice the
rectum contour ended on.
Treatment prescription and planning objectives: The prescription was written for 180cGy
/day for 28 days for a total of 5040cGy delivered to the tumor. The plan was prescribed to
isocenter and normalized to the 95% isodose line. The way Pinnacles normalization works is
every time you drop the normalization from 100% the total dose is increased. This helps when
trying to obtain a specific coverage to the PTV. This will increase the dose to all tissues, not just
the PTV. In non-protocol patients the normal practice in clinic is 95% of the PTV must be
covered by the 100% isodose line so usually plans are normalized to the 98 or 97% isodose line.
For this patient, however, since the protocol required 97% PTV coverage the only way the
medical dosimetrist was able to achieve this is to drop the normalization down to 95%. With all
plans there has to be a tradeoff, with the increased coverage the rest of the plan became hotter as
well which pushed the bladder and femoral heads from per protocol to a minor deviation. When
treating the whole pelvis including lymph nodes it can be very challenging to curve the dose
around the bladder and maintain such high level of coverage. When planning with an ARC, and
adding objectives to the bladder and rectum the obvious place for the dose to enter is laterally,
but this makes it hard to meet an objective for the femoral heads. The objectives added to the
IMRT optimization page started with the PTV, a min dose of 5040cGy, max dose of 105% of the
prescription or 5292cGy and min DVH of 97% of the PTV. An objective was added to the
bladder of 30% < 45 Gy and 50% < 40Gy. The rectum was considered and an objective of 50% <
30Gy was added and 20% <50 Gy. Lastly, a 3mm expansion was added to the PTV and then a
planning ring of 1 cm was added to limit the dose to the normal tissue and a max dose of 85% of
the prescription was added, or 42.84 Gy.
Planning technique and beam arrangement: The dosimetrist started by adding a single beam
and changing the modality from a static beam to VMAT. The angle of rotation started at 201

degrees and rotated clock wise to 151 degrees. A 45 degree collimator rotation was added and the
IMRT page was set up for the TPS to mirror the first ARC when creating the second ARC. The
plan was run seven times before hitting an acceptable combination of beams and objectives.
Plan outcome: The plan outcome was per protocol with a few minor deviations to a few of the
OR. The PTV was per protocol, 97% was covered by the 100% isodose line, < 93% received <
50.4 Gy and no more than 20% of the PTV received > 110% of the dose. The bladder did not
meet the criteria of 35 > 45Gy, but it did meet the minor deviation criteria of 35% up to 50Gy.
The rectum was per protocol of 60% to receive > 30 Gy. Small bowel was per protocol of < 30%
to receive > 40Gy. Femoral heads were a minor deviation as well with 20% receiving 30 Gy.

Prescription:

Beams:Beams eye view (BEV) of each ARC with the GTV, ITV and PTV displayed in 3D
view:

Isodose lines in all 3 views, the GTV and ITV are turned on in Poly and the PTV in
colorwash:

DVH:

DVH showing 97% PTV coverage:

OR table:
Organs at risk

Desired objective

Achieved objective

PTV

<97% to receive 100%

< 20% to receive >110%
< 30% to receive 40 Gy
30% to 40Gy (minor
deviation)

97% gets 100%

0% gets > 110%
30% = 38.50Gy

Rectum

< 60% to receive 30 Gy

35% to 50 Gy (minor
deviation)

60% = 27.40Gy

Bladder

< 35% to receive 45 Gy

35% to 50Gy (minor
deviation)

35% = 47.00Gy

Femoral heads

15% to receive 30Gy

20% to 30Gy (minor
deviation)

20% = 30Gy

Small bowel