Alyssa Olson

February 24, 2016

Clinical Practicum I
3-Field Rectum Lab
A. A single PA beam through the posterior side of the patient shows a high build-up region
of dose near the skin surface on the posterior side of the patient. Maximum hot spots
within the field reach as high as 146%, and are most prevalent within the first few
centimeters of beam entry on the posterior side of the patient. While the majority of the
PTV is encompassed by the 95% isodose line (dark blue), it is also receiving well over
105% of the dose (yellow) in Figure 1 below. Despite the prevalence of large hot spots,
the isodose lines are smooth and rectangular in shape. This can be attributed to the flat
surface of the patients buttocks on the posterior side of beam entry. Lower energy
beams are often used in thinner areas, and since the tumor is deeply seated, 6 MV
photons are not an ideal choice of energy selection, nor a single posterior beam.

B. Changing the PA beam to a higher energy of 15 MV provided a few benefits. The

maximum hot spot was reduced from 146.7% to 132%. In addition, the 15 MV provided
more skin sparing as can be seen by the increased build-up region below the patient
surface in Figure 1. This can be attributed to the increased penetrating ability of higher
energy photon beams. Finally, higher energy beams pull isodose lines closer to beam
entry. This action can be observed in Figure 1 as all isodose lines above 95% were all
pulled slightly posteriorly.
6 MV

15 MV

Figure 1: Plan Evaluation of a Single PA Beam Using 6 MV and 15 MV Photons

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C. Adding two lateral 6 MV fields is not as helpful as one would hope. The patients thigh
area is receiving over 100% of the prescribed dose (Figure 2). This results in a large
amount of normal tissue receiving unnecessary high doses of radiation. Reasoning for
this is due to the lower penetrating ability of a 6 MV beam and the increased thickness of
the pelvic area in relation to the PTV. In addition, where all 3 beams converge, there is a
large hot spot area of over 120% posterior to the PTV. Therefore, higher energies should
be utilized on the lateral fields when trying to penetrate a greater amount of tissue.

D. Increasing the lateral field energies to 15 MV resulted in both a decrease in hot spots on
the lateral aspect of the patient in addition to a reduction of the 120% hot spot area on the
posterior side of the patient (Figure 2). The percentage of dose to the thigh area has been
reduced to 90%; however, there are other options to consider that could improve the plan
outcome. Perhaps a higher energy on the PA field will pull the isodose lines posteriorly,
further reducing the posterior hot spots.

Figure 2. Comparison of 6 MV and 15 MV Lateral Beams

E. By changing the PA beam to 15 MV, there is a decent reduction in the size of the 120%
posterior hot spot. Also, due to the increased penetrating ability of 15 MV, the 50%
isodose line on the posterior aspect of the patient was pushed deeper into the patient.
This action increased skin sparing along their posterior surface. However, they may still
experience an uncomfortable skin reaction in between their buttock as radiation reactions
tend to worsen in areas where skin-to-skin contact occurs.

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F. Wedges were placed on both lateral fields with the orientation of heel towards the
posterior of patient. This attenuates more of the beam there is less tissue to penetrate
through due to the curvature of the patients bottom. The wedges helped to further
reduce the hot spots in the lateral thigh area and also broke up the 115 percent hot spot
section on the posterior aspect of the patient (pink isodose). The only remaining 115
percent hot spots noted are where the lateral beam converges with the posterior beam on
both sides. The wedges also pulled the 110 percent line more posteriorly due to the
increased beam attenuation from the wedge. A thicker wedge, however, would provide a
more significant benefit to this plan.

Figure 3. Comparison of 3-Field Pelvis Plan with and without Wedges

G. When trying alternate wedges, I kept with the same orientation or heel towards the
posterior aspect of the patient. I tried both 30-degree and 45-degree wedges. Both did a
nice job with further attuentating the hot areas near the posterior side of the patient.
However, the 45-degree wedge broke up the 105 percent line a little better and further
reduced the hot spots of radiation to the lateral aspect of the patient. In comparison to the
15-degree wedge, the 115% hot spot that was present at the beam convergence on the
posterior side of the patient was completely attenuated by using the 45-degree wedge.

H. I evaluated the possiblity of changing the PA beam energy to 6 MV. That change created
more area of hot spots where the PA beam converged with each lateral beam. In addition,
the PTV is located quite deep within the patient, so in order to get adequate coverage, a

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higher energy beam is needed. With regard to the weighting, the patient was slightly
thicker on their left side. This caused a larger area of 90% to appear in the left hip in
comparison to the right hip. To balance out that variance, I added more weight to the left
lateral beam, which created uniformity in the distribution of the 90% line on both sides of
the hips. At the completion of this plan, I used 15 MV on all fields, 45-degree wedges on
both lateral fields, and adjusted weighting to PA at 36.4%, Lt Lat at 32.6%, and Rt Lat at
31%. My goal of adjusting the weighting feature was to create uniformity in the
distrubition of the hotspots and dose to the PTV. I reviewed this plan with my preceptor
to which they had no other concerns or adjustment comments.

Ogan at Risk (OR)

Desired Objective

Achieved Objective

1. Bladder

V30 < 40%

V30: 22.8%

2. Large Bowel

V30 < 30%

V30: 0.48%

Max < 52 Gy

Max: 46.43 Gy

V30 < 30%

V30: 59.7%

Max < 52 Gy

Max: 47.44 Gy

4. Right Femoral Head

Max < 52.5 Gy

47.48 Gy

5. Left Femoral Head

Max < 52.5 Gy

47.33 Gy

3. Sigmoid

Table 1: Plan Evaluation of Desired and Achieved Objectives for OR

Final evaluation of the 3-Field pelvic plan reavealed that all constraints were met with the
exception of the sigmoid. The maximum dose was kept under 52 Gy, however, the V30 of
59.7% was significantly higher than the requested 30%. These constraints were taken from the
patients actual dosimetry order from the initial treatment plan. Reasons for such a high sigmoid
dose could be due to the lack of MLC or custom blocking in the fields. The bowel dose was kept
significantly low, showing the importance and benefits of using a bellyboard for prone rectum
patients.

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Figure 4. Plan DVH

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Figure 5. Axial View

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Figure 6. Coronal View

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Figure 7. Sagittal View

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4-Field Pelvis
With the addition of an AP field, there were notable changes in the isodose
distribution. In comparison to the 3-field plan, the 4-field plan has definite advantages
and possible disadvantages for consideration. As can be seen in Figure 8, the
contribution of the AP field significantly reduced the dose to the lateral aspect of the
patient. The 4-field arrangment creates a very conformal and uniform box around the
target, sparing the surrounding normal tissue from excessive dose. On the contrary, the
AP beam now includes the entire bladder and a portion of bowel in the field, which,
despite the uniformity, is irraditing more normal tissue. This can increase the possibility
of unwanted side effects such as moderate diarrhea, frequency or urgency in urination,
and even dysuria. Finally, the hot spot did increase slightly inside the posterior-lateral
aspect of the patient. If the 4-field plan is requested, the use of wedges on the lateral
fields should be considered to attenuate more of the hot spots within the dose gradient.

Figure 8. Comparison of 4-field Plan to a 3-Field Plan

Just out of plane curiosity, I decided to see what impact a wedge would have on
the 4-field plan. Because the size of the hot spot was relatively small, a 15-degree wedge
was selected and produced quite positive results (Figure 9). The hot spot was further
reduced to 107% in comparison to 110% without wedging. In addition, the size of the
105% hot spot was significantly reduced, resulting in an almost uniform box-shaped plan
of prescription dose. The only thing that could further improve this plan would be to

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consider the use of custom blocking to help shape and conform the radiation beam to the
target.

Figure 9. Plan Evaluation of a 4-Field Plan with and without Lateral Wedges