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Yinan Wang
Pelvis Clinical Lab
April 2016

Planning Assignment (3 field rectum)


Use a CT dataset of the pelvis. Create a CTV by contouring the rectum (start
at the anus and stop at the turn where it meets the sigmoid colon). Expand
this structure by 1 cm and label it PTV.
Create a PA field with the top border at the bottom of L5 and the bottom
border 2 cm below the PTV. The lateral borders of the PA field should extend
1-2 cm beyond the pelvic inlet to include primary surrounding lymph nodes.
Place the beam isocenter in the center of the PTV and use the lowest beam
energy available (note: calculation point will be at isocenter).
Contour all critical structures (organs at risk) in the treatment area. List all
organs at risk (OR) and desired objectives/dose limitations, in the table
below:
Organ at risk
Bladder

Small Bowel

Large Bowel

Femoral Heads

Desired objective(s)
V40 <= 40%
V45 <= 15%
Dmax < 50 Gy
V35 <= 180 cc
V40 <= 100 cc
V45 <= 64 cc
Dmax < 50 Gy
Dmax < 50 Gy

Achieved objective(s)
V40 = 10.5%
V45 = 0.0%
Dmax = 44.8 Gy
V35 = 40.0 cc
V40 = 32.9 cc
V45 = 6.0 cc
Dmax = 45.7 Gy
Dmax = 45.5 Gy

V40 <= 40%


V45 <= 25%
Dmax < 50 Gy

V40 = 33.2%
V45 = 13.2%
Dmax = 45.9 Gy

a. Enter the prescription: 45 Gy at 1.8 /fx (95% of the prescribed dose to


cover the PTV). Calculate the single PA beam. Evaluate the isodose
distribution as it relates to CTV and PTV coverage. Also where is/are
the hot spot(s)? Describe the isodose distribution, if a screen shot is
helpful to show this, you may include it.

The patient was treated in prone position to minimize the dose


to small bowel. With 6 MV PA beam alone, the dose distribution
was hot in the posterior region, and the coverage to the PTV
and CTV was poor, with 95% isodose line covers 77.4% of the
PTV, and 84.3% of the CTV. (Figure 1) The hot spot was 121%
of the prescription (5458 cGy) and at the right side 1.5 cm away
from the posterior surface of the patient.

Figure 1. Isodose distribution with 6 MV PA beam alone.


b. Change to a higher energy and calculate the beam. How did your

isodose distribution change?


When 18 MV was used, the plan was less hot in the posterior
region, and the coverage to the PTV and CTV was improved a
little bit, due to the higher penetration capability of the higher
energy beam. The 95% isodose line covered 81.6% of the PTV,
and 87.4% of the CTV. (Figure 2) The hot spot was 117% of the
prescription (5264 cGy) and at the right side 3 cm away from
the patient posterior surface.

Figure 2. Isodose distribution with 18 MV PA beam alone.

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c. Insert a left lateral beam with a 1 cm margin around the ant and post

wall of the PTV. Keep the superior and inferior borders of the lateral
field the same as the PA beam. Copy and oppose the left lateral beam
to create a right lateral field. Use the lowest beam energy available for
all 3 fields. Calculate the dose and apply equal weighting to all 3
beams. Describe this dose distribution.
The dose distribution is more conformal and less hot in the
posterior region. (Figure 3) The hot spot was 108% of the
prescription (4856 cGy) and at the left side 4 cm away from the
patient posterior surface. However there are some doses in the
left and right lateral regions after two lateral beams were
added. The coverage to the PTV and CTV was not better. The
95% isodose line covers 80.9% of the PTV, and 85.5% of the
CTV.

Figure 3. Isodose distribution with equal weighted 6MV PA and


opposed lateral beams.
d. Change the 2 lateral fields to a higher energy and calculate. How did

this change the dose distribution?


When the two lateral fields were changed to 18 MV, the dose in
the two lateral sides became less hot than before. (Figure 4)
The coverage of the PTV and CTV became better. The 95%
isodose line covered 85.4% of the PTV, and 90.5% of the CTV.
The hot spot was at the same place and decreased to 106% of
the prescription (4790 cGy).

Figure 4. Isodose distribution with 6MV PA beam and 18 MV


opposed lateral beams.
e. Increase the energy of the PA beam and calculate. What change do you

see?
If the energy of the PA beam was increased to 18 MV, the
posterior region became less hot and the coverage was a little
better. (Figure 5) The 95% isodose line covered 86.9% of the
PTV, and 92.3% of the CTV. The hot spot was at the same place
and reduced to 105% of the prescription (4737 cGy).

Figure 5. Isodose distribution with 18 MV PA and opposed


lateral beams.

f.

Add the lowest angle wedge to the two lateral beams. What direction
did you place the wedge and why? How did it affect your isodose
distribution? (To describe the wedge orientation you may draw a
picture, provide a screen shot, or describe it in relation to the patient.
(e.g., Heel towards anterior of patient, heel towards head of patient.)
A 10 degree wedge was added to each lateral beam with the
heel on the posterior side of the patient to compensate thinner
tissue passed by the beams. The heel (thicker part) of the

wedge attenuated more of the beam than the toe (thinner


part), which shifted the isodose lines anteriorly and produced
a more uniform dose distribution. The coverage was better for
the CTV and PTV, with the 95% isodose line covered 89.0% of
the PTV, and 94.6% of the CTV. The hot spot was still at the
posterior region. (Figure 6)

Figure 6. Isodose distribution with 10 degree wedges on the


lateral beams.
g. Continue to add thicker wedges on both lateral beams and calculate for
each wedge angle you try (when you replace a wedge on the left,
replace it with the same wedge angle on the right). What wedge angles
did you use and how did it affect the isodose distribution?
The wedge angles were increased to 15, 20, 25, 30, 35, and 40
degrees. The coverage to the PTV and CTV was at the best
with 40-degree wedges. The hot sport moved anteriorly and
decreased to 101% of the prescription (4549 cGy). After the
wedge angles were increased more than 40 degrees, the
coverage became less conformal and the two lateral regions
became hot (more than 95% of the prescription). (Figure 7)

Figure 7. Isodose distribution with 40-degree wedges on the


lateral beams.

h. Now that you have seen the effect of the different components, begin
to adjust the weighting of the fields. At this point determine which
energy you want to use for each of the fields. If wedges will be used,
determine which wedge angle you like and the final weighting for each
of the 3 fields. Dont forget to evaluate this in every slice throughout
your planning volume. Discuss your plan with your preceptor and
adjust it based on their input. Explain how you arrived at your final
plan.
I adjusted the beam energies and weightings, and finally found
the best plan I can achieve was to use 18 MV for PA, left and
right lateral beams with weightings of 46%, 27%, and 27%,
respectively. Forty-degree wedges for both lateral beams
provided the plan with the best uniformity. By increasing the
weighting on the PA beam and reducing the weighting on the
lateral beams, the dose in the two lateral hot regions was
reduced dramatically. Although the hot spot increased a little
to 103% of the prescription (4621 cGy), it was pushed inside of
the PTV. The dose constrains to all the organs at risk were
achieved. My preceptor agreed with me that this was the best
result we can achieve.
i. In addition to the answers to each of the questions in this assignment,
turn in a copy of your final plan with the isodose distributions in the
axial, sagittal and coronal views. Include a final DVH.
Figure 8 and 9.

Figure 8. Final plan.

Figure 9. Final plan DVH.

4 field pelvis
Using the final 3 field rectum plan, copy and oppose the PA field to create an
AP field. Keep the lateral field arrangement. Remove any wedges that may
have been used. Calculate the four fields and weight them equally. How does
this change the isodose distribution? What do you see as possible
advantages or potential disadvantages of adding the fourth field?
The coverage to the PTV and CTV did not change much. The 95%
isodose line covered 100% of both the PTV and CTV. Since adding
one AP beam reduced the weighting of the other three fields, the
dose in the two lateral hot regions and the femoral heads were
reduced. The maximum dose to almost all ORs decreased. However,

the anterior region of the patient got more dose and the mean dose
to the small bowel and bladder increased. (Figure 10)

Figure 10. Isodose distribution with four-field plan.