Phillip Lin

DOS 771 Clinical Practicum I

3/27/17
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 Desired objective(s) Achieved objective(s)

Lt/Rt Femoral heads <45 Gy (point max)* Max point dose:
Lt-50 Gy, Rt-50.2 Gy
Mean dose:
Lt-34 Gy, Rt-33 Gy
Achieved
Bladder <45 Gy (or less than Mean dose: 32.5 Gy
105% rx)* Achieved

Small Bowel < 54 Gy (or less than Max point dose: 43 Gy

105% rx)* Mean dose: 10.8 Gy
Achieved
*objectives based on clinic specific guidelines

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. Isodose distribution: CTV line
is displayed in brown, PTV line is displayed in pink. 91% of the CTV
volume is irradiated to 45 Gy with 82% of the PTV volume irradiated to
45 Gy. The hotspots for 65% of both volumes reach to a hot spot point
of 47.5 Gy with the PTV trailing off into higher hotspots. A max hotspot
of 67.3 Gy appears at the posterior aspect of the inferior sacrum,
presumably where the most attenuation occurs in the treatment field
 volume. Please refer to Figure 1-1 below.

Figure 1-1. Hot spot locations and DVH comparing CTV and PTV
isodose lines.
b. Change to a higher energy and calculate the beam. How did your
isodose distribution change?
The penetration of the PA beam increases which shifted the isodose
lines further anterior. This also brought the overall maximum hotspot
dose from 67.3 Gy to 61.3 Gy. This reflects the skin sparing properties
of a higher beam energy. Compare with Figure 1-2 below.

Figure 1-2. Hot spot locations and shifting of isodose lines in a

transverse view.
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 became
more non-uniform due to the lateral beams. Hot spots were also more
apparent in the posterior lateral edges of the fields where two beams
meet. Hot spots also appeared on the lateral aspects of the pelvis. See
 Figure 1-3 below:

Figure 1-3
d. Change the 2 lateral fields to a higher energy and calculate. How did
this change the dose distribution? The hotspots were eliminated from
the sides of the pelvis anatomy. The overall hotspot was also reduced.
See Figure 1-4 below:

Figure 1-4. Dose buildup in tissue of lateral aspects of pelvis not

present anymore.
e. Increase the energy of the PA beam and calculate. What change do you
see? Outer isodose lines were pushed in due to deeper penetration
from 15X compared to 6X.
f. Add the lowest angle wedge to the two lateral beams. What direction
did you place the wedge and why? I placed the wedge orientation with
the heel side posterior, and toe side anterior in relation to the patient.
This allows the thicker part of the wedge to attenuate the hotspots
created by the overlap between the PA field and both lateral fields.
How did it affect your isodose distribution? The wedges pushed the hot
 spots and dose distribution more anterior without weighting the PA
beam to compensate for the lack of dose coverage to the entire field.
(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...) See Figure 2-1
below:

Figure 2-1. Wedge orientation on lateral fields. Picture to the right is

BEV for RLAT field.
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? I
experimented with wedge angle degrees of 15, 30, 45, and 60. The
isodose distributions kept being pushed from the posterior (where the
heel was) towards the anterior (where the toe was) in addition to the
hotspots accumulating more anteriorly.
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. I decided to use 15X
energy for all 3 fields. 15X for the laterals due to the increased
separation and increased skin sparing, and 15X for the posterior field
due to better dose coverage into the treatment field. 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. With equal beam weighting, 30 degree wedges with
the heel facing posterior provided the best overall dose distribution
and lowest hot spots. However, with weighting- I decided to use 45
degree wedges for the lateral fields with the same orientation. I was
able to push the PA field to achieve more coverage and move/reduce
the posterior hot spots with the thicker wedges. This was the best
balance between the 30 wedge (did not push isodose distribution for
enough field coverage) and 60 degree wedge (pushed the isodose
distribution too far anterior into the bladder and small bowel). My field
coverage increased (from 95 to 99%) and hotspots were decreased
 (108% to 106.3%) in comparison. My final beam weighting (out of
100%) was fairly even- PA: 39%, RLAT: 30.5%, LLAT 30.5%
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. See Figure 2-2 &
2-3 Below:

Contour and Isodose line color legend

Figure 2-2. Top to bottom, left to right: Axial plane, PA field BEV,
coronal, and sagittal planes displaying dose distributions covering CTV
and PTV volumes.
 Figure 2-3. DVH with CTV, PTV, and critical structures.

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
isodose distribution was relatively similar considering there was no beam
weighting or wedge compensation to optimize the coverage. The four field
plans dose distribution did present very evenly and coverage was almost
identical but on comparing the DVHs for both plans, higher bowel and
bladder dose were given with the four field plan. The 3 field plan also had a
steeper dose fall off in comparison. See Figure 3-1 below:
Figure 3-1. DVH lines tracked with squares reflect 3 field plan, lines tracked
with triangles were 4 field plan.