Seth Crumpton

1) After the application of the first step in the assignment, I was able to achieve
82% (CTV) and 75 % (PTV) isodose line coverage using a single 6MV PA
beam. A hotspot of 6062cGy occurred on the posterior portion of the patient
at the superior portion of the sacrum. You can clearly see where the 100%
isodose line coverage is limited by observing this slice. The 6MV energy beam
doesnt penetrate deep enough to get the coverage we need. You can also
clearly see a progression of fall off as we move from the posterior portion of
the patient (110% isodose line) to the anterior portion of the patient (20%
isodose line).

2) After increasing the beam energy from 6MV to 18MV isodose line distribution
improved to 87.5%(CTV) and 83%(PTV). A hotspot of 5556cGy occurs in the
superior portion of the sacrum one again. However, this time it occurs along
the bony anatomy more inferior in relation to the previous hotspot. The
distribution improved very slightly. It is almost unnoticed at first glance, but if
you look close you can see essentially every isodose line has moved
anteriorly encompassing more of the PTV with the 100% isodose line.
Seth Crumpton

3) Utilizing three 6MV beams and equal weighting I was able to achieve 91.5%
(CTV) 85.5% (PTV) isodose line distribution. A hotspot of 5412cGy occurs in
the right buttock of the patient. This is where isodose line distribution
changed drastically. Here the 100% isodose line broke up into three separate
sections on either side of the femur and over the PTV. At this point femoral
head dose also began to increase, while bladder dose greatly decreased.
Seth Crumpton

a) Increasing the energies of the lateral fields to 18MV increased isodose line
distribution to 96.5%(CTV) and 91.5(PTV). The distribution appeared more
uniform. A hotspot of 5241cGy occurred in a similar area to the previous
hotspot, maybe slightly more inferior in relation to the previous. Rather
than having three separate 100% isodose lines, we now have a uniform
rectangle encompassing the PTV. However, we are still lacking coverage
on the anterior portion of the PTV.
Seth Crumpton

b) Increasing the PA beam to 18MV to match the energy increase of the

lateral fields improved isodose line distribution to 97.5%(CTV) and 93%
(PTV). Overall, the isodose line distribution appears more block like. A
hotspot of 5138cGy occurs appears in the right buttock once again, but
closer to the rectum. Also, the 100% isodose line coverage on the anterior
border of the PTV is greatly improved.
Seth Crumpton

4) Using 15 degree wedges improved the isodose line distribution to 100%(CTV)

and 98%(PTV). I oriented both wedges with the heel of the wedge posterior to
the patient. I did this because this is where tissue uniformity becomes an
issue. The back side of a patients pelvis contains a lot of soft tissue. The
bony anatomy is located more anteriorly. To compensate a placed to heel
posterior so that gradient of the wedge would even out the dose to the field.
Seth Crumpton

a) 30 Degree wedge (same wedge orientation): 100% isodose line appears

more block like doesnt dip as much anteriorly. 105% isodose line is
separated. 100% isodose line distribution for both CTV and PTV. A hotspot
of 4931cGy occur on the posterior bony portion of the right pelvis.
b) 45 Degree wedge (same wedge orientation): 100% isodose line appears to
start dipping in on posterior portion of the patient. Could be an indication
that too much wedge angle is being used. Isodose line distribution
remains 100% for both CTV and PTV once again. Hotspot of 5048cGy on
bony anatomy of right pelvis.
c) 60 Degree wedge (same wedge orientation): 100% isodose line is broken
up into three separate areas. One over each femur and one over field.
Isodose line distribution decreases to 99.5% (CTV) and 90% (PTV). Also,
greatly increases dose to the femoral heads. Hotspot of 5551 cGy occurs
along bony anatomy of right pelvis.
5) The achieve the best plan possible, I used three 18MV beams (PA, both
laterals), PA-45%, LT Lat-27.5%, Rt Lat 27.5% beam weighting and 30 degree
wedges on the lateral beams oriented with heel facing the posterior portion
of the patient. I went with this combination because it provided the best
isodose line coverage while sparing the organs at risk most effectively.
Increasing the posterior beams weight allowed me to limit dose to the femurs
without compromising coverage to the CTV and PTV. The tradeoff is that more
dose is focused on the bladder now. But, that is okay because the bladder is
more durable in terms of radiation and it still falls way below the DVH limit.
Seth Crumpton

The hotspot that occurred was also relatively lower than most of the other
plan alternatives (4972cGy).
Seth Crumpton
Seth Crumpton

6) Adding an AP beam makes the 100% isodose line a nice uniform rectangle
around the isocenter. However, it does pull the 2250cGy isodose line
anteriorly within the patient. A hotspot of 4944 occurs just to the right of the
PTV. One of the main disadvantages associated with using a fourth field is the
dose to the bladder. You are now directly radiating the bladder in an attempt
to reach a target that is located just behind it. However, as mentioned before,
the bladder is structure that can resist radiation more than most. One
advantage of using a fourth field is the reduced dose to the femoral heads.
Other things should be considered, but depending on the patients situation
this could be a positive tradeoff. A dosimetrist could use this to their
advantage. For example, if the doctor was more focused on reducing dose to
the femurs and less concerned about dose to the bladder, using a fourth field
could be an effective method of treatment.
Seth Crumpton