Pelvis Clinical Lab Assignment

Kyle Garafolo

Prescription: 45 Gy in 25 Fractions to the PTV

Planning Directions: Place the isocenter in the center of the designated PTV (note: calculation point will be at
isocenter). Create a PA field with a 1 cm margin around the PTV. Use the lowest beam energy available at your
clinic. Apply the following changes (one at a time) as listed in each plan exercise below. After adjusting each
plan, answer the provided questions. Tip: Copy and paste each plan after making the requested changes so
you can compare all of them as needed.

Plan 1: Calculate the single PA field.

• Describe the isodose distribution.

o Single PA field – Because only one single field is utilized, dose distribution is focused entirely
only on posterior side of the patient. The PTV is not covered, even by the 80% isodose line. The
PTV is receiving a 3D max of 150.3% and a minimum of 60.2% coverage.
• Where is the hot spot and what is it?
o The hot spot is located in the superficial soft tissue (about 1.5cm from the skin surface),
posterior to the sacrum and spine. The hot spot is 169%.
• What do you think creates the hot spot in this location?
o Given the fact that only one PA field is used, dose is only being applied from the posterior side
of the patient. The Dmax for 6MV photons is 1.5cm, so it makes sense that a single field would
produce a hot spot in this area.
• Using your DVH, what percent of the PTV is receiving 100% of the dose?
o According to the DVH, only 48.6% of the PTV is receiving 100% of the Rx dose
Plan 2: Change the PA field to a higher energy and calculate the dose.

• Describe how the isodose distribution changed and why?

o Compared to the 6MV beam, the 18MV beam is not as hot near the skin surface. The depth of
the 110, 105, 100, 98 and 95% isodose lines are all very similar compared to the 6MV beam.
Once you move past the 95% isodose line the 18MV beam pushes the dose more noticeably
deeper (anterior) in the patient. The PTV is still not adequately covered but because of the
higher energy used, the dose is going deeper inside the patient. With a single 18MV beam, the
PTV is now receiving a 3D max of 138.5% and a minimum of 70.3%. The hot spot is now 143.2%
• Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
o With an 18MV beam, 52.7% of the PTV is now receiving 100% of the Rx dose

Plan 3: Insert a left lateral field with a 1 cm margin around the PTV. Copy and oppose the left lateral field 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 fields.

• Describe the isodose distribution. What change did you notice?

o Adding lateral opposed fields, in addition to the PA field, helped to spread the dose to slightly
improve coverage of the PTV. However, with all three fields utilizing 6MV energies, the 100%
isodose lines still favor the posterior and now the lateral sides of the patient. The anterior side
of the patient is still not receiving proper dose to cover the PTV. The PTV is now receiving a 3D
max of 111.9% and a minimum of 81.1%.
• Where is the hot spot and what is it?
o The plan is still hot on the posterior side of the patient, with the maximum hot spot located
lateral to the sacrum in the right buttock muscles. The hot spot is now 113.9%
• What do you think creates the hot spot in this location?
o The addition of the lateral fields helps to distribute the dose more evenly throughout the
patient’s body. Given that there is no AP field to offset the PA beam weight, it is
understandable that the plan is hot near the posterior aspect of the patient. In addition,
 because the PTV contour slightly favors the patient’s right side, the beams (particularly the PA)
covers slightly more on the right side, which is where the hot spot appears.

Plan 4: Increase the energy of all 3 fields and calculate the dose.

• Describe how this change in energy impacted the isodose distribution.

o Increasing beam energy on all three fields to 18MV provided better coverage to the PTV. The
patient’s anatomy is not as hot anymore on either lateral side, since the higher energy caused
the dose to be pushed more medially (lower skin / superficial dose). The PTV has better
coverage anteriorly, but it is still not sufficiently covered. The PTV is now receiving a 3D max of
110.6% and a minimum of 87.1%. The hot spot is 111.4%.
• What are the benefits of using a multiple-field planning approach? (Refer to Kahn, 5th ed, Ch 11.5B)
o According to Khan, using multiple fields (3 or more) can help to achieve lower dose to the
superficial tissue as well as normal tissue near the tumor. Increasing the number of fields
increases the ratio of tumor dose compared to normal tissue dose.
• Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the
prescription dose?
o This plan now covers 56.7% of the PTV with 100% of the Rx dose. This is up 4% compared to the
single field in plan 2.
Plan 5: Using your 3 high energy fields from plan 4, adjust the field weights until you are satisfied with the
isodose distribution.

• What was the final weighting choice for each field?

o The final weighting I chose for these three fields were: PA = 0.4, Right Lat= 0.3, and Left Lat =
0.3
• What was your rationale behind your final field weight?
o The use of three fields in this instance did not provide satisfactory coverage to the PTV
regardless of field weight used. However, I did decide to weigh the PA more than the laterals
due to the proximity of the PTV to the posterior of the patient. In doing so, lower dose from the
patient’s lateral sides were reduced but it did slightly increase the hot spot posteriorly to
113.2%. I noticed that by increasing the PA weight the isodose lines tended to “flatten” in the
middle of the patient instead of the “cup shape” that was present prior to adjusting field
weights. This should help even more with the addition of an anterior field.
Plan 6: Insert a wedge on each lateral field. Continue to add thicker wedges on both lateral fields until you are
satisfied with your final isodose distribution. Note: When you replace a wedge on the left, replace it with the
same wedge angle on the right.

• What final wedge angle and orientation did you choose? To define the wedge orientation, describe it in
relation to the patient. (e.g., Heel towards anterior of patient, heel towards head of patient..)
o The final wedge angle I used were: Left Lat – EDW30IN (heel towards posterior of patient) and
Right Lat- EDW30OUT (heel towards posterior of patient).
• How did the addition of wedges change the isodose distribution?
• Adding wedges to the lateral fields greatly improved the isodose distribution to the anterior of the
patient. The anterior portion of the PTV is now nearly covered with the 100% isodose line. Coverage is
still lacking, however, in the superior and inferior PTV margins. The PTV is now receiving a 3D max of
107.0% and a minimum of 91.8%. The hot spot is 107.1%.
• According to Kahn, what is the minimum distance a wedge or absorber should be placed from the
patient’s skin surface in order to keep the skin dose below 50% of the dmax? (Refer to Kahn, 5th ed, Ch.
11.4)
o Khan recommends a distance of at least 15cm between any absorber in the beam and the skin
surface.

Plan 7: Insert an AP field with a 1 cm margin around the PTV. Remove any wedges that may have been used. Calculate
the four fields. At your discretion, adjust the weighting and/or energy of the fields, and, if wedges will be used,
determine which angle is best. Normalize your final plan so that 95% of the PTV is receiving 100% of the dose. Discuss
your plan rationale with your preceptor and adjust it based on their input.

• What energy(ies) did you decide on and why?

 o Given the thickness/separation of patient anatomy being treated, I decided to use all 18MV
beams in order to provide adequate coverage to the PTV while minimizing dose to the
surrounding structures
• What is the final weighting of your plan?
o The final weighting I chose was: AP= 0.28; PA= 0.32; Lt Lat= 0.185; Rt Lat= 0.215
• Did you use wedges? Why or why not?
o I compared plans with and without wedges. At first glance, I did like the plan that used 15
degree EDWs (heel toward the patient’s posterior side) on each lateral . I found that the
wedges helped to push dose anteriorly to cover the PTV. In doing so, the fields were weighted
more from the PA and AP than the laterals, thus reducing low dose to the lateral soft tissue.
However, upon closer examination of the critical structures on the DVH, I found that the plan
with wedges was overall slightly hotter in most regards. Given that the plan without wedges
had contributed less dose to the critical structures, I decided to continue without wedges.
• Where is the region of maximum dose (“hot spot”) and what is it?
o The hot spot is located in the patient’s anterior left side, slightly anteromedial to their left hip.
The hot spot is 105.9%
• What is the purpose of normalizing plans?
o Plan normalization is an optimization method used to adjust the isodose lines to better cover
the target volume. While normalizing a radiation dose prescription can help to achieve target
coverage goals, it also affects the dose delivered to the surrounding healthy tissue.
• What impact did you see after normalization? Why?
o Prior to normalization, the DVH indicated that only 91% of the PTV was receiving 4500 cGy.
After plan normalization, 95% of the PTV was receiving 4500 cGy. This increase in PTV coverage
resulted in a slightly hotter plan by only 0.9%.
• Embed a screen cap of you final plan’s isodose distributions in the axial, sagittal and coronal views. Show the PTV and any OAR.

GREEN = 100% Rx DOSE

• Include a final DVH. Be sure to include clear labels on each image (refer to the Canvas Clinical Lab module for clear expectations of how
to format your DVH).
• If you were treating this patient to 45 Gy, use the table below to list typical organs at risk, critical planning objectives, and the achieved
outcome. Please provide a reference for your planning objectives.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Bladder V65<50% (QUANTEC) V65 = 0% (max = 4699.7 cGy)

Rectum V50<50% (QUANTEC) V50 = 0% (max = 4712.8 cGy)

Femoral Heads V45<25% (RTOG 0822) V45 = 1.59%

V40<40% (RTOG 0822) V40 = 6.9%

Bowel Space V45<195cc (QUANTEC) V45 = 293cc

(small bowel constraint)