Ontida Apinorasethkul

DOS791
April 22, 2015
Clinical Pelvis Lab Assignment
In a pelvis case at my institution, the medical dosimetrist would draw normal structures,
including bladder, small bowel, femoral heads, sacrum, rectum, and body-PTV structures
(Figures 1-3). The body-PTV structure was created to review the dose of tissue outside the
PTVs. Physician would check all the normal structure contours and draw the treatment volumes
(Figure 4). In this case, there was no gross tumor volume (GTV), because it was post-operative
pelvic radiation therapy. The clinical target volumes (CTVs) were drawn as CTV nodal and
CTV primary in which the CTV primary was labeled as CTV 5040. Both CTVs were to receive
5040cGy. The CTVs from full bladder and empty bladder scans were fused to create an internal
target volume (ITV). ITV was generated to account for internal organ motion. The physician
then created 0.7cm expansion to the planning target volumes (PTVs) from ITV.
Intensity Modulated Radiation Therapy (IMRT) was chosen as a treatment planning
technique in this case. Nine fields were used with each being 40 apart. The beam angles used
were 20, 60, 100, 140, 180, 220, 260, 300and 340 in which all were 6MV (Figure 5).
Homogeneity correction was used for optimization and plan calculation. The treatment plan was
done on the full bladder scan. Isocenter was placed during CT simulation at the mid pelvis and
mid depth (Figure 6). The CT slices were scanned with 0.3cm thickness. According to RTOG
0418, the dose prescription was 50.4Gy in 28 fractions.
All prescription goals were well met. 97% of the PTV volumes met 100% of the dose as
well as at least 99% of the PTVs received higher than 93% of the dose. Dose prescription
coverage is shown in Figure 7 and the prescription dose specification details are shown in Table
1. Maximum dose of the plan was 112%, however, >110% of dose was less than 0.2% of the
PTV volume. Not all the organs at risk (ORs) meet the desired objectives (Table 2, Figure 8).
Small bowel, femoral heads and body-PTV met the constraints. Bladder did not meet the critical
structure objectives, however, it was within the minor deviation which is V50 of bladder = 29%.
Rectum exceeded both desired and minor deviation objectives. The protocol in section 6.5.5
stated that participants are strongly encouraged to remain within these limits, though it did not
have any deviation unacceptable limits. Therefore, it was an assumption that the critical

structure objectives were not hard constraints and the patients would still be able to participate in
the protocol. Because 46% of the rectum overlapped with the PTVs, it was a challenge to spare
the rectum without sacrificing the PTV coverage (Figure 9). PTVs were very well covered and
tightly conformed by the prescription dose. There are some dose streaks and spills as expected
from an IMRT plan (Figures 10-11).
A VMAT plan may have been more conformal given if full arcs could be used. At my
facility, there are table rails that we avoid shooting the beam through, therefore, approximately
240 degree for each arc could be used instead of the full arcs. With the limited arc angles, it
could contribute to why the VMAT plan outcome was not as great as the IMRT. The posterior
arc angles could help achieve a more optimal result. Another consideration was to use higher
energy on the IMRT plan. The ORs and TVs did not significantly benefit from using 15MV
other than a lower hot spot in the plan. For that reason, 6MV was the treatment plan choice with
no neutron contamination.

Figures and Tables

Body-PTV
Bladder

Rectum

Sacrum

Figure 1: Organs at risk contours

Small
bowel

Large
bowel

Figure 2: Organs at risk contour (contd)

Bladder
Femoral
head_right

Femoral
head_left

Rectum

Figure 3: Organs at risk contours (contd)

CTV nodal

PTV nodal

CTV 5040
PTV vagina
50.4

Figure 4: Treatment volume contours (ITV, CTVs and PTVs). ITV is overlapping with CTVs.

Figure 5: Beam arrangements.

Figure 6: Isocenter placement.

Figure 7: Dose prescription to PTV in dose color wash.

Desired Objectives
V100% > 97%
V110% < 20%
V93% > 99%

Achieved Objectives
PTV_5040
PTV_nodal
V100% = 98.5%
V100% = 98.6%
V110% = 0%
V110% = 0.25%
V93% = 100%
V93% = 100%

Table 1: Prescription dose specification.

Organ at Risk
"Body - PTV" or tissue
outside PTV
Small bowel
Bladder
Femoral head_LT
Femoral head_RT
Rectum

Desired Objective

Achieved Objective

V110% < 1% or 1cc

V40 < 30%
V45 < 35%
minor: V50 = 35%
V30 < 15%
V30 < 15%
V30 < 60%
minor: V50 = 35%

V110% = 0%
V40 = 23%
V45 = 41%
V50 = 29%
V30 = 2.8%
V30 = 1.3%
V30 = 94%
V50 = 54%

Table 2: Organs at Risk Objectives.

PTVs
Rectum
Bladder

Small
bowel

Femoral
head_rig
ht

Femoral
head_left

Figure 8: Dose volume histogram of TVs and ORs.

CTVs/IT
V

Figure 9: Diagram showing rectum overlapped with PTV.

Figure 10: Axial, coronal and sagittal planes showing isodose lines to the treatment volumes.

Figure 11: Axial, coronal and sagittal planes showing dose color wash to the treatment volumes