Ryan Clark

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
Small Bowl

Femoral Heads

Bladder

Desired objective(s)
No more than 150
cc above 3,500
cGy
No more than 70
cc above 4,000
cGy
No more than 35
cc above 4,500
cGy
None above 5,000
cGy
No more than 50%
above 3000 cGy
No more than 40%
above 4000 cGy
No more than 5%
above 4500 cGy
No femoral head
volume should
receive over 5000
cGy
Mean dose <4000 cGy

Achieved objective(s)
Yes (0 cc)
Yes (0 cc)
Yes (0 cc)
Yes (Max dose 2295 cGy)

Yes (2950 cGy)

Yes (2975 cGy)
Yes (4455 cGy)
Yes (Max dose 4590 cGy)

Yes (2925 cGy)

Ryan Clark

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 maximum hotspot is 131% of the dose and is at the patients

posterior surface of the incident beam. The PTV and CTV are
receiving only 80% of the prescribed dose. The isodose lines
bend forward as the beam is attenuated less when traveling
through the air cavity.

b. Change to a higher energy and calculate the beam. How did your
isodose distribution change?

The hotspot is still in the same region, but decreased to 120% of

the dose. The isodose lines extend deeper into the patient, but
still share the same overall shape as the 6X beam did because of
the tissue heterogeneities and normalization to the isocenter.
The extended distance is much more noticeable in the lower
isodose levels. The 70% isodose line increased in depth by
roughly 2.5 cm and the 50% isodose line completed traverses
the patient throughout the whole width of the field.

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.

Ryan Clark

The hotspot is still in the posterior direction, but occurs at each

location where the right and left lateral fields overlap with the PA
field. There is noticeable dose build at the incidence of both the
right and left lateral beams. The fluence of the isodose lines is
more symmetrical in the AP/PA direction with the added lateral
fields.
d. Change the 2 lateral fields to a higher energy and calculate. How did
this change the dose distribution?
The dose build up at the surface is no longer present with the
higher energies. The 70% isodose lines traverses through the
area of both the right and left lateral fields. The hotspot where
the lateral fields overlap with the PA decreased to 108-110%. The
isodose lines bend inward within the air cavity and bend outward
when interacting with the femoral heads.
e. Increase the energy of the PA beam and calculate. What change do you
see?
The isodose lines that traverse from the patients left to right are
flatter and do not bend out as much despite the air cavity
heterogeneity. Each isodose line symmetrically fits the field size
and except where the dose naturally bends outward farther away
from the central axis. The dose coverage is better superiorly
where the sacrum attenuated the lower energy beam before.
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.)

Ryan Clark

Ten degree EDWs were added and were oriented with the heel
anterior and the toe inferior. The wedge was oriented this way
to help reduce the hotspot where the lateral fields overlap with
the PA and to have the toe effect of the wedge bring more dose
to the patients anterior. The heel of the wedge also
compensates for the patients less thick anterior while the toe of
the wedge is oriented over the wider portion of the patients
hips. This wedge orientation required a 90 degree collimator
rotation due to the Y jaws being used to create wedge effect on
the isodose lines. The field size and MLC pattern was
reconfigured to match the fields before the collimator rotation.

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?

Without changing the normalization, energy, or beam weighting;

45 degree EDWs to both lateral fields provided the best
coverage of the PTV. The hot spot toward the patients posterior
was reduced to 95% of the dose with the increased angle of the
wedge. The beam weighting will need to be further adjusted to
get dose back toward the posterior portion of the PTV at both the
superior and inferior. The 100% isodose line now extends far
enough anteriorly to where it encompasses all of the PTV. A
hotter isodose region of 90% appeared a few cm deep in the
region where the toe of each lateral field is.

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

Ryan Clark

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.
Energies of 18 MeV were used for each field. The lateral fields
utilized 45 degree EDWs. Lower beam energies and wedge
angles were unable to provide dose coverage toward the
patients anterior. EDWs of 60 degrees for the lateral fields
caused a loss of coverage towards the patients posterior and
caused a 110% hotspot anteriorly. The beam weighting was
adjusted to 52% from the PA and 24% from each of the lateral
fields. This weighting optimized dose coverage of the PTV and
reduced the hotspot to 108%. A majority of this hotspot is
located within the PTV as well. The higher beam weighting from
the PA field was also used to help meet the dose criteria for the
femoral heads. This combination of beam weighting and wedges
provided 99% of the PTV to be covered by 100% of the
prescribed dose.
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.

Ryan Clark

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 four field plan provides adequate coverage of the PTV but
does not have as sharp of a dose fall off due to the presence of a
much larger hot spot. The hot spot grew in size posteriorly and
the isodose distribution is roughly the same shape. Adding the
fourth field reduces the mean dose to the femoral heads by
about 5%. The bladder, sigmoid colon, and small bowel receive a
much higher increase in mean dose of about 5%, 4%, and 6%
respectively.