Pelvis Clinical Lab Assignment

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 0.5 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 beam.

 Describe the isodose distribution as it relates to PTV coverage. If a screen shot is helpful to show this, you may include it.
With a single 6MV PA beam and a 0.5cm margin MLC around the PTV, the isodose distribution is similar to 6MV isodose
curves. Given the PTV is a large volume and only one PA field is created, the 80% isodose line is barely covering the PTV with
hotspots over 110% leaking out of the posterior side. The 100% isodose line is covering about half of the PTV from the PA
field and leaking out of the PTV in the posterior side. The dose gradient follows the principle of radiation beam attenuation as
it goes through the body with dose falloffs from posteriorly to anteriorly. The dose max is 181.2% (extremely HOT!). The
isodose distribution of Plan 1 is shown in Figure 1.
 Where is the hot spot and what is it?
The global maximum dose is along the central axis of the PA beam near the skin surface of the posterior side and it is 181.2%.
 What do you think creates the hot spot in this location?
Since we only have one PA beam covering a large PTV, the hot spot is at the posterior side where the PA beam enters.
Figure 1: Plan 1 Screenshot
Plan 2: Change the field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed.
The isodose distribution are similar to the isodose curves in Plan 1, except the depth of each isodose line has increased with
the higher energy—15MV. With the 15MV PA beam, the isodose curves are shifted more forward as a whole with 80%
isodose line covering almost all of the PTV. The 100% isodose line is covering about 2/3 of the PTV, but it is still leaking out of
the PTV in the posterior side. The dose max has dropped down 158% (still VERY hot!) with dose over 110% in almost half of
the PTV posteriorly. The isodose distribution of Plan 2 is shown in Figure 2.
 Where is the hot spot and what is it?
The global maximum dose is around the same location as Plan 1 near the posterior surface of the PA beam but at a greater
depth and it is 158%.
 What do you think creates the hot spot in this location?
The hot spot is in this location because of the dosimetric parameters of the PA beam covering a large PTV. With a higher
energy, the dose max decreased significantly ~23.2%. Dose is more evenly distributed and pushed more centrally with the
15MV beam compared to the 6MV beam (as demonstrated in Plan 1). I chose 15MV as a higher energy beam in Plan 2
because the patient's body habitus is hypersthenic and the PTV is in the center of the patient’s pelvis. A 15MV beam is able
to deliver the prescription dose to the PTV in a more conformal and less hot way compared to 10MV (my clinical site does
not use photon beam energies higher than 15MV for external photon beam radiotherapy).
Figure 2: Plan 2 Screenshot
Plan 3: Insert a left lateral beam with a 0.5 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 beams.
 Describe the isodose distribution.
The 100% isodose line is no longer leaking out of the PTV in the posterior side with a PA beam plus two opposed lateral fields
with equal weighting to all three beams. The anterior side of the PTV is still lacking dose coverage superiorly and inferiorly.
There are high dose (over 105%) leakage on both the left and right lateral sides close to the skin surface given that the lowest
beam energy, 6MV, was used. The 80% isodose line is now covering the PTV entirely. Coverage of 90% isodose line has also
improved to cover most of the PTV. The dose max has reduced significantly to 115.6%. Hot spots over 110% are in the
posterior side where the PA beam converges with the lateral fields. The dose distribution of Plan 3 is shown in Figure 3.
 Where is the hot spot and what is it?
The global maximum dose is just outside of the right posterior region of the PTV and it is 115.6%.
 What do you think creates the hot spot in this location?
The hot spot is in the posterior side where the PA beam converges with the lateral fields. With equal weighting of the lateral
beams, I expected it to be more along the central axis. However, the hot spot is more towards the right side and that could
be because the patient is wider on the left side compared to the right side as shown in the CT dataset. Thus the beam is
attenuated more from the left side as it travels through more soft tissue, muscle, and bone etc., and the hot spot is on the
side with less beam attenuation (right).
Figure 3: Plan 3 Screenshot
Plan 4: Change the 2 lateral fields to a higher energy and calculate the dose.
 Describe the impact on the isodose distribution.
There is no more 105% dose leakage out of the PTV on the lateral sides of the patient's body with higher energy beams,
15MV; some 80%-90% isodose lines still exist near the skin surface laterally. The 100% isodose line is covering more of the
PTV compared to previous plans, but coverage is lacking anteriorly, superiorly, and inferiorly. Hot spots over 110% are in the
posterior side. The dose distribution is shown in Figure 4.
 Where is the hot spot and what is it?
The global maximum dose is around the same location as Plan 3—right posterior side—and it is 116.2%.
 What do you think creates the hot spot in this location?
Since the plan is similar to Plan 3 except the lateral fields are now at a higher energy (15MV), the reason is the same as Plan
3: the hot spot is in a location where the PA beam converges with the right lateral field as the patient's body is thinner on the
right side which results in less beam attenuation and higher hot spot compared to the left lateral field.
Figure 4: Plan 4 Screenshots
Plan 5: Increase the energy of the PA beam and calculate the dose.
 What change do you see?
Overall, the plan is less hot compared to Plan 4 with a dose max at 114.5%. The 100% isodose line has moved forward
anteriorly with 90% isodose line covering the PTV. Coverage is still lacking superiorly and inferiorly. Horns on the isodose
lines in the axial view were a result of the PA beam in a higher energy. The isodose distribution of Plan 5 is shown in Figure 5.
 Where is the hot spot and what is it?
The global maximum dose is at the same location as Plan 3 and Plan 4 just outside of the PTV in the right posterior side and it
is 114.5%.
 What do you think creates the hot spot in this location?
For the same reasons at Plan 3 and Plan 4, the hot spot is at the right posterior side near the PTV where the PA and right
lateral beams converge in which the right lateral beam is attenuated less and hence more hot spot compared to the left
lateral beam.
Figure 5: Plan 5 Screenshot

Plan 6: Add the lowest angle wedge to the two lateral beams.
 What direction did you place the wedge and why?
I rotated the collimator 90° for the two lateral fields so the toes of the wedges point towards the anterior side and heels
towards the posterior side. In this setting, the dose is pushed away from the posterior side where it is hot and towards the
anterior side to cover where the PTV is missing coverage. The lowest angle wedge, 10°, was used for the two lateral beams as
instructed in the directions of Plan 6.
 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..)
The 100% isodose line is now covering more of the PTV with two horns within the PTV. Dose decreased with a dose max at
111.8%. However, there is a tiny bit ~ two CT slices of 95% isodose line leaking on the right lateral side. MU has increased
with addition of wedges. The isodose distribution with wedges is shown in Figure 6.
 Where is the hot spot and what is it?
The global maximum dose is near the right posterior side of the PTV and it is 111.8%.
 What do you think creates the hot spot in this location?
Since only the lowest wedge angle was added to the two lateral beams for a large PTV and the beam weighting was not
adjusted, the hot spot is in the same location as the previous plan. The hot spot is created where the PA beam converges
with the right lateral beam. There is less attenuation in the right lateral beam compared to the left lateral beam converging
with the PA beam.
Figure 6: Plan 6 with Wedges (Axial)
Plan 7: 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). You may weight your fields to get a better dose distribution.
 What final wedge angles and weighting did you use?
I ended up using 30° wedge angles on both lateral beams. I started with 45° wedge angle just to see how the isodose
distribution looks (rule of thumb: Wedge Angle = 90° - (Hinge Angle / 2); however, the 45°wedge angle was too high and the
100% isodose line moved anteriorly almost half way. I then started to add thicker wedges from 10° to 60° by changing the
same wedge angles on both lateral beams.
Final beam weighting:
PA: 39.6%
Lt Lat: 30.1%
Rt Lat: 30.3%
 How did each change affect the isodose distribution?
The isodose distribution is more homogenous compared to the previous plans after adjusting the wedge angles and beam
weighting. The middle section of the PTV is now covered entirely by the 100% isodose line. There are no isodose lines over
110%—the dose max is at 108.3%. The PTV coverage is missing 100% isodose line superiorly and inferiorly with the 90%
isodose line is covering the PTV. The isodose distribution is shown in Figure 7.
 Where is the hot spot and what is it?
The hot spot is around the same location in the right posterior side as Plan 6 just outside of the PTV and it is 108.3%.
 What do you think creates the hot spot in this location?
For the same reasons as the previous plans, the hot spot is where the beams converge. I did try to weigh the right lateral
beam less than left lateral beam to try to move the hot spot more centrally located within PTV. However, the hot spot just
moved over to the left side where the PA beam converges with the left lateral beam instead of the right lateral beam, which
is expected.
Figure 7: Plan 7 Screenshot
Plan 8: Copy and oppose the PA field to create an AP field and adjust the collimators to keep a 0.5 cm margin around the PTV. Keep
the lateral field arrangement. Remove any wedges that may have been used. Calculate the four fields and weight them equally.
Adjust the weighting of the fields, determine which energy to use on each field, and, if wedges will be used, determine which angle
is best. Evaluate your plan in every slice throughout your planning volume. Discuss your plan with your preceptor and adjust it
based on their input. Normalize your final plan so that 95% of the PTV is receiving 100% of the dose.
 What energy(ies) did you decide on and why?
I decided to use 15MV on all four beams so the plan is more conformal and homogenous compared to lower energy beams.
The PTV is large and centrally located within the body. With higher energy, the beam has greater penetration and is more
skin sparing.
 What is the final weighting of your plan?
AP: 26.9%
PA: 23.4%
Rt Lat: 26.5%
Lt Lat: 26.9%
This final weighting provides the best coverage and pushed dose away from the rectum, which is my main OAR to constraint.
 Did you use wedges? Why or why not?
No; there are four beams in this field and coverage is missing both superiorly and inferiorly hence it is contraindicative to add
wedges to improve coverage superiorly/inferiorly as either will become even more cold than what it is.
 Where is the region of maximum dose (“hot spot”) and what is it?
The global maximum dose is at the left anterior section of the PTV and it is 109.9%
 What do you think caused the hot spot in this location?
The location of the hot spot is a result of the four-field box technique and my final beam weighting with the AP field more
than the PA field and the left lateral field more than the right lateral field.
 What is the purpose of normalizing plans?
The purpose of normalizing plans is to achieve the most optimal PTV coverage with minimal hot spots and create the most
conformal and homogenous plan by making the plan either hotter or colder as a whole.
 What impact did you see after normalization? Why?
Coverage increased to cover the PTV superiorly and inferiorly. The dose max went up from 108% to 109.9%. By normalizing
the plan so 95% of the PTV is receiving 100% of the prescription dose, the treatment planning system increased the amount
of MUs and made the plan hotter as a whole to cover the lack of coverage before.
 Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and coronal views. Show the PTV and any
OAR’s.
After discussing my plan with my preceptor, I have increased the margins around the PTV from 0.5cm all around to 0.7cm on
the lateral sides and 1cm on the superior/inferior sides. This was done to improve PTV coverage as the PTV is large and the
beam energy is high. 1cm margins were used for superior/inferior sides as coverage was missing more superiorly/inferiorly
compared to the lateral sides. My clinical preceptor also suggested normalizing to a lower prescription dose (i.e. 98%) to
minimize the extensive 105% in this plan; (this plan was normalized to 95% of the PTV covered by 100% of prescription dose
as per instructions). The isodose distributions in the axial, sagittal, and coronal views are shown in Figures 8, 9, 10
respectively.
Figure 8: Plan 8 Axial
Figure 9: Plan 8 Coronal
Figure 10: Plan 8 Sagittal
 Include a final DVH. Be sure to include clear labels on each image.
 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.
The OAR constraints in this plan were only met for the bowel space (just at the constraint limit) and femurs. This is due to the
large overlap of bowel bag, bladder, and rectum with the PTV prescribed to 45Gy. Generally, at my clinic, VMAT is used for a
pelvis case such as this to be able to deliver high dose to the PTV while minimizing dose to the surrounding OARs by modulating
the MLCs around the PTV and setting upper objectives (max dose) to limit high dose to structures overlapping with the PTV as
much as possible.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome Met/Not Met
Bladder V45Gy < 35% V45Gy < 91% Not Met
Bowel Space V40Gy < 30% V40Gy < 30% Met
Femurs V30Gy < 15% Lt: V30Gy < 12% Met
Rt: V30Gy < 13%
Sum: V30Gy < 14%
Rectum V30Gy < 60% V30Gy < 93% Not Met
RTOG Protocol 0418