3-­‐FIELD PRONE

PELVIS VS 4-­‐FIELD
PRONE PELVIS
About my patient:
■ Gender: Male
■ Age: 41 at the time of treatment
■ Diagnosis: adenocarcinoma of the rectum with
metastasis to his liver and lung
■ Stage: 4
■ Treated at the James on V2 in December 2017
Critical Structures
■ Small bowel – 4000 cGy
■ Bladder – 6500 cGy
■ Femoral Heads - 5200 cGy
Immobilization:
■ Prone
■ Belly Board indexed on table with board number
■ Hands above head grasping bar
■ Head face down on head rest (indexed)
■ Ankle sponge (unindexed)
Belly Board
Advantages:
■ Less dose to the bladder
■ Less dose to small bowel
■ Board number to help with
positioning the patient
Disadvantages:
■ Harder position to reproduce
■ Sometimes more uncomfortable for
the patient
■ Depending on the patient, if the
patient is not positioned exactly the
same way it can actually push the
bladder up into the treatment area
3 Field Prone Pelvis
■ 100 SAD: PA/ R LAT/ L LAT
■ 180 cGy for 25 fractions
■ Giving a total dose of 4500 cGy
■ Energies:
– 10 MV for the PA field
– 15 MV for the two lateral fields
■ Normalized – 98.7%
– This is because we are re-normalizing the
plan so that 95% of the PTV is getting our
prescription dose; if we didn’t then we
could potentially be under-dosing the tumor
 With weighting

3 Field Prone Pelvis

What weighting was used? Why?
■ PA – 41%
■ R LAT – 25.9%
■ L LAT – 25.9%
Without weighting
■ Weighting was used to get more of the boxed shaped
With weighting Without weighting
3 Field Prone Pelvis
Why are wedges used on the laterals?
■ R LAT – 45 degree wedge (EDW45IN)
■ L LAT – 45 degree wedge (EDW45OUT)
– 45 or 60 degree wedges are
commonly used for a 3 field prone
pelvis patients on the laterals
– This is to avoid hot spots with the
PA beam
■ PA – 10 degree wedge (EDW10OUT)
– This isn’t very common; one was
needed for this patient because of
the shape
3 Field Prone Pelvis
What is the shape of the isodose curves?
■ Square isodose curves
■ Max for PTV – 105.1% or 4730 cGy
■ Min for PTV – 93.7% or 4216 cGy
3 Field Prone Pelvis
MU on each field:
■ PA – 84 MU
■ L LAT – 95 MU
■ R LAT – 95 MU

■ More MU on the lateral fields because of the more tissue you have to
go through
4 Field Prone Pelvis
■ 100 SAD: PA/ AP/ R LAT/ L LAT
■ 180 cGy for 25 fractions
■ Giving a total dose of 4500 cGy
■ Energies:
– 10 MV for the PA field
– 15 MV for the AP field and the two lateral fields
■ Normalized: 98.9%
– This is because we are re-normalizing the plan so that 95% of the PTV is
getting our prescription dose; if we didn’t then we could potentially be under-
dosing the tumor
 With weighting

4 Field Prone Pelvis

What weighting was used? Why?
■ AP – 28.5%
■ PA – 21.5%
■ R LAT – 25%
■ L LAT – 25% Without weighting
■ Weighting was used to get more of a boxed shape.
■ In this case, the patient has a large stomach and
more tissue to pass through so the AP beam
needs more MU’s pushed through it in order to
get the same amount of dose to our isocenter.
4 Field Prone Pelvis
What wedges are used in this plan? Why?
■ Only one wedge used on the AP field
– EDW20IN
■ This was used to account for the difference in thickness of the patient’s body
4 Field Prone Pelvis
What is the shape of the isodose curves?
■ Square isodose curves
■ Max to PTV – 104.4% or 4697 cGy
■ Min to PTV – 92.3% or 4152 cGy
4 Field Prone Pelvis
MU on each field:
■ PA – 41 MU
■ AP – 78 MU
■ L LAT – 61 MU
■ R LAT – 61 MU

■ More MU on the lateral fields and AP field because you have more tissue to go
through
DVH – Dose Volume Histogram
4- field
3- field

Bladder
PTV 45
Small Bowel

3 Field Mean Dose Max Dose 4 Field Mean Dose Max Dose
Small Bowel 465.8 cGy 3988.5 cGy Small Bowel 795.3 cGy 3582.4 cGy
Bladder 2604.1 cGy 4695.9 cGy Bladder 3344.2 cGy 4671.1 cGy
PTV 45 4730.5 cGy PTV 45 4697.2 cGy
Which plan is better?
3-Field Prone Pelvis
■ Advantages:
– Less dose to small bowel
– Less dose to bladder
– Less integral dose
■ Disadvantages:
– Harder to set up and position
patient on the belly board
– Patient comfort
4-Field Prone Pelvis
■ Advantages:
– Can be better for patients with
‘weird’ contours
■ Disadvantages:
– More dose to bladder
– More dose to small bowel
– Harder to set up and position
patient on the belly board
– Patient comfort
My Overall Opinion: