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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 Bowel

Desired objective(s)
45gy 25%

Achieved objective(s)
0.5%

Bladder

65gy 50%
40gy 25%

0%
32%

Femoral Head

40gy 40%
45gy 25%

RT. 0% LT. 0%
RT. 0% LT. 0%

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.

Figure 1

As figure one shows, the 100% line covers all of the GTVwith the exception of the most anterior
aspect. Much more of the PTV is not covered by the 100% line. The reason being is the
normalization was set so 95% of the PTV is covered by the 100% line. Theoretically, figure one
should show that 5% of the PTV is not within the 100% line. The reason the GTV coverage is
better is it falls in the center of the PTV because margin was added equally to the GTV. So in
most cases the GTV should have better coverage then the PTV when the PTV is used for plan
normalization.
The hot spot is located posteriorly because thats where the beam is coming from. In order to
push the dose from a single beam to cover the anterior aspect of the PTV, a hot spot of 153.1%
occurs. It should be close to the point of Dmax for 6MV energy.
b. Change to a higher energy and calculate the beam. How did
your isodose distribution change?

Figure 2

After changing the energy to 16MV, the isodose lines are very similar to the 6MV beam with
some exceptions. Because the plan is still normalized to cover 95% of the PTV with 100% dose,
the 100% line and 98% line are almost in the same position. However the distance between the
isodose lines have increased due to the fact that the higher energy beam does not attenuate as
quickly as the lower energy. Therefore, the dose travels father into the patient before being
deposited. Also, the higher energy beam has a lower hot spot of 134.4% because not as much
dose is required to push the 100% line to the anterior aspect of the PTV. The hotspot is deeper
because the higher energy has a greater Dmax distance.
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.

Figure 3

After adding laterals, the hotspot was lowered to 125% because some of the dose is coming from
the laterals and a less dose is required to come from the posterior aspect of the patient. Again,
because the normalization values are set to cover 95% the PTV the same anterior portion of the
PTV is being missed by the 100% line. There is some substantial dose at the lateral aspects of the
patient because of the longer depth required to get the dose to the center of the patient.
d. Change the 2 lateral fields to a higher energy and calculate.
How did this change the dose distribution?

Figure 4

The energy coming from the laterals really lowered the dose on the lateral aspects of the patient.
Figure 4 shows that the 100% lines that used to be lateral are completely eliminated by
increasing the energy of the laterals. The hotspot decreased significantly to 119.5%. As expected,
the hotspots location increased its depth because of the higher energy. Again the PTV and GTV
were covered about the same because of the plan normalization values.
e. Increase the energy of the PA beam and calculate. What
change do you see?

Figure 5

The hotspot decreased even more to 117.5% while maintaining the same dosemetric coverage of
the PTV. There is also a slight decrease of dose on the lateral aspects of the patient.
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..)

Figure 6

A 10 degree wedge was placed with the heel towards the patients posterior aspect. Figure 6
shows that the patients separation is smaller on the posterior aspect. Therefore, the heel side
(thicker portion) of the wedge was placed over the area of less tissue in order to compensate for
the difference of tissue. The wedges lowered the hotspot to 114.7% and maintained the same
coverage of the PTV. Also, note the 80% isodose line has shrunk substantially on the posterior
aspect of the patient due to the heel of the wedge.
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?
After trying a couple of different wedges, the findings are similar to the story of Goldilocks and
the Three Bears. The 30 wedge is too hot. The 60 wedge is to cold (posteriorly) and the 45
wedge is just right. Well, it was the best option anyway. The 30 degree wedge plan had a
substantially large hot spot in the posterior aspect of the patient, and the 100% line does not

cover the anterior aspect of the PTV as well as the 45 wedge plan. The hot spot for the 30 wedge
plan is 109.1%, the 60 wedge plan is 122% and the 45 wedge plan is 108.4%. So, the 45 wedge
plan has better coverage and a slightly lower hot spot so the 30 wedge plan is ruled out. The 60
wedge plan has a large 110% line because the heel is so thick that in order to push dose through
the heel to cover the posterior PTV the anterior portion (toe of wedge) is extremely warm. The
60 wedge is over compensating for the difference in separation. Figure7 shows the 45 wedge
plan.

Figure 7

The 45 wedge plan has the best coverage without being too warm.
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 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.
The 45 wedge plan was used to get started. The weighting of the three fields was adjusted until
the optimal weighting was found. The optimal weighting settings are: PA a weighting of 1.23,
and laterals a weighting of 0.88 each. The wedges were taken off to see if weighting by itself

without the use of wedges would be a viable option but it was not. Without the wedges, the
posterior aspect of the field was way too hot. So 45 degree wedges were placed back on the plan.
Next, the PA field energy was changed from 16mv to 6mv. The 6mv PA plan is a little warmer
and the inferior portion of the PTV is not covered as well as the 16mv plan. Figure 8 shows the
DVH of both plans. After talking to the department dosimetrist, it was decided that the 6mv PA
treatment plan is the better plan because the dose to the bladder is smaller because the exit dose
with the PA 6mv beam is lower.

Figure 8

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.
The DVH for the final plan is shown above, indicated by the triangle lines. Figures 9-11 are
snapshots of the final plan. The table at the beginning of this paper shows that all dose
constraints were met.

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Figure 9

Figure 10

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Figure 11

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?
One advantage of adding the fourth field is that usually the anterior portion of the patient has a
smaller separation than the lateral aspect. So when an anterior field is used there is a lot less
integral dose deposited around the femoral heads and the lateral aspects of the patient. Figure 12
shows a four field treatment with equally weighted fields. Notice the nicely shaped box that
the 70 to 98 dose line form. The four fields create a nice evenly shaped dosemetric coverage of
the area.

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Figure 12

One disadvantage to adding an AP field to this treatment area is the increased dose
to the bladder. With just a PA field there is only the exit dose hitting the bladder. The
AP field that was added goes directly through bladder in order to deliver dose
posteriorly of the bladder. Figure 13 is a DVH comparing the three field wedge plan
with the four field plan. The square lines are correlated to the three field plan while
the triangle lines correlate with the four field plan.

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Figure 13

Notice how much more dose the bladder is getting with the four field plan than the three field
plan. In this particular plan, its not a huge deal because the prescribed dose to the PTV is only
45gy so the thresholds in the pelvis are easier to meet. As was mentioned previously, the femoral
heads receive less dose with the four field plan then the three field plan and it is evident on the
DVH. The PTV coverage is very similar with both plans.