Kevin Dwyer

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
Bladder

Desired objective(s)
Mean < 40Gy

Achieved objective(s)
Mean = 18.6 Gy

Bowel

V35Gy <150cm3 Max

<50
V45Gy <35cm3
V30Gy < 50% V40Gy <
40%
V45 < 5%
V20Gy <50% V30Gy <
35%
V40 Gy < 35%

Max = 13.5Gy

Femoral Heads

Genitalia

V30Gy=49.7% V40Gy =
2.8%
V45Gy < 1%
Max = 11 Gy

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 isodose lines are shaped with what I would call a double hump
parabola (very non-techinical). It is better shown described by viewing
the screen shot below. There are many hot spots near the posterior
surface.

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

The isodose lines have the same general shape. However, they
penetrate more deep into the patient and the hot spot is less.

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.
Dose distributions are symmetrical on right and left sides. The two
lateral fields do not penetrate deep enough to greatly influence dose
from the PA beam, but they do have a minor affect. The PA beam no
longer has such a high posterior hot spot. The hot spot is now coming
from the left side beam.

d. Change the 2 lateral fields to a higher energy and calculate. How did
this change the dose distribution?
The dose distribution is spread more centrally around the PTV The
lateral hot spots are now around 100% in some spots instead of
127%.Hot spots are posterior to the PTV.

e. Increase the energy of the PA beam and calculate. What change do you
see?
The dose distribution is spread more centrally around the PTV. The 105
isodose line is centered toward the posterior of the PTV. Hotspots in
same location, but not as high.

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..)
I chose the wedge for each beam so that the heel was toward the
posterior of the patient. This seemed to pull the dose more anterior like
I was hoping, but also created a 100% lateral isodose line near the left
side of the patient.

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?
60 degree wedge: way too hot

30 degree wedge: Hot spots too lateral

20 Degree wedge: Dose not as well distributed across PTV as 10 degree, but
not as hot.

15 Degree wedge:

25 Degree wedge: Out of all of them I think I like this distribution the best,
but am unsure any of them are appropriate.

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.
After talking my plan over with Pete (preceptor) we changed a few
things to my original plan. I had an equal weighting of 28% for both
lateral beams with a 30 degree wedge (heel to posterior) and 46%
weighting for the PA beam for this patient. The dose was also
normalized so 95% dose covered 100% of the volume. Pete and I
looked at45 degree wedges and decided that they were a better fit. We
also normalized dose to DPV_Rec reference point, which I had placed at
the center of the rectum. We changed the weighting to be a bit heavier
on the right side to take away dose from the superficial hot spot on the
left lateral side. on the next page is a few screenshots of my plan. Pete
also caught a few things that would be helpful for therapist. When
setting my collimator the right side was at 270 and the left at 90

degrees. I should have kept the same angle of the collimator to save
the therapist from moving the collimator. Also my fields were different
sizes as well for the opposed beams, but they should have been
symmetrical.
Once Pete went back to work and I began to re-evaluate the DVH, I noticed
that the plan did not meet the required constraints for ORs (particularly the
femoral heads). Pete told me that when treating through without MLCs, using
another angle, or another field, a high dose to the femoral heads should be
expected. I went through and modified the plan. 96% dose to 95% volume
normalization with weighting PA 1.386 and LO/RO .806. I also used 30 degree
wedges to help pull dose away from the femoral heads. In the next section
are some screen shots of my plans.
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.
Pete + Me

Me adjusted:

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?

Dose is more symmetrically shaped. There is less of a posterior hot spot and
better coverage anteriorly. These are favorable changes, but some possible
disadvantages are the increased dose to normal tissue volume. Also there
will be an increase in dose to the genitalia since the beam will be passing
directly through it. The bowel will also receive some more dose. A screen
shot is on the next page.