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 Desired objective(s)* Achieved objective(s)

Max 5000cGy Max point 4459 cGy
Bowel 4000cGy to < 150 mL 1252 cGy to 150 mL

Bladder <45% to 6000 cGy Max point 2337 cGy

Right Femur Max 4500 cGy Max 4428 cGy

30% <3600 cGy 30% to 3298 cGy
Left Femur Max 4500 cGy Max 4399 cGy
30% <3600 cGy 30% to 3288 cGy
*Objectives are physician provided and/or QUANTEC values.

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 distribution
appears to be similar to the standard appearance of an unmodified
single beam isodose chart. The PTV is fully encompassed by the 95%
isodose line due to normalization. The hotpsot is towards the posterior
surface and is approx. 1.4 cm deep. This is about what expected as it
is very close to Dmax for a 6MV beam. The hot spot itself measures at
159.8% though, meaning that this single field plan is insufficient for
treatment.
 Image 1: Isodose distribution for a single PA beam of 6MV energy.
Normalization of 100% volume to 95% isodose line.

b. Change to a higher energy and calculate the beam. How did your
isodose distribution change? I used a 10MV energy for the next beam.
At first glance, the isodose for the higher energy isodose beam does
not look that different. Each isodose line extends only slightly
shallower than with the 6MV energy. The hotspot dropped to 143.8%
strictly by the change in energy though. The hotspot is about 2cm
deep falling in line with my expectations for Dmax of a 10MV beam.

Image 2: Isodose distribution for a single PA beam of 10MV energy.

Normalization of 100% volume to 95% isodose line.
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. I used 6MV energy for all 3 of
these beams. The 3 fields have created a box surrounding the PTV
where the 3 beams intersect. There are hotpots at the entrances to
the 2 lateral beams and in the posterior half of the box created by the
3 intersecting beams. The hotspot has now dropped down 119.5%.
There is a slight imbalance to these equally weighted fields because
there is slightly more hotspot at the right entrance compared to the
left entrance.

Image 3: Isodose distribution for parallel opposed lateral beams and a

PA beam. All beams are 6MV energy. Normalization of 100% volume
to 95% isodose line.

d. Change the 2 lateral fields to a higher energy and calculate. How did
this change the dose distribution? The PA beam is 6MV energy and the
2 lateral beams are 18MV energy. By increasing the energy on the
lateral beams we have eliminated the lateral hotspots that were
present on the prior example. The hotspot area is still in the posterior
of the box created by the intersecting beams but the overall hotspot
has now dropped to 114.7%. It is interesting to see that the isodose
line extending out into bladder and bowel has decreased as well. This
is telling me that the PA beam is not having to push as much dose to
meet the 95% normalization value we are forcing. Although it is not
shown on the image, there was a noticeable decrease in monitor units
to support this.
 Image 4: Isodose distribution for 18MV parallel opposed laterals and
6MV posterior beam. Normalization of 100% volume to 95% isodose
line.

e. Increase the energy of the PA beam and calculate. What change do you
see? This was performed using 18MV lateral beams and 10MV PA
beam. The overall hotspot has continued to lower and is now 113.5%.
The hot area in the posterior box created by the intersecting beams
has started to break up on this slice and is starting to bow in
resembling a bowtie on other slices. We can see that the 80% isodose
on the lateral fields has now broken up as well. The 30% isodose
extends into the bladder and bowel slightly more due to the higher
energy of the posterior beam.
 Image 4: Isodose distribution for 18MV parallel opposed laterals and
10MV posterior beam. Normalization of 100% volume to 95% isodose
line.

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 placed 15 degree wedges with the heel oriented to the patients
posterior. I chose to put them in this way because the hottest area of
the three intersecting beams is posterior and this orientation will help
to cool off the posterior portion of the box created by the 3 intersecting
beams. The 110% plus hotspot has been completely eliminated and
now the hotspot is 108.8%. It is still located in the posterior of the box.
The 30% isodose line has extended into the bladder and bowel more as
well. There was also about a 20% increase in monitor units on both
lateral fields.

Image 4: Isodose distribution for 18MV parallel opposed laterals with

15 degree wedge and 10MV posterior beam. Normalization of 100%
volume to 95% isodose line.

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?
The 30 degree wedges eliminated the entire 105% isodose line and
continued to add a more pronounced bowtie effect to the 100%
isodose line. The 45 degree wedges moved the hotter area of the field
to the anterior area of the box created by the intersecting beams.
These 45 degree edges increased the hotspot back up to about 114%.
The 60 degree wedges added more hot areas to the anterior portion of
the field and we start to see higher dose creeping back out to the
lateral surfaces as well.

Image 5: 30 degree lateral wedges, heel posterior.

 Image 6: 45 degree wedges, heel posterior.

Image 7: 60 degree wedges, heel posterior.

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 evaluating my options and how they affected my isodose
distribution, I decided on the plan shown below in Image 8. I used a
6MV energy PA beam with 18MV opposed lateral beams. I used 45
degree wedges with the heels oriented to the posterior of the patient.
With the 100% coverage by 95% dose normalization imposed, my
maximum hotspot is 100.3% and is basically a spec of dose that is
slightly to the left of the PTV. My field weighting is 41.5% PA, 29.0% Rt
Lat, and 29.5% Lt Lat. This is the plan I showed my clinical preceptor
and we discussed. The discussion I had was very interesting because I
learned that I could argue for several plans using different variations of
wedging and posterior beam weighting. In fact, we were able to
achieve fairly equivalent plans using 30, 45, and 60 degree wedges.
The difference is that the weighting either forced more dose into the
anterior bladder and bowel or out towards the lateral tissues. Overall, I
feel the plan with the 45 degree wedges offered the best balance. I
now see how I could use wedges and weighting to tailor isodose
distribution to meet specific goals though.

Image 8: Axial cut from Final Plan

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.
 Image 9: Transvers, Coronal and Sagittal image of isocenter for the
final plan. Image also shows correct prescription and normalization.

Image 10: Dose Volume Histogram for Final Plan.

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? Some
advantages of the 4 field plan include lower overall dose outside of the box
created by the intersecting beams and an easier plan to deliver for the
therapists because they do not have to go in and place hard wedges. This
could also be achieved by using dynamic wedges in place of hard wedges
though so is not of huge consideration. Some disadvantages of the 4 field
plan include extra dose to the anterior organs such as bladder and bowel.
The hotspot is about equivalent to my 3 field plan and can reach as low as
99.3% with proper weighting. It is important to recognize that both 3 field
and 4 field plans can be reasonably used for many situations. Knowledge of
the patients case and the physicians goals can ultimately help me decide
which plan is best for the given situation.

Image 10: 4 field plan with equal field weighting.