Taisa Polishchuk

DOS 771 Clinical Practicum I - Lab 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).
Calculations were performed on the 21EX with the lowest energy
6MV and second energy 18MV. The patient was treated prone in
attempt to eliminate the radiation dose to the small bowel and
colon. The calculation point was at the isocenter, which was in the
center of the PTV.
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
Femoral Heads

Desired objective(s)
<52 Gy

Achieved objective(s)
46 Gy

Bladder

<65 Gy

46 Gy

Colon

<45 Gy

Small Bowel

<40-45 Gy
V45Gy<195 cc
(Quantec)

Max 4606cGy,Mean
1246cGy
V45Gy<26cc
V45Gy<33 cc

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.
Utilization of 6MV beam on just one PA field did not provide a
good coverage. CTV was covered by 91% isodose line, while
PTV was only covered by 70%. The hot spot of 123% was on
the most posterior and superior part of the patients back.
I knew that prescribing the dose to 95% and calculating it to
the point (isocenter) will not give me as good of the coverage
as calculating it to the max dose. When calculating to the
point, the dose gets pushed towards that particular point we
pick and therefore our hot spot will be very high.

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

Changing to 18MV energy, the dose coverage wasnt much

better when comparing to the 6MV energy. CTV was covered by
the 89% line and PTV remained the same with the 70% line
coverage. There was a decrease in the hot spot (114%) and no
change to its location (still posterior). In addition there was a
higher exit dose to the small bowel and colon.
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.
Three fields used with 6MV energy and equally weighted. CTV
was covered by 90%, while PTV by 73%. The hot spot was still
posterior and went back up to 123%. The dose to anterior
structures, such as small bowel and colon decreased, however
there was a dose to the femoral heads now due to utilization of
the lateral fields with equal weighting.

d. Change the 2 lateral fields to a higher energy and calculate. How did
this change the dose distribution?
By changing 2 of lateral fields to 18MV energy I noticed the
decrease to the dose to the femoral heads. Since 18MV can
penetrate deeper and its dmax is higher than 6MV (6MV dmax
is 1.5 cm, and 18MV dmax is 3.5 cm), the concentration of the
dose is further away from the surface versus using 6MV.
Overall, the coverage got better, CTV was covered by 97% and
PTV by 81%. The hot spot decreased to 116%.

e. Increase the energy of the PA beam and calculate. What change do you
see?
By using 18MV on the PA the overall coverage remained pretty
much the same (CTV dose covered by 97% and PTV by 82%),
however the dose to small bowel increased. The dose to all
other critical structures remained the same. The hot spot
decreased to 112% compared to the previous plan.
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..)
f(a). The lowest available wedge angle in my clinic is 15 degree
wedge. I placed the wedge with the heel towards posterior of
patient in order to decrease the hot spot I was getting on the
posterior aspect in all of the previous plans. CTV was covered
by 99% and PTV by 92%, with the hot spot of 108%. The
isodose distribution got better but I could tell that the hot spot
can be pushed down more by increasing the angle of the
wedge and attenuating the beam even more.

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?
f(b). Increasing the wedge angle to 30 degrees gave me better
coverage (CTV - 100%, PTV 98%, with the hot spot of 106%).
f(c). By using 45 degree wedge I was able to achieve almost
perfect coverage (CTV -100%, and PTV 99%, with the
decrease of the hot spot to 105%). The hot spot moved
anteriorly towards my PTV structure due to the correct angle
of the wedge used.
f(d). Using 60 degree wedge clearly showed the over-wedged
effect. I lost my coverage posteriorly and my hot spot of 113%
moved from the PA to the most anterior aspect of the field.
This significantly increased the dose to the bowel. In addition
97% covered CTV, while only 84% covered PTV.

g. 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.
I decided to use 6MV for the PA field and 18MV for the laterals
with the 45 degree wedge. I knew that by using lower energy
on the PA I can minimize the dose to colon and small bowel. I
weighted PA 30%, and added extra on the laterals, 35% on
each. Both of the CTV and PTV were covered by 100% when
prescribed to 95%, and the hot spot stayed low of 105%. I was
able to achieve the dose constrains to almost all of the critical
structures. I struggled with achieving the desired objective for
the colon since most of it was in the field. My objective was to
stay under 45Gy and according to the DVH only 26cc received
45Gy. My max dose to colon was 4606 cGy instead of 4500 cGy,
and the mean was 1248 cGy. Overall this was the best plan
possible since I could only utilize wedges and no step and
shoot technique, where I could have achieved a more
conformal plan.
h. 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 shaded red structure is the CTV, and the brown shaded
structure is the expansion of the CTV PTV. The red isodose line
represents 95% of prescribed dose to cover the PTV.

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?
By utilizing 4-field technique instead of 3-field there is an increase
to small bowel and colon. There is a decrease to the femoral heads
because the weight of the dose is equally distributed among the 4
fields instead of the 3. The coverage was good even though I didnt
have to use the wedges on the lateral fields. The coverage was
achieved by bringing the 4th field in, however I would not use this
plan due to the increase of the dose to some of my critical
structures as I mentioned above.