Pelvis Clinical Lab Assignment

Shelby Hall

Prescription: 45 Gy in 25 Fractions to the PTV

Planning Directions: Place the isocenter in the center of the designated PTV (note: calculation
point will be at isocenter). Create a PA field with a 1 cm margin around the PTV. Use the lowest
beam energy available at your clinic. Apply the following changes (one at a time) as listed in
each plan exercise below. After adjusting each plan, answer the provided questions.

Plan 1: Calculate the single PA field.

 Describe the isodose distribution.
o The isodose distribution for a single 6MV PA field shows that the beam doesn’t
penetrate deep enough into the patient to get adequate coverage. Using a
single 6MV beam creates a really hot plan posteriorly, with the hottest being
near the skin surface, because the beam is pushing in dose in order to get 100%
of the dose to the isocenter. Once it reaches isocenter, the dose begins to fall
off. The isodose line I found that seems to encompass the PTV is the 60%
isodose line.
 Where is the hot spot and what is it? What do you think creates the hot spot in this
location?
o The overall hot spot in this field is located in the superior portion of the field,
about 1.37cm into the patient posteriorly. The overall hotspot of the plan is
171.3%. For a 6MV beam, the depth of maximum dose (dmax) is 1.5cm, which
is why the hot spot is located at that depth, close to the patient’s skin surface.
 Using your DVH, what percent of the PTV is receiving 100% of the dose?
o Only about 47.5% of the PTV is receiving 100% of the dose.
Plan 2: Change the PA field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed and why?
o When changing the PA to a 16MV beam, the isodose lines fan out more
towards the anterior surface, penetrating deeper into the patient. The higher
energy gives us a deeper dmax, therefore more penetrating power. The hot
spot in the plan also goes down.
 Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
o Only about 51.5% of the PTV is receiving 100%

Plan 3: Insert a left lateral field with a 1 cm margin around the PTV. Copy and oppose the left
lateral field 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 fields.
 Describe the isodose distribution. What change did you notice?
o When adding in two laterals, the isodose lines combine to start forming a ‘box’
around the PTV. This ‘box’ refers to the fields creating more dose uniformity
across the tumor volume. The higher, or hotter, isodose lines such as 105, 100,
95, 90, are at the entrance of the lateral beams on each side of the patient and
also starting to encompass the PTV. The higher doses being in normal tissue on
the patient’s sides can be due to the use of the lower energy, which is not ideal
and in this plan is a lot higher than you would want to treat. The 80% isodose
line seems to cover the PTV.
 Where is the hot spot and what is it? What do you think creates the hot spot in this
location?
o The hot spot is 113.2%, and it is located posteriorly. I think the hot spot is
located here because it is where the lateral fields merge with the PA field,
making the posterior aspect the hottest part of the field.
Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution.
o This change in energy impacts the dose distribution by getting rid of the hot
spots(or higher isodose lines) that were at the entrance of the lateral beams on
each side of the patient in the last plan. You can clearly see this change by
comparing the plan 3 image to the plan 4 image. Majority of the dose is now
going in the ‘box’ around the PTV, creating more dose uniformity. The 90%
isodose line is beginning to cover more of the PTV, but is still missing coverage
anteriorly.
 What are the benefits of using a multiple-field planning approach? (Refer to Kahn, 5th
ed, Ch 11.5B)
o The benefit of using a multiple-field planning approach, mainly 3 fields or
more, is being able to create dose uniformity across the tumor volume. This
dose uniformity also allows for a reduction of dose to, or sparing of, the normal
surrounding structures and tissues. Other strategies, such as beam weighting,
direction, use of modifiers, energy, etc., can be combined with multiple fields
to help create an even better dose distribution.
 Compared to your single field in plan 2, what percent of the PTV is now receiving 100%
of the prescription dose?
o Compared to the plan 2, 57.2% of the PTV is now receiving 100% of the
prescription dose.
Plan 5: Using your 3 high energy fields from plan 4, adjust the field weights until you are
satisfied with the isodose distribution.
 What was the final weighting choice for each field? What was your rationale behind
your final field weight?
o Given these fields, and only being able to adjust the field weights, it isn’t a plan
that I am overall ‘satisfied’ with. But under there circumstances, I choose to
weight my PA field 28%, and each lateral field equal at 36%. My rationale
behind this weighting was to try to cover the PTV by the 95% isodose line as
much as I could. By adding more weight to the laterals, I brought more dose
into the normal tissues on the patient’s sides, but was also able to pull the
dose more anteriorly to cover more of the PTV.

Plan 6: Insert a wedge on each lateral field. Continue to add thicker wedges on both lateral
fields until you are satisfied with your final isodose distribution. Note: When you replace a
wedge on the left, replace it with the same wedge angle on the right.
 What final wedge angle and orientation did you choose? To define the wedge
orientation, describe it in relation to the patient. (e.g., Heel towards anterior of patient,
heel towards head of patient..) How did the addition of wedges change the isodose
distribution?
o First, I changed the weighting from previous plan. I started with all equal
weighting, and increased the PA until the dose to the patient’s normal tissue
on each side had gone down. I ended up with the PA at 52%, and each lateral
field at 24%. This weighting kept the dose from being in the patient’s normal
tissues on the side, but is also hot posteriorly. From here I added wedges, and
the final angle and orientation I used was a 45-degree wedge on each side with
the heel towards the posterior of the patient. The addition of wedges was
effective in pushing the dose anteriorly and getting rid of some of the hotter
spots in the posterior aspect of the patient. Once the wedges were in, I
adjusted the weighting again so that the right lateral was 24.5% and the left
lateral was 23.5%. This slight adjustment was to make sure one side wasn’t
 significantly hotter than the other across the entire field. The isodose
distribution is now a lot more uniform across the PTV. In comparison, the hot
spot for this plan 107.8%, and 82% of the PTV is receiving 100% of the
prescribed dose.

 According to Kahn, what is the minimum distance a wedge or absorber should be placed
from the patient’s skin surface in order to keep the skin dose below 50% of the dmax?
(Refer to Kahn, 5th ed, Ch. 11.4)
o The minimum distance a wedge or absorber should be placed from the
patient’s skin surface is about 15cm.

Plan 7: Insert an AP field with a 1 cm margin around the PTV. Remove any wedges that may
have been used. Calculate the four fields. At your discretion, adjust the weighting and/or
energy of the fields, and, if wedges will be used, determine which angle is best. Normalize your
final plan so that 95% of the PTV is receiving 100% of the dose. Discuss your plan rationale
with your preceptor and adjust it based on their input.
 What energy(ies) did you decide on and why?
o I decided on 16MV energy for all fields because the target is deeper into the
patient and I want to spare the normal tissues where the fields enter as much I
can.
 What is the final weighting of your plan?
o The final weighting of my plan was the PA at 28.8%, the RLAT at 26.9%, the
LLAT at 24.6%, and the AP at 22.5%.
 Did you use wedges? Why or why not?
o I did not use wedges because with the AP field added, I only needed to adjust
the field weights to create a uniform dose distribution.
 Where is the region of maximum dose (“hot spot”) and what is it?
o The region of maximum dose is located posteriorly where the PA and the two
laterals merge. The hot spot is 107.9%
 What is the purpose of normalizing plans?
o Essentially normalizing to the isocenter (or a point), gives us a point to
calculate monitor units at based on the desired dose. From that point, we can
scale the dose up or down in order to get the desired coverage needed across
the plan.
 What impact did you see after normalization? Why?
o After normalizing by increasing the beam weights/monitor units so that 95% of
the PTV received 100% of the dose, the impact was an increase in dose
throughout the entire plan by about 2.7%.
 Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and
coronal views. Show the PTV and any OAR.
 Include a final DVH. Be sure to include clear labels on each image (refer to the Canvas
Clinical Lab module for clear expectations of how to format your DVH
  If you were treating this patient to 45 Gy, use the table below to list typical organs at
risk, critical planning objectives, and the achieved outcome. Please provide a reference
for your planning objectives.
o My planning objectives are based on one of this department’s planning
directives for a similar case using a similar prescription dose. Based on the
outcomes, one suggestion would be to see if having the patient fill their
bladder would reduce the dose to the bladder and bowel.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Bladder V45Gy[%]≤50% V45Gy = 89.9%
Rectum V50Gy[%]≤2% V50Gy=0%
Bowel V45Gy[cc]≤250cc V45Gy=280cc
Femoral Heads V30Gy[%]≤20% V30Gy=16%