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Cinira Johnson
January 27, 2014
Planning Assignment (Brain)

Target organs or tissue being treated: Whole Brain
Prescription: 250cGy in 10 Fractions using 6MV photons energy.
Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below):

Organs at risk Desired objective(s) Achieved objective(s)

Lens and globes
Treat the brain. Lens and
globes are contoured for dose
documentation purposes not as
dose limiting structures.

Cribriform plate region was
not blocked or under dosed.

Plan 1a - The 100% isodose line is uniform across the brain.
1b - Hot spot is the area that receives more than 100% of the dose. Equally weighted beam will
produce 2 hot spots: one at the frontal bone region and the other one at the occipital bone region.
The reason there are hot spots in this areas is because they are the thinnest portion of the brain
area treated.

Plan 2a - Adjusting the weight changes the placement of the hot spot towards the more heavily
weighted beam. I used 1700/1300 cGy.
2b The isodose coverage changed. The hot spot moved toward the more heavily weighted
beam. This change also created a bulge of the 95% isodose line in the side of the lesser weighted
beam. Hotter on the side of the heavier weighted beam and cooler on the side of less weighted
beam.

Plan 3 Whole brains at University of Colorado Hospital are done mostly at an Elekta Synergy
machine with fixed jaws. The field size is a limiting factor for this machine. We use a
collimation rotation technique for whole brains to accommodate the field size limitation.
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3.1 The heel of the wedges were placed towards the head and toes towards the feet of the
patient. I first used 30 and 60 degrees wedges. These wedges moved and increased the size of the
hot spots to the inferior part of the field. It did get rid of the hot spot anteriorly because the heel
of the wedge is over that area. I got a good uniform 100% isodose line superiorly but inferior I
got a larger hot spot area compared to the equally weighted treatment plan described on plan 1.
3.2 The dose distribution was most evenly distributed when using a 7 degree angled wedge.
Both hot stops decreased in size and the 100% isodose line was more uniform across the brain
compared to plan 1.

4 The technique used to treat a whole brain at UCH will depend on the machine that will be
used to treat the patient. As said before, our Elekta Synergy machine is limited in size so a
collimation rotation technique is used. For the Varian True Beam machines some doctors will
use the half-beam blocking with an off-axis prescription point.
4a Collimation rotation technique is used when there is a machine limitation in field size. The
half-beam blocking technique with placement of the isocenter inferiorly, is done in cases where
there will be a need for a future spine treatment for better matching field purposes. Here at UCH,
for pediatric whole brain we also use field within field technique.
The anterior oblique technique is used to spare lens and globes.
4b In my opinion, the plan that looks the best with smaller hot spots and more uniform 100%
isodose line was the plan with the 7 degree wedge. But here at UCH most plans are done with a
collimation rotation and no wedges.

Which treatment plan covers the target the best? What is the hot spot for that
plan?
The treatment plan that covers the target the best is the 7 degree wedged plan, because the
100% isodose line coverage is more uniform across the brain while having the smallest hot
spot compared to the other plans. The hot spot is located anteriorly in the frontal bone region
and posteriorly on the occipital bone region.

Did you achieve the OR constraints as listed on page 1? List them in the table.
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As mentioned earlier, the organ at risk would be the lens and the globes, here at UCH these
ORs are not dose limiting factors. They are only contoured for documentation purposes.

What did you learn from this planning assignment?
I have learned:
1 To put wedges in the field and how to manipulate the different wedge angles to change the
hot spot;
2 How to manipulate the field weights to change the isodose lines.
3 Be aware of the ORs.
4 Different techniques to treat a whole brain.
5 What an optimum dose distribution looks like in a whole brain treatment plan.

What will you do differently next time?
Next time, I will take my time and try to be more open to different ways to plan. I will try
different techniques such as using wedges, changing the weight of the beams and half-beam
blocking. I will be more creative with my plans.