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Lee Culp

Planning Assignment (Brain)

February 24, 2014
Target organ(s) or tissue being treated:
Prescription:____250cGy, 10 fractions --> 2500 cGy to 100% isoline________________
Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below):
Organ at risk Desired objective(s) Achieved objective(s)

Lt & Rt. lens

Cover whole brain while sparring

Yes to all.

Lt. & Rt. orbit

Lt. & Rt. lens, Lt. & Rt. orbit, Lt. &

Lt. & Rt. optic nerve

Rt. optic nerve

Contour all critical structures on the dataset. Place the isocenter in the center of the skull. Create a single Rt.
lateral plan using the lowest photon energy in your clinic. Refer to Bentel pp. 336-340 to add a block to the Rt.
Lateral field. From there, apply the following changes (one at a time) to see how the changes affect the plan
(copy and paste plans or create separate trials for each change so you can evaluate all of them):
Plan 1: Create a beam directly opposed to the original beam (Lt. lateral) (assign 50/50 weighting to each
a. What does the dose distribution look like? uniform, covering the brain, with some cold spots
within the brain.
b. Where is the region of maximum dose (hot spot)? What is it? Ant/Sup of skull (frontal bone)
at 109.6%
Plan 2: Adjust the weighting of the beams to try and decrease your hot spot.
a. Did it help the hot spot? No, the fields still make the hot spot on the top of head and seeing as
treatment fields are aimed at the isocenter in the middle of the brain, changing the weight to
either field is not going to decrease it.
b. Did your isodose coverage of the brain change? Yes, the higher weighted field drew more of the
dose, leaving the side of the brain with the lower weight colder.

Plan 3: Does your facility ever use wedging or segmented fields to decrease the hot spot? If so, try one of
those techniques (wedging is easier at this point). My facility does not use wedging nor segmented
field to decrease the hot spot in whole brain treatments; in other treatments yes, but not in whole
a. Evaluate the isodose lines. Which direction does the wedge need to go? Out (Heel is Sup, while
Toe is Inf)
b. Which wedge provides the most even dose distribution? EDW10OUT

Plan 4: Does your facility use other techniques to treat whole brains? No.
Discuss this with your clinical instructors and work on creating different whole brain plans. Several of
these other techniques include slight anterior obliques, collimator rotations, half-beam blocking with
an off-axis prescription point.
Slight anterior oblique - hot spot posteriorly smaller, but cold spot bigger in center of the brain
throughout(cools whole brain down)
Collimator rotations - This is no longer used at all at this facility, and highly frowned upon if presented.
The reasoning behind this is because with this field, the lower jaw blocks part of the temporal
lobe and some residual disease could remain there. This is especially bad in children with
leukemia because reoccurrence would occur there.
a. What are the advantages to these other techniques? Overall, there are less cold spots, but larger
hot spots (the plans get hotter).
b. When designing and evaluating different techniques, which one produces the most ideal plan?
For this particular patient, a 10
- "Out" Wedge in the Right Lateral field, along with the MLC
design used in the opposed Lateral field with no collimator rotation, and beam angles at 90

and 270
- gave the most ideal plan. The isodose lines covered more, the plan was cooler, and
the dose distribution was more uniform throughout the brain.

Which treatment plan covers the target the best? What is the hot spot for that plan?
As mentioned above, 10
- "Out" Wedge in the Right Lateral field, along with the MLC
design used in the opposed Lateral field with no collimator rotation, and beam angles at 90

and 270
- gave the most ideal plan for this particular patient. The wedge included gave the
optimal plan because her head was at a tilt during the simulation. Without the tilt though, a
wedge would not be necessary and the opposed lateral field, no collimator rotation, and angles
of 90
and 270
would be the best. For this plan, the hot spot was 108.7%

Did you achieve the OR constraints as listed in the table on page 1? List them in the table.
Yes, I was able to achieve the OR constraints listed in the table on page 1. This is a normal
whole brain treatment/setup here at Cancer Care of Western New York (CCWNY), so I
anticipated that I would meet the constraints.

What did you learn from this planning assignment?
I believe I can plan a whole brain treatment now, going forward. This plan helped to establish
my confidence in planning this type of treatment. I also learned why the German Helmet
(collimator rotation) is no longer used, and why the Opposed Lateral field plan is the best, ideal,
most commonly used plan for a whole brain treatment here at CCWNY.

What will you do differently next time?
Next time, I plan on planning a whole brain treatment from memory. I am becoming
increasingly confident in planning these type of treatments. Next time I think I will do it as a