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Jenny Kouri
Clinical Practicum I
4/3/15
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
Bladder

Desired objective(s)
40% < 40 Gy

Achieved objective(s)
7.99%

Small Bowel

Maximum dose < 50Gy

4804.2cGy

Femoral Head (R,L)

100cc < 40Gy

40% < 40 Gy

3947.0cGy
Right= 0.29%
Left= 1.26%

Maximum dose <5 0 Gy

Right= 4489.0cGy
Left= 4680.7cGy

*** Results are from the 3-field FINAL plan.

a. Enter the prescription: 45Gy at 1.8 /fraction (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.

In this plan, a single 6MV posterior beam was used. The maximum dose point was 6699.4cGy.
At the VA Medical Center in Minneapolis, the maximum dose point is kept under 120% of the
prescription dose. For this plan, the hot spot should be less than 5400cGy. The hot spot was
6699.4cGy. This goal is not met and therefore this plan is not acceptable. The PTV coverage
was 88.42%. The 100% isodose line (red) clipped the PTV anteriorly. In the coronal plane, the
100% isodose line is not clean or distributed homogenously.
b. Change to a higher energy and calculate the beam. How did your isodose distribution
change?

This plan used an 18MV posterior beam. In comparison to the previous 6MV posterior beam,
dose was pushed more anteriorly with 18MV. 18MV has a greater dose build up region than
6MV and as a result, dose was spread at a greater distance before fall-off. The difference of dose
build up, allowed the 18MV maximum dose point to be cooler than the 6MV point. The 18MV
hot spot was 11% cooler than the 6MV hot spot. This plans maximum hot spot was 5962cGy.
This plan was unacceptable due to the hot spot being 132% higher than the prescription dose.
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.

All 3 fields in this plan utilized 6MV beam energy. Although all the beams are equally weighted,
the right lateral produced a warmer pool of dose. However, the maximum dose point is located
to the left of the PTV. The hot spot was 5145.7cGy. The PTV coverage was 65.69%. In the
transverse plane, the PTV appeared to be covered by the 100% isodose line (red) but in the
sagittal plane, the PTV was clipped anteriorly. The PTV was clipped inferiorly in the coronal
plane.
c. Change the 2 lateral fields to a higher energy and calculate. How did this change the dose
distribution?

This plans right and left laterals used 18MV beam energy. The posterior beam used 6MV. The
PTV is not fully covered by the 100% isodose line (red). The PTV coverage was 77.53%. The
hot spot was 5145.7cGy. Even though the hot spot was under 120% of the prescription dose, this
plan was still unacceptable due to the low PTV coverage.
Increase the energy of the PA beam and calculate. What change do you see?

All the beams were changed to 18MV. The PTV coverage was 84.05%. The maximum hot spot
was 5156.8cGy. Like the previous plan, the hot spot was under 120% of the prescription dose.
However, this plan was still unacceptable due to the low PTV coverage.
d. 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 was curious how the orientation of the wedges would affect the plan. To compare, I created
plans with 15-degree wedges oriented as a wedge pair with the heels posterior and another
oriented anterior. These are shown below.

This plan used 15-degree wedges with the heels oriented posterior. The PTV coverage was
89.50%. The hot spot was 4995.9cGy. The PTV is almost covered by the 100% isodose line
(red) but is barely clipped anteriorly. In comparison to the previous plans, the anterior portion of
the PTV is covered more than without the wedges. The wedges allowed for more dose to shift
anteriorly due to more attenuation by the thicker end of the heels. If this plan were normalized
down from 100% to 98%, this plan would have been acceptable.

This plan used 15-degree wedge pair with the heels placed anterior. The PTV coverage was
74.87%. The hot spot was 5199.7cGy. Dose was pushed posteriorly due to the wedging. The
100% isodose line (red) clipped the anterior portion of the PTV. In comparison to the heels
oriented posterior, PTV coverage was better in the previous plan.
e. 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?

This plan used a 30-degree wedge pair with the heels placed posterior. The PTV
coverage was 98.57%. The hot spot was 4927.7cGy. The thicker heels allow for more
dosage to cover the PTV anteriorly.

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This plan used a 30-degree wedge pair with the heels placed anterior. The PTV coverage was
81.45%. The hot spot was 5317.6cGy. This wedge orientation cooled the anterior portion of the
PTV too much. The 100% isodose line (red) clipped the PTV anteriorly.
f. 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.

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The best dose coverage and homogenous beam distribution was achieved with 45-degree wedge
pair with the heels oriented posterior. The beam weighting for the posterior, left lateral, and right
lateral is 46%, 27%, and 27%, respectively. The PTV coverage was 100%. The hot spot was
4918cGy. This hot spot is 1.09% hotter than the prescription dose. The rule of thumb at this
clinical department is to keep the hot spot under 120% of the prescription dose.
g. 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 axial, sagittal, and coronal views are shown above.

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Even though both femurs were kept under 50Gy, blocking or IMRT would significantly
lower the dose to the right and left femur.
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?

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The maximum hot spot was 4845, 107% hotter than the prescription dose. The isodose lines
created a clean look and described the beam orientation of a 4-field box. The PTV is fully
covered by the 100% isodose line.
Advantages of the 4-field box include the following:
-Better coverage of PTV
-More homogenous dose distribution
-Less conformal in the event of rectal filling
Disadvantages of the 4-field box include the following:

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-Increase dose to bladder