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2D conformal lumbar spine TP Summary

1. Under the treatment plan, I first set up the user origin to isocenter, by
checking simulation GE doc for correct location of isocenter in comparison to
the points in fields (TP uses cm unit but mm used in simulation doc, and the
X, Y sign are opposite to TP).
2. Reference points: create iso point with (or without) dose prescription input to
the plan as a calculation point for normalization. Created another point
without dose and location as a primary reference point for dose tracking.
3. As I did the most contouring and attended simulation, I knew the
backgrounds: this is a palliative treatment for the lumber spine area; patient
had lot of pain in that area status post laminectomy with hardware in place,
and patient body size is medium.
4. I thought an AP and PA fields would be adequate. However, I still tried
bilateral fields to see how that covers the target and how the dose
distributed. Obviously, the coverage and dose distribution are poor. (Mary
and I reviewed the reasons of why not using bilateral beams. Patient was
simulated with arms down which limited our choices to create fields from
bilateral or oblique sides. However, this is a palliative case and the physician
was not interested at a more complicated treatment plan).
5. The default beams from simulation was ap and lat. I deleted the lat field and
worked on the ap field by starting rename the field, select the correct
machine by checking encounter-verify correct linac, select 16 MV beam based
on patients size and the treatment location through abdomen area, and
other setup under properties.
6. I added DRR and MLC with 1.0 cm margin to fit the PTV structure.
7. Once I completed the first field, I just insert an opposite field with opposed
gantry degree, same DRR, same beam energy, and then just simply re-fit the
8. I then went through checking the fields setup, dose prescription with correct
dose and fraction by checking dose intense or simulation doc with physicians
dose prescription, select algorithm AAA.
9. Ready to calculate
10.After caculation, I checked the plan DVH for coverage, isodose lines, the
maximum dose for the plan, the hot spot location was more anterior and the
plan was hot, the dose coverage was good though.
11.I decreased the weighting of the AP beam with small steps while PA beams
weighting was increasing to shift the hot spot more posteriorly in the PTV,
and I also watched the plan was also cold down a little bit and the isodose
line coverage shifting posteriorly too.
12.With the thought of making the plan colder with better coverage, I checked
the PTV coverage in DVH with absolute dose, found the 95% volume covered
dose which was near to 97% of prescribed dose. I then changed the
prescribed percentage dose to 98% (which is the full prescribed dose) to

evaluate the coverage and dose distribution. Per Marys suggestion, a 98%
dose line is better created in isodose level for plan evaluation.
13.At this point, I had Mary reviewed my plan and explained the process to her.
She suggested me to increase the MLC margin to 1.5 cm for right, left,
superior sides and 1.3 cm for inferior side to cover the superior part better. I
made the change and observed a little improvement of the coverage to the
superior of PTV on the sagittal view. AS the hardware was fully covered by the
full dose (98% isodose line) per physicians instruction, we stopped at this
point for doctors approval.

Approved by clinical instructor: Mary Henry on July 1, 2016

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