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Alecia Eliason
March 24, 2017
Clinical Practicum I
Lab: 3 Field Prone Rectum

A. With a prescription of 45 Gy at 1.8 Gy/fraction (PTV covered by 95% of the prescribed

dose), using a single 6 MV PA beam to deliver the entire dose prescribed led to a very
undesirable plan. Because the calculation point was in the center of the PTV and low
energy was used, more photons were needed to achieve 100% of the prescribed dose at
isocenter, causing a very high hot spot of 5935 cGy. The high isodose lines and maximum
dose were very posterior due to the dmax of 6 MV being only 1.5 cm. The 100% isodose
line splits the PTV in half coronally, so the anterior portion of the PTV didnt receive
nearly enough dose. About 79% of the PTV is covered by the 95% isodose line (4275
cGy) when using a single 6 MV posterior beam.

Figure 1. Axial slice of single 6 MV posterior beam

B. Changing the single PA beam from low energy to high (6 MV to 18 MV) lowered the hot
spot from 132% of the prescribed dose to 119%. The dmax of 18 MV is about 3 cm, so
the 45 Gy isodose line went deeper into the patient than with a 6 MV beam, leading to
more skin sparing. However, the PTV coverage decreased slightly, with 77% coverage of
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the 95% isodose line. The isodose lines seemed to be a little tighter with this higher
energy beam than when using the 6 MV beam.

Figure 2. Axial slice of single 18 MV posterior beam

C. To even out the dose distribution and have better PTV coverage, 2 lateral beams were
added to the existing PA beam. All 3 beams were equally weighted with low energy (6
MV). Using this technique, the hot spot was reduced significantly to 109% of the
prescribed dose. The higher doses were still more posterior, so the anterior portion of the
PTV lacked coverage. There was one area of dose (4050 cGy isodose line) that appeared
on the patients right side due to the addition of these lateral beams. This makes sense
when thinking about the energy used; 6 MV beams have a dmax of 1.5 cm, so this higher
lateral dose is a result of using a lower energy lateral beam. PTV coverage increased to
82% receiving 4275 cGy.
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Figure 3. Axial slice of 3 field plan, 6 MV beams

D. The lateral beam energies were increased to 18 MV, and doing so caused PTV coverage
to increase to 85%. The isodose lines were tighter using higher energies, so the dose was
kept closer to the desired volumes. The hottest point dose was 4801 cGy, equating to
106.7% of the prescribed dose. This area of high dose remained posterior, but the isodose
lines did reach more anteriorly than in any of the previous plans.

Figure 4. Axial slice of 3 field plan, 6 MV PA beam, 18 MV lateral beams

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E. Changing all 3 beams to 18 MV led to even better dose distribution, since 18 MV beams
have greater penetrating power than 6 MV and the dose could reach isocenter without
depositing dose peripherally. This change increased PTV coverage to 88%, and the dose
seemed to be more evenly distributed around the PTV than with previous plans. Although
not a significant reduction, the hot spot did decrease slightly to 4798 cGy.

Figure 5. Axial slice of 3 field plan, 18 MV beams

F. On each lateral beam, adding a 5-degree wedge with heels posterior helped to even out
the dose distribution due to lack of tissue in this area. The wedges were experimentally
turned by 90 degrees, 180 degrees, and 270 degrees, but having the heels posterior to
compensate for less tissue gave the best dose distribution by increasing anterior PTV
coverage. The hot spot lowered to 4787 cGy, and PTV coverage increased to 91%. The
wedges changed the dose distribution such that the anterior portion of the PTV, which has
been lacking coverage in previous plans, was better covered due to the toe effect of the
wedge.
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Figure 6. Axial slice of 3 field plan, 18 MV beams, 5-degree lateral wedges with heels posterior

G. An Elekta Infinity linear accelerator, the machine model with which these plans have
been made, has a dynamic wedge with angle possibilities ranging from 1-60 degrees. To
make things a little simpler, I used wedge angles with 5 degree increments to observe the
changes within the plan. Table 1 reveals the PTV coverage and hot spots for each wedge
angle used. Both 35 and 40 degree wedges were the best fit for this patients plan, lending
100% PTV coverage. The 40-degree wedge had a slightly lower hot spot than the 35-
degree wedge. The high angle wedges (50 degrees and greater) revealed lateral areas of
increased dose due to the toe effect of the wedge. This effect also dramatically increased
the hot spot in these high angle wedges. Axial slices are shown in figures 7,8, and 9
revealing usage of 10-, 40-, and 60-degree lateral wedges, respectively.
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Table 1. PTV coverage and hot spots for wedge angles of 5-60 degrees

Wedge Angle (degrees) PTV coverage (95% of 45 Gy) Hot spot (cGy)
5 91% 4787
10 94% 4760
15 97% 4738
20 98% 4711
25 99% 4686
30 99% 4662
35 100% 4641
40 100% 4620
45 99% 4627
50 98% 4702
55 95% 4807
60 89% 4942

Figure 7. Axial slice of 3 field plan, 18 MV beams, 10 degree lateral wedges with heels posterior
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Figure 8. Axial slice of 3 field plan, 18 MV beams, 40 degree lateral wedges with heels posterior

Figure 9. Axial slice of 3 field plan, 18 MV beams, 60 degree lateral wedges with heels posterior

H. To arrive at my final plan, I took into consideration the effects of different energies for
each beam as previously discussed, as well as wedge options for the lateral beams. I
chose 18 MV photons for each beams energy in order to get adequate dose deep into the
patient where isocenter lies. The patient is tipped slightly to the right; to compensate for
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this, the left lateral beam was weighted just a little higher than the left at 35% and 32%,
respectively. The PA beam then held 33% of the weight, so overall the dose was divided
almost equally among each of the 3 beams. 40-degree wedges were chosen for the lateral
fields due to compensating for lack of tissue posteriorly, lowering the hot spot, and
providing the best dose distribution around the PTV. One small area of concern is the
inferior 1.5 cm of the lateral fields which caused less than 1 cm of flash posteriorly mid-
commissure. After reviewing this with my preceptor, I discovered that this issue is
common with 3 or 4 field prone pelvis patients, and the amount of flash and dose in my
plan would be acceptable from a physicians standpoint. The hot spot was low at 4607
(102% of prescription), and 100% PTV coverage at the 95% isodose line was achieved.
My preceptor agreed with the plan I created and recommended no changes. All organs at
risk and their dose constraints are identified in table 2.

Figure 10. Axial slice of final 3 field plan, 18 MV beams, 40-degree lateral wedges with heels
posterior
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Figure 11. Sagittal slice of final 3 field plan, 18 MV beams, 40-degree lateral wedges with heels
posterior

Figure 12. Coronal slice of final 3 field plan, 18 MV beams, 40-degree lateral wedges with heels
posterior
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Table 2. Organs at risk and their constraints (wished values specific to attending physician).

Organ at Risk Constraints

Small bowel V (4500 cGy) 50%
Dmax < 5300 cGy
Colon V (4500 cGy) 50%
Dmax < 5300 cGy
Anus Dmax < 5300 cGy
Bladder V (4500 cGy) 50%
Dmax < 5300 cGy
Left femur Dmax < 5300 cGy
Right femur Dmax < 5300 cGy
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Figure 14. DVH summary of final 3 field plan. Wished values for organs at risk listed in Table
1.
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4 Field Prone Rectum

Using the final 3 field plan presented, an AP field was added to mirror the PA field.
Wedges were removed from the lateral fields, and all 4 fields were weighted equally. Making
these changes led to a less-than-desirable plan. Firstly, although not a huge jump in dose, the hot
spot increased to 4635 cGy. The AP field added unnecessary dose to the bladder, colon, pubic
bone, and prostate. The AP beam would also need to pass through the bellyboard, resulting in the
need to account for beam attenuation. Adding a 4th treatment field also increases the time spent
taking port films during verification simulation, which could allow for more patient discomfort
and movement. A potential advantage of using this technique is in the wedge removal. Wedged
fields require more MUs, so removing the wedges could lower MUs, consequently lowering
fractional treatment time, resulting in less potential patient movement during the treatment.

Figure 15. Axial slice of 4 field plan, 18 MV beams