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Planning Assignment ( Prone 3 field rectum)

Lisa Spanovich
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 Desired objective(s) Achieved objective(s)

Bladder 15% of volume <80 Gy 15% of volume receiving 35 Gy
25% of volume <75 Gy 25% of volume receiving 19 Gy
35% of volume <70 Gy 35% of volume receiving 16 Gy
50% of volume <65 Gy 50% of volume receiving 14 Gy
Bowel Max Dose <50 Gy Max Dose 47 Gy
<100cc to 40 Gy <100cc to 46 Gy
<180cc to 35 Gy <180cc to 46 Gy
<65cc to45 Gy <65cc to 46 Gy

Femurs Max Dose <50 Gy Max Dose 46 Gy

25% of volume <45 Gy 25% of volume receiving 35Gy
40% of volume <40 Gy 40% of volume receiving 31Gy

Mobius_DV_constrain
ts.pdf

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

For a 6x single PA beam, the hot spot is on the patients left buttocks. The hot spot is
135.6%. I measured the depth of the hot spot and it is 1.46 cm into the patients skin,
which coincides with the Dmax for a 6 MV photon beam of 1.5 cm. The isodose
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distribution is somewhat even. You can tell that the isodose lines go further through the
large gas pockets in the rectum. As a radiation therapist, I always assumed that a large
amount of gas in the rectum wasnt good because it wasnt reproducible. Now I am
learning that it does affect the actual plan.

Diagram 1: Single 6x PA field on prone pelvis.

b. Change to a higher energy and calculate the beam. How did your isodose distribution
change?

The first difference I noticed with using the 16x beam is that the isodose lines are more
flat, because of the more forward tendency of the higher energy beam. There is more
forward scatter with the higher energy, so there is less attenuation from different
densities in its path. The hot spot dropped by 8% by switching to a 16 MV beam. The
new hot spot is now 125.2%. The hot spot still resides in the same area, in the left
buttocks of the patient.
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Diagram 2: Single 16x PA field on prone pelvis.

c. 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.

By adding 2 lateral beams (all fields 6x), I was able to get more coverage on the PTV. The
hot spot jumped up slightly by 0.7% (by the single field of 16x) to 125.9%. The location
of the hot spot did change, it moved more superiorly. This would make sense because
the patient is thinner superiorly, and because there are 3 beams converging on one
spot, the hot spot would be in the most posterior/superior portion of the body, when
taking into consideration the shape of the patients anatomy. We still do not have
coverage on the most anterior portion of the PTV, while the posterior portion is
extremely hot.
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Diagram 3: 3 field prone pelvis 6x.

d. Change the 2 lateral fields to a higher energy and calculate. How did this change the
dose distribution?
When the lateral fields were increased to 16x beams, the 90% isodose line (pale green)
got pushed further into the body. In the 6x plan, the 90% isodose line was showed on
the lateral portions of the patients buttocks (see picture from section C). The 90% line
now conforms to the target. The hot spot is still in a similar spot, but is more deep in the
patient (more anteriomedial). The hot spot also decreased to 119.6%.
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Diagram 4: 3 field prone pelvis. PA 6x, laterals 16x.

e. Increase the energy of the PA beam and calculate. What change do you see?

I didnt notice any major difference except for the skin sparing effect on the PA beam.
When comparing the 3 field plan with a 6x and 16x PA beam, you can see that due to
the Dmax of the higher penetration of 16x, the skin is spared to a greater degree. There
is more coverage on the anterior portion of the PTV with the higher energy, but not
without its reservations. Higher dose from the PA field, means more dose to the bowel,
which is just beyond the PTV. The patients separation is 22 cm, so given the 20 cm rule
of thumb, we could generally switch over to using the higher energy beam.
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Diagram 5: 3 field prone pelvis. 16x, no wedges.

Diagram 6: Comparison of 6x vs. 16x PA beam

6x 16x
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f. 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 added a 10 degree wedge on each lateral field. Because we utilize dynamic wedging at
my clinical site, and that wedges are simulated using the Y jaws, the collimator must be
turned to 90 degrees and the original field size must be reset (since the X and Y jaws
flip). I inserted the wedge so that the heel was posterior to the patient. There were 2
reasons for why I did this. The first reason is because from looking at the isodose lines,
we are very hot posteriorly, and very cool anteriorly. By putting the heel posterior, that
thick part of the wedge attenuates some of the beam so that the most posterior portion
of the body is not receiving as much dose, while more of the dose is able to reach the
anterior portion. I think of it as pushing the dose anteriorly. The second reason I knew
the heel has to be posterior is because of the anatomy of the patient. When you are
visualizing the lateral beams going through the patient, it can be agreeable that the
more anterior part of the patient is thicker (due to bone and the bulk of the body),
posteriorly, it is just the buttocks and the beam does not have to attenuate as much
tissue in that area. The global max was reduced to 114.7%, however, the location of the
hot spot is still in the same area.
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Diagram 7: 3 Field prone pelvis with 10 wedges on lateral fields.

g. 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?

Because dynamic wedging gives a larger number of options for wedging, I decided to
only show the remainder of the wedges with the more standard angles of 30, 45, and 60
degrees, respectively. For the 30 degree wedge (heel posterior), the hot spot was
further reduced to 110%. The hot spot is still in the same area as the previous screen
captures. I am receiving more dose anteriorly now.
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Diagram 8: 3 Field prone pelvis with 30 wedges on lateral fields.

For the 45 degree wedge, it gave a nice box around my PTV. The hot spot was further
reduced to 107.4. As of now, I like the 45 degree wedge due to its anterior and most
even coverage of the PTV. Another way that shows the dose is more even, is that the
hot spot is more centralized within the patient. The hot spot now jumped into the right
pelvic bone. According to the isodose lines, the hottest spot of the patient is in the more
anterior portion of the body. By seeing this, I already know that a 60 degree wedge will
be too much and will be considered what by Preceptor, Neil Joyce, CMD, calls over
wedging. This happens when you cool off the hot area too much that the hot area then
becomes too cool, while the cool area becomes too hot, thus reversing what you were
initialing trying to do- obtain an even dose. For demonstration purposes, I will show
what the 60 degree wedge looks like. The hot spot is 107.4.
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Diagram 9: 3 Field prone pelvis with 45 wedges on lateral fields.

For the 60 degree wedging, the hot spot jumped back up to 117%. This is indicative of
over wedging. The hot spot is in a similar area as the 45 degree wedge hot spot, but now
it is very obvious that most of the dose is being pushed anteriorly.
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Diagram 10: 3 Field prone pelvis with 60 wedges on lateral fields.

h. 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.

It would be best to use 16x photons on the laterals due to the depth that we are trying
to reach. I also decided to use 16x on the posterior field, because the dose to the small
bowel did not increase significantly. Also, referencing my previous statement where I
knew I had to use 45 degree wedges on both of the lateral fields, I must retract that
statement. Prior to weighting my fields appropriately, I believed that I needed 45
wedges. However, after weighting my fields, I realized that I actually did need to utilize
the 60 wedges. More weighting through the posterior field helps decrease dose to the
femoral heads, as well as dropping dose in the lateral cutaneous tissues. Per my
Preceptor, Neil Joyce, CMD, we do not want any spillage of anything over the 60%
isodose line. There was a decent amount of bowel in the treatment field, so in order to
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deliver dose to the rectum, the bowel is also receiving a large dose. This can change with
each patients anatomy.

i. 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.

See end of assignment for isodose distributions and final DVH (Figures 12-15).

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?

For this last plan modification, I added an opposed PA field, to make an AP field. I removed both
wedges used on the lateral fields. I then gave equal weighting to each of the four fields (25%).
From using the 4 field box technique, we are giving more dose to the small bowel and bladder,
but we are decreasing the dose to the femoral heads. It does help get coverage on the anterior
portion of the PTV, which gives a nice box appearance around the PTV.

By using the 3 field technique, we are giving a higher dose to the femoral heads, but because
we are giving roughly 50% from the PA and less just over 25% to each lateral field, it is
negligible in comparison. We are also sparing dose to the bladder and to the bowel, since they
are only receiving exit dose. For my final plan, I chose this 3 field beam arrangement, using all
16x energies, with 60 wedges on the laterals.
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Diagram 11: 4 field box

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Diagram 12: Axial view of final treatment plan

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Diagram 13: Coronal view of final treatment plan

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Diagram 14: Sagittal view of final treatment plan

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Diagram 15: Dose Volume Histogram of final treatment plan