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Amber Mehr 1

Pelvis Clinical Lab Assignment


Prescription: 45 Gy in 25 Fractions to the PTV

Planning Directions: Place the isocenter in the center of the designated PTV (note: calculation
point will be at isocenter). Create a PA field with a 0.5 cm margin around the PTV. Use the
lowest beam energy available at your clinic. Apply the following changes (one at a time) as
listed in each plan exercise below. After adjusting each plan, answer the provided questions.
Tip: Copy and paste each plan after making the requested changes so you can compare all of
them as needed.

Plan 1: Calculate the single PA beam.


• Describe the isodose distribution as it relates to PTV coverage. If a screen shot is helpful
to show this, you may include it.
The isodose distribution is rectangular in appearance in the transverse plane and
sagittal plane. In the coronal plane the isodose lines mimic the shape of the PTV due
to blocking and are more circular in appearance. The isodose is mainly posterior on
the patient and coverage of the PTV is poor. Prescription dose covers about 46.63% of
the PTV and skin dose is high.
• Where is the hot spot and what is it?
The hot spot is 80.88 Gy and is located medially and posteriorly within the patient
near the skin. The hot spot is posterior to the sacrum.
• What do you think creates the hot spot in this location?
The single beam and its location and the energy of the beam create the hot spot in this
location. Lower energy attenuates superficially when compared to higher energy.

Figure 1. Plan 1 isodose lines in the transverse plane


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Plan 2: Change the field to a higher energy and calculate the dose.
• Describe how the isodose distribution changed.
The isodose distribution penetrates deeper into the body. The 22.50 Gy isodose spans
the whole body instead of just partially like with the 6 MV beam.
• Where is the hot spot and what is it?
The hot spot is 68.50 Gy and located medially and posteriorly within the patient. The
hot spot is approximately two centimeters deeper within the patient’s tissue when
compared to the 6MV beam. The hot spot is still posterior to the sacrum.
• What do you think creates the hot spot in this location?
The single beam and its location and energy of the beam. The higher energy pushed
the hot spot more anteriorly when compared to the lower energy posterior beam.

Figure 2. Plan 2 isodose lines in the transverse plane

Plan 3: Insert a left lateral beam with a 0.5 cm margin around the PTV. Copy and oppose the
left lateral field 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 the isodose distribution.
The isodose distribution has an uppercase T appearance in the transverse plan. The
sagittal plane’s isodose appearance is square with an indent on the top border
posteriorly. The coronal plane the isodose lines are dumbbell shaped in appearance.
The dose is distributed more to the lateral edges because of the depth the beam has
to travel to get to the isocenter.
• Where is the hot spot and what is it?
The hot spot is 50.41 Gy and is located posteriorly to the right iliac bone. The hot spot
is located more laterally within the patient’s body.
• What do you think creates the hot spot in this location?
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The convergence of the isodose lines from the two lateral and posterior beam causes
the hot spot to be in this location. Its located more posteriorly due to the contribution
posterior beam.

Figure 3. Plan 3 isodose lines in the transverse plane

Plan 4: Change the 2 lateral fields to a higher energy and calculate the dose.
• Describe the impact on the isodose distribution.
The higher energy lateral fields push the dose more medially. The higher isodose lines
were located left laterally and right laterally before and now they are medial
surrounding more of the PTV and sparing more soft tissue.
• Where is the hot spot and what is it?
The hot spot is 50.88 Gy and is located posteriorly to the right iliac bone. This hot spot
is higher due to the higher energy lateral beams distributing more dose at depth than
the low dose beams.
• What do you think creates the hot spot in this location?
The buildup of dose within this region. The convergence of the two lateral and
posterior beams isodose lines result in the hot spot being located posteriorly and
laterally.
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Figure 4. Plan 4 isodose lines in the transverse plane

Plan 5: Increase the energy of the PA beam and calculate the dose.
• What change do you see?
The isodose lines that were posteriorly located were pushed anteriorly towards the
PTV and more posterior skin is spared.
• Where is the hot spot and what is it?
The hot spot is 50.02 Gy and is located posteriorly to the right iliac bone.
• What do you think creates the hot spot in this location?
The convergence of the two lateral and posterior beams isodose lines result in the hot
spot being located posteriorly and laterally within this location.

Figure 5. Plan 5 isodose lines in the transverse plane


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Plan 6: Add the lowest angle wedge to the two lateral beams.
• What direction did you place the wedge and why?
The heel of the wedge for both the right and left lateral beams are located posteriorly
to the patient towards the posterior beam. The wedges were placed in this orientation
because it increased the coverage anteriorly and lowered and moved the hot spot
dose closer to the PTV.
• 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..)
The wedges pushed the isodose lines more anteriorly to help cover the PTV better. It
also eliminated the 49.50 Gy isodose line because the maximum dose does not
surpass this.
• Where is the hot spot and what is it?
The hot spot is 48.17 Gy and located posteriorly to the right iliac bone within the PTV.
• What do you think creates the hot spot in this location?
The hot spot moved more anteriorly and closer to the right iliac bone. This is because
the wedges pushed the composite isodose curves more anteriorly resulting in a more
anterior hot spot.

Figure 6. Plan 6 isodose lines in the transverse plane

Plan 7: 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). You may weight your fields to get a better dose distribution.
• What final wedge angles and weighting did you use?
The wedge angles used were 45-degrees with the heels posteriorly located. These
angles gave the best coverage of the PTV. The weighting was posterior beam 48.40%,
left lateral beam 27.40% and right lateral beam of 24.20%. This gave a PTV coverage of
82.75%.
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• How did each change affect the isodose distribution?


The beam weighting pushed the isodose lines more posteriorly and less laterally. It
made the lines more centralized and conformal around the PTV. The wedges push the
dose more anteriorly and allow the isodose lines to cover more of the PTV.
• Where is the hot spot and what is it?
The hot spot is 50.07 Gy and is in the anterior left corner of the PTV.
• What do you think creates the hot spot in this location?
The wedges push the hot spot anteriorly.

Figure 7. Plan 7 isodose lines in the transverse plane

Plan 8: Copy and oppose the PA field to create an AP field and adjust the collimators to keep a
0.5 cm margin around the PTV. Keep the lateral field arrangement. Remove any wedges that
may have been used. Calculate the four fields and weight them equally. Adjust the weighting of
the fields, determine which energy to use on each field, and, if wedges will be used, determine
which angle is best. Evaluate your plan in every slice throughout your planning volume. Discuss
your plan with your preceptor and adjust it based on their input. Normalize your final plan so
that 95% of the PTV is receiving 100% of the dose.
• What energy(ies) did you decide on and why?
The energy used to treat the patient was 18MV. This energy was used because of the
thickness of the patient at the pelvic region.
• What is the final weighting of your plan?
The final weighting of the plan was close to even between all four beams. Anterior
beam is weighted at 23%, posterior beam is weighted at 27%, the left lateral is
weighted at 25%, and the right lateral is weighted at 25%. This helped increase PTV
coverage.
• Did you use wedges? Why or why not?
No. Wedges were not used because the isodose lines were already conformal around
the PTV. Adding wedges would have decreased the coverage.
• Where is the region of maximum dose (“hot spot”) and what is it?
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The hot spot is 50.83 Gy and is in the anterior lateral left corner of the PTV.
• What do you think caused the hot spot in this location?
The near equal weighting of the beams and the isodose composite lines would cause
the hot spot to be in one of the corners of the PTV.
• What is the purpose of normalizing plans?
Normalizing the plan can help increase PTV coverage because it warms the plan. It
heats everything up.
• What impact did you see after normalization? Why?
The hot spot increases and the PTV coverage increases. Decreasing the normalization
is used to increase the dose around the PTV. The hot spot increases because
decreasing the normalization warms the plan.
• Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and
coronal views. Show the PTV and any OAR’s.

Figure 8. Transverse plane, including isodose lines, beams and OARs, of final 4-field
pelvis plan.
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Figure 9. Sagittal plane, including isodose lines, beams and OARs, of final 4-field pelvis
plan.
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Figure 10. Coronal plane, including isodose lines, beams and OARs, of final 4-field pelvis
plan.
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Figure 11. Isodose lines in transverse, sagittal and coronal planes for the 4-field pelvis
plan.

• Include a final DVH. Be sure to include clear labels on each image.


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Figure 12. Dose volume histogram for a four-field pelvis plan (Anterior, Posterior &
Laterals).

• If you were treating this patient to 45 Gy, use the table below to list typical organs at
risk, critical planning objectives, and the achieved outcome. Please provide a reference
for your planning objectives.

Table 1. Organs at risk of the pelvis for 45Gy in 25 fractions


Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome
Bowel Space¹ V50 = 0 cm³ 0 cm³
Right Femur¹ V40 < 35% 4.15%
V44 < 5% 2.09%
Left Femur¹ V40 < 35% 3.90%
V44 < 5% 2.03%
Bladder² Max Dose ˂ 65 Gy 49.53 Gy
Rectum² V50 ˂ 50% 0.00%
V60 < 35% 0.00%
V65 < 25% 0.00%
V70 < 20% 0.00%
V75 < 15% 0.00%
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1. Brown E, Cray A, Haworth A, et al. Dose planning objectives in anal canal cancer IMRT: the TROG
ANROTAT experience. J Med Radiat Sci. 2015;63(2):99-107.
doi: 10.1002/jmrs.99.
2. Radiation Oncology/Toxicity/QUANTEC. WikiBooks Web site.
https://en.wikibooks.org/wiki/Radiation_Oncology/Toxicity/QUANTEC. Updated September 23,
2015. Accessed March 26, 2018.