Bianca Tester

3/21/2018

Pelvis Clinical Lab Assignment

Plan 1: Calculate the single PA beam.

Describe the isodose distribution as it relates to PTV coverage.

The majority of the dose is deposited in the posterior aspect of the patient. It looks essentially like only
half of the PTV is being covered with the 95% isodose line. Just the posterior aspect has coverage, the
anterior portion only has coverage with the 70% isodose line (and there are still small areas where not
even the 70% isodose is covering the most anterior aspect of the CTV total volume). There is A LOT of
PTV not being covered.

Where is the hot spot and what is it?

The hot spot is located 1.5 cm anterior from the most posterior surface of the patient along the center
of the CAX. The hot spot is 7,699 cGy.

What do you think creates the hot spot in this location?

Since this plan was created with a single PA field, using 6 MV, the dmax of 6 MV is 1.5 cm, so this is
where I would expect the hot spot to be since there were no beam modifications used and no other
beams were placed to shift the hot spot to another location.
Plan 2: Change the field to a higher energy and calculate the dose.

Describe how the isodose distribution changed.

The shape of the isodose distribution pretty much stayed the same, but just shifted anterior an
additional 1.5 cm. By using 15 MV versus 6 MV that decreased the hot spot by 723 cGy. The 95%
isodose line still only covers about half of the PTV volume.

Where is the hot spot and what is it?

The hot spot is located about 3 cm anterior from the most posterior surface of the patient along the
center of the CAX. The hot spot is 6,976 cGy.

What do you think creates the hot spot in this location?

Just as I discussed with Plan 1, Plan 2 was still created with a single PA field, but this time with the use of
15 MV. 15 MV’s dmax is 3.0 cm, which is roughly where the hot spot is located, since no beam
modifications were used and no other beams were placed to move the hot spot.
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.

On the right and left lateral fields, the isodose distribution is shifted to the outer (lateral) edges of the
patient. The 100% isodose line is located about 2.6 cm medial from the skin surface of the patient on
the right and left lateral (there is essentially no real dose contributing to the tumor volume – just exit
dose). The PA field is the only field that’s truly contributing dose to the PTV, however only about 50% of
the PTV is receiving the prescribed dose (4500 cGy).

Where is the hot spot and what is it?

The hot spot is located about 5 cm anterior to the posterior surface of the patient and to the right of the
CAX by 7 cm. The hot spot is 5,114 cGy.

What do you think creates the hot spot in this location?

It looks like there is less tissue to penetrate on the right lateral versus the left lateral at the depth of the
hot spot. According to my measurement of the separation at the depth of the hot spot, the right lateral
measures 21.2 cm from the CAX, and the left lateral measures 22.7 cm from the CAX. The hot spot is
also located where the right lateral beam and PA beam intersect.
Plan 4: Change the 2 lateral fields to a higher energy and calculate the dose.

Describe the impact on the isodose distribution.

The isodose distribution for the right and left lateral fields, that was previously all on the outer edges of
the patient’s body, has now shifted more internally (the 100% isodose line isn’t close to the skins surface
now). With plan 3, the right and left lateral fields weren’t contributing dose to the PTV (using 6 MV),
now with Plan 4, (with 15 MV on the lateral fields), they are contributing dose to the PTV now since 15
MV has a deeper dmax (3.0 cm).

Where is the hot spot and what is it?

The hot spot is located about 5 cm anterior from the most posterior aspect of the patients’ surface, and
to the right of the CAX 7 cm. The hot spot is 5,145 cGy.

What do you think creates the hot spot in this location?

The hot spot seems to stay in the same relative position even with changing the beam energies. I
believe this has to do with the patient’s body separation and that the hot spot is located where the right
lateral field and the PA field intersect.
Plan 5: Increase the energy of the PA beam and calculate the dose.

What change do you see?

The hot spot has moved, and is slightly less dose than Plan 4. The PTV is getting slightly better coverage
(Plan 4’s PTV coverage at 96% is 4,085.33 cGy, while Plan 5’s PTV coverage at 96% is 4,162.9 cGy). With
the increase in energy for the PA field (from 6 MV to 15 MV) there is more exit dose being distributed
into the soft tissue on the anterior aspect of the patient (the 900 cGy isodose curve is larger).

Where is the hot spot and what is it?

The hot spot has shifted slightly more towards the CAX and slightly more anterior (instead of the usual
spot where the right lateral and PA field intersect at their field edges). The hot spot is 5,110 cGy.

What do you think creates the hot spot in this location?

I think by increasing the PA field’s energy from 6 MV to 15 MV is what moved the hot spot more
anterior, while having the right lateral’s field contribute to push the hot spot more towards the CAX.
Plan 6: Add the lowest angle wedge to the two lateral beams.

What direction did you place the wedge and why?

I placed the wedges with the heel edge posteriorly, and toe edge anteriorly. I did this because the
isodose distribution needs to shift more anteriorly.

How did it affect your isodose distribution?

The higher dose isodose distribution in the periphery of the patient is slightly less with Plan 6 versus Plan
5. The 95% isodose line also has better coverage of the PTV with Plan 6. With Plan 5 there were areas
on the posterior aspect of the patient that had 10% hot spots, with Plan 6 there are none that hot.

Where is the hot spot and what is it?

The hot spot is located about 8.7 cm anterior to the most posterior surface of the patient, 6.7 cm to the
right of the CAX, and is 4,853 cGy. With the addition of wedges on the lateral fields, this has decreased
the max dose by 257 cGy.

What do you think creates the hot spot in this location?

I think the hot spot is still staying in that relative area due to the PA field and right lateral fields dose
contributing to that area, and with the separation of the right side being slightly smaller than the left
side, this explains why the hot spot is located more on the right side of the patient than the left (if the
separation on the left was smaller I would expect the hot spot to be more on the left side of the
patient.)
Plan 7: Continue to add thicker wedges on both lateral beams and calculate for each wedge angle you
try. You may weight your fields to get a better dose distribution.

What final wedge angles and weighting did you use?

I used 45-degree wedges for both lateral fields. I used a weighting of 51% on the PA, 24.29% for the left
lateral, and 24.71% for the right lateral.

How did each change affect the isodose distribution?

With the use of thicker wedges, this caused initial hot spots in the anterior lateral periphery, and I had
to adjust the beam weighting more to the PA field to pull the dose back. Also, with the addition of
thicker wedges the anterior PTV coverage improved.

Where is the hot spot and what is it?

The hot spot is located 5.3 cm anterior to the most posterior surface of the patient, and about 6.1 cm to
the right of the CAX. The hot spot is 4,914 cGy.

What do you think creates the hot spot in this location?

The hot spot has been staying relatively in the same spot, even though I’ve adjusted the wedge
thickness. I believe this is due to the fact that I adjusted the beam weighting the weight the PA more.
Before I adjusted the beam weighting the hot spot had shifted more anteriorly and this was due to the
positioning of the wedge with the toe anterior (thinner part of wedge means it lets more dose through
to the patient).
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?

I used 15 MV for all four treatment fields, because the dmax of 15 MV is 3 cm, and that is the highest
energy available in the department. The PTV is located (roughly) centrally within the patient, and at iso,
the patient’s separation (from right to left) is about 39 cm so in order to deposit dose to the PTV a
higher energy is necessary.

What is the final weighting of your plan?

The AP field was weighted 18.5%; the PA field was weighted 40.5%; the right lateral field was weighted
21%; and the left lateral field was weighted 20%. Due to how the wedges were positioned (heel
posteriorly), the AP field didn’t need as much weighting because of the dose contribution from the right
and left lateral fields.

Did you use wedges: Why or why not?

I used 30-degree wedges on both the right and left lateral, with the heel positioned posteriorly.
Normally, I would have thought to put the heel anteriorly due to the patient’s body slope but after
calculating with the heel anteriorly it caused more hot spot in the periphery, and didn’t have good PTV
coverage, even with adjusting the beam weighting or adjusting the wedge thickness. With the patient’s
body slope, it looked very misleading, but what it all comes down to is a good dose distribution and
coverage of the PTV.

Where is the region of maximum dose (“hot spot”) and what is it?
The max hot spot is 4,986.8 cGy and is located about 5.8 cm to the left and anterior 6.7 cm to the CAX at
the depth of the hot spot.

What do you think caused the hot spot in this location?

The first reason I think the hot spot is in that location, is because of the orientation of the wedges – with
the toe end anterior that’s going to make the dose shift anteriorly. Secondly, the patient’s body slope
anteriorly has less panis on the left side of the patient’s body versus the right side.

What is the purpose of normalizing plans?

Normalizing plans is essentially like skewing a grading bell curve. If the highest grade in the class was a
90, and the teacher wants to normalize the grading curve, the 90 becomes 100, and essentially
everyone’s grade is increased by 10%. Normalization can either be increased or decreased depending
on the action you want to achieve. If you want less of a max hot spot, you might want to normalize up
to 105%. However, if you want more PTV coverage, you might want to normalize down. When planning
you must look at both instances to try to achieve a good balance between max hot spot and PTV
coverage – sometimes a hotter max hot spot must be sacrificed in order to have better overall PTV
coverage.

What impact did you see after normalization? Why?

I normalized my plan down to help the dose coverage to the PTV (wasn’t quite at 95% volume receiving
45 Gy), but it increased the maximum hot spot. When I normalized down to 96.5%, the isodose curves
expand out slightly to where I could achieve 95% of the PTV volume received a dose of 4,535.77 cGy (or
100% prescription dose - or slightly more.) If I left my normalization at 100%, the max hot spot would
only be 4,800.4 cGy, but 95% of the PTV would only receive a dose of 4,366.22 cGy. As explained above,
normalization is just like skewing a grading bell curve, and when planning you must balance between
PTV coverage and an acceptable max hot spot.

Embed a screen cap of final plans isodose distribution in all 3 plains (show PTV and any OAR’s)

Include a final DVH w/ clear labels

 Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome
Bladder 50% volume < 65 Gy 53% volume receiving 47.2 Gy
Rectum 50% volume < 60 Gy 55% volume receiving 47.7 Gy
Femoral Heads 40% volume < 40 Gy 42% volume receiving 21.3 Gy
Bowel Space Max dose < 50 Gy Max dose 48.8 Gy