Helen Nguyen

Pelvis 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 1 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 field.

 Describe the isodose distribution.
o The 100% isodose line only emcompasses about half of the PTV. The 110 isodose
line is outside of the PTV, and covers a lot of the posterior portion of the patient.
This is because there is only one beam and it’s coming from the posterior side.
The 50% isodose line encompasses the whole PTV and spreads to the anterior
portion of the body.

 Where is the hot spot and what is it?

o The hot spot is 170.0% (7650.7 cGy) and it is about 1.4 cm from the posterior.

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

o The hot spot is in the location because of the PA beam coming in from the
posterior side. There are no other beams, so all the dose is entering through the
same area. It makes sense that dmax is about 1.4cm deep because dmax for a 6x
photon beam (which is what I used) is 1.5cm.

 Using your DVH, what percent of the PTV is receiving 100% of the dose?
o 48.37% of the PTV is receiving 100% of the dose.

Plan 2: Change the PA field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed and why?
o The hot spot lowered to 155.4% (6992.2 cGy) and is now 2.30 cm from the
posterior. This is because with higher energies, the beam is able to penetrate
through matter more deeply. Therefore, more dose pushed to the anterior side,
which gave me better PTV coverage compared to plan 1. The rest of the isodose
lines have the a similar shape to plan 1 and that’s because no new fields have
been introduced, so the beams are really only going in from one direction.

 Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
 o 49.5% of the PTV is receiving 100% of the dose

Plan 3: Insert a left lateral field with a 1 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 fields.
 Describe the isodose distribution. What change did you notice?
o The 100% isodose line is covering the PTV slightly more when compared to plans
1 and 2. There are also 100% isodose lines on the lateral sides of the patient,
which is to be expected since we added lateral fields. There are small triangles of
110% isodose lines outside the posterior portion of the PTV, which are caused
from adding the lateral fields. There is less 50% isodose lines on the anterior
side, but more 25% isodose lines all around from where the beams are coming
in. 100% dose to PTV is about 45.55%.

 Where is the hot spot and what is it?

o The hot spot is 114.6% (5156.0 cGy) and it’s 5 cm away from the posterior, 12.88
cm away from the right, and 29 cm from the left.

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

o This hot spot is probably here because of the posterior PA beam, which explains
why its on the posterior side versus the anterior. It’s more towards the right side
of the patient because the right side has less matter to go through than the left
side. When looking at the patient on the axial view, you can tell that the left
lateral beam has to travel through much more matter than the right. So, this
explains the dmax is on the right posterior side.

Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution.
o The hot spot is in a similar location, however is deeper into the body. The hot
spot is now 112.4% (5057.6 cGy). The isodose lines coming from the lateral fields
cooled off and now don’t have as much 100% isodose lines on the right and left
side of the patient. They are showing mostly 90% isodose lines. The PTV has
better 100% isodose line and is encompassing about 46.44% of the PTV. The
110% hot areas have cooled down a little bit, but still are outside of the PTV
which is unfavorable.

 What are the benefits of using a multiple-field planning approach? (Refer to Kahn, 5th
ed, Ch 11.5B)
o Using multiple fields increases the ratio of the tumor dose to the normal tissue
dose.1 This helps dose uniformity in the PTV and helps to spare the organs at
risk.
  Compared to your single field in plan 2, what percent of the PTV is now receiving 100%
of the prescription dose?
o In plan 3, about 45.55% of the PTV was receiving 100% of the dose. With same
fields but higher energy in plan 4, about 46.44% of the PTV is receiving 100% of
the dose.

Plan 5: Using your 3 high energy fields from plan 4, adjust the field weights until you are
satisfied with the isodose distribution.
 What was the final weighting choice for each field?
o PA beam:38%
Lt Lat: 32%
Rt lat: 30%

 What was your rationale behind your final field weight?

o I found that having the PA beam weighted a little higher gave the PTV better
overall coverage. I weighted the left lateral field a little higher than the right
lateral field because there is more matter to go through. This weighting makes
the isodose lines best in my opinion, given the energy and fields given, however
it still needs more help since there is still a lot of 110% outside the PTV and the
global max is 113.2% (5095.1 cGy) and is outside the PTV. About 47.4% of the
PTV is getting 100% prescription dose.

Plan 6: Insert a wedge on each lateral field. Continue to add thicker wedges on both lateral
fields until you are satisfied with your final isodose distribution. Note: When you replace a
wedge on the left, replace it with the same wedge angle on the right.
 What final wedge angle and orientation did you choose? To define the wedge
orientation, describe it in relation to the patient. (e.g., Heel towards anterior of patient,
heel towards head of patient..)
o I put a 10 degree wedges on the lateral sides of the patient. Heel towards
posterior, toes pointed anterior.

 How did the addition of wedges change the isodose distribution?

o The isodose lines shifted anteriorly. The PTV is getting more coverage now.
53.7% of the PTV is getting 100% prescription coverage. The addition of wedges
also helped to cool down the isodose lines on the lateral sides of the patient.

 According to Kahn, what is the minimum distance a wedge or absorber should be placed
from the patient’s skin surface in order to keep the skin dose below 50% of the dmax?
(Refer to Kahn, 5th ed, Ch. 11.4)
 o The minimum distance of about 15 cm is required between any absorber in the
beam and the surface in order to keep the skin dose below 50% of Dmax

Plan 7: Insert an AP field with a 1 cm margin around the PTV. Remove any wedges that may
have been used. Calculate the four fields. At your discretion, adjust the weighting and/or
energy of the fields, and, if wedges will be used, determine which angle is best. Normalize your
final plan so that 95% of the PTV is receiving 100% of the dose.Discuss your plan rationale with
your preceptor and adjust it based on their input.
 What energy(ies) did you decide on and why?
o I decided to use 15 MV because of the large separation of the pelvic area.

 What is the final weighting of your plan?

o PA: 21.5%
LT LAT: 23.5%
RT LAT: 26.5
PA: 28.5

 Did you use wedges? Why or why not?

o Yes. For the left lateral field, I used 15 degree wedge, heel on the posterior side
of the patient and toe on the anterior. For the right lateral field, I used a 10
degree wedge, heel on the posterior side of the patient and toe on the anterior. I
used these to make the dose more homogenous since the lateral sides of the
patient are slightly curved. The left side has a steeper curve. The curves cause
the dose to be less homogenous.

 Where is the region of maximum dose (“hot spot”) and what is it?
o It is on the anterior left side of the PTV and it is 4925.4 cGy (109.5%)

 What is the purpose of normalizing plans?

o The purpose of normalizing a plan is to tell the treatment planning system a
certain percentage of the dose that you want to give to a certain percentage of
the PTV. This makes sure you can get adequate coverage.

 What impact did you see after normalization? Why?

o The hot spot is 109.5% (4925.4cGy) and is located on the anterior left side of the
PTV. The PTV got more 100% isodose coverage after normalization. This is
because I basically told the treatment planning system that I want 100% of the
dose to 95% of the PTV. It is expected that the hot spot would be in the PTV (or
near it) after normalization because that is where you are pushing full
prescription dose to.
 Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and
coronal views. Show the PTV and any OAR.

 Include a final DVH. Be sure to include clear labels on each image (refer to the Canvas
Clinical Lab module for clear expectations of how to format your DVH).
  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.

RTOG Protocol 0418

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome
Bladder V45Gy<35% V45 = 90%
Not met
Bowel Space V40Gy<30% V40 = 38%
Not met
Femurs V30Gy<15% V30 = 14%
Met
Rectum V30Gy<60% V30 = 92%
Not met
References:
1. Khan, F. M. Khan’s The Physics of Radiation Therapy. Philadelphia, PA: Lippincott Williams &
Wilkins; 2014.