Jenna Cimmiyotti

DOS 771: Clinical Practicum I

Spring 2021
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 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. Each plan will build in complexity off of the previous one. After
adjusting each plan, answer the provided questions. Include a screen shot for each plan to show
the isodose distribution along with a DVH clearly displaying your PTV coverage.
 Important: Please do not normalize your plan when making these adjustments until
instructed to do so in the final plan.
 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.
The isodose distribution is very warm posteriorly and the prescription coverage is cool on the
anterior side of the PTV. This isodose distribution is very typical for a single beam field. The
dose is greatest at any depth at the central axis of the beam because it is the most forward
directed part of the beam. At the edges of the beam, the dose fall is partly due to reduced side
scatter.1

 Where is the hot spot and what is it?

The hot spot is located posteriorly near the beam entrance and skin surface. The dmax of a 6MV
beam is 1.5 cm, which correlates to where the global hot spot is located in this plan as shown in
the screen shot below. The hot spot is 8196.6 cGy (182.1%).
  What do you think creates the hot spot in this location?
All of the dose enters through a single beam and creates the hot spot at the entrance. As the
photon beam interacts with tissue at the surface, electrons are set in motion. The dose builds up
until a point of maximum dose at a particular depth. This depth is where electron equilibrium is
reached.2 The depth at which the dose reaches its maximum is 1.5 cm for a 6MV beam and then
the dose gradually decreases as the depth increases. Single field isodose distributions do not have
any skin sparing.2

 Using your DVH, what percent of the PTV is receiving 100% of the dose? 56.9%

Plan 2: Change the PA field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed and why?
The dose travels deeper into the patient because of the higher photon beam energy. With higher
energies, the photon beam is more forward penetrating and has more skin sparing. The percent
depth dose also increases with increasing photon energy. The Dmax for an 18 MV beam is
deeper compared to a 6 MV beam with a greater buildup region. This results in less surface dose
and greater skin sparing. The percent of 100% coverage to the PTV has increased by 4.7%.
  Using your DVH, what percent of the PTV is receiving 100% of the prescription
dose? 61.6%

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?

By adding in the two lateral beams, the posterior global hot spot near the entrance of the single
beam as seen in previous plans has improved. By evenly weighting all 3 of these beams, there is
now 100% and 105% dose in the lateral soft tissue. The isodose distribution is taking on a “box”
like appearance around the PTV. Compared to the single posterior field beam arrangement, the
dose to the anterior soft tissue has decreased due to less beam weighting to the posterior field.

 Where is the hot spot and what is it?

The hot spot is located outside of the posterior and lateral edges of the PTV. The global dose
maximum is 5108.6 cGy (113.5%).

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

The hot spot is in a location where all three of the beams intersect near the posterior side of the
PTV. Dose from all three of the beams contributes to the hot spot. Additionally, the 6 MV beam
energy is not high enough to penetrate the depth of the soft tissues in the pelvis. This results in
unnecessary prescription isodose lines in the lateral soft tissue of the pelvis.

Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution.
By increasing the energy of all three fields from 6 MV to 18 MV, the dose is penetrating deeper
into the patient. Therefore, the excessive dose in the lateral soft tissue that was seen previously
has been eliminated. The beams are still converging to create an isodose box distribution around
the PTV. Hot spots still remain in the posterior third of the PTV.

 In your own words, summarize the benefits of using a multi-field planning

approach? (Refer to Khan, 5th ed, Ch. 11.5B)

In using a multi-field planning approach, the ratio of the tumor dose to the normal tissue dose is
increased.1 A more uniform dose distribution can be achieved by using multiple beams and the
surrounding tissue receives less dose. Although more tissue is exposed using multiple beams, the
dose is lower compared to a single beam. When selecting an appropriate beam arrangement, the
planner should be aware of the organs at risk in the path of the beam. Although a treatment plan
with numerous beams may look appealing in the treatment planning system, it is also important
to consider the practicality of setup reproducibility and treatment delivery.
  Compared to your single field in plan 2, what percent of the PTV is now receiving
100% of the prescription dose?

In plan 4, 55.9% of the PTV is now receiving 100% of the prescription dose. Compared to plan
2, in which 61.6% of the PTV is covered by 100% of the prescription dose.

Plan 4:

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?

Posterior field: 0.400

Left lateral: 0.295
Right lateral: 0.305
  What was your rationale behind your final field weight?

When adjusting the field weights, I strived to balance the coverage and 105% on all sides of the
target to aim for a homogenous dose distribution. I chose to weight the posterior beam slightly
more than the opposed lateral beams because the PTV is positioned more posteriorly. The
slightly higher weighted posterior beam resulted in the best target coverage, but still limiting the
amount of 105%. The lighter weighted lateral beams help to make the dose more conformal to
the target and avoid having excess dose anteriorly near the bowel.
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. Also, if you desire to adjust
the field weights after wedge additions, go ahead and do so.
 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..)

I chose to use a 30 degree wedge with the heel positioned towards the posterior side of the
patient for both of the lateral beams. I also adjusted the field weights slightly to balance the dose
distribution on each side of the PTV. My final beam weighting was:

Posterior: 0.440
Right lateral: 0.280
Left lateral: 0.270

 How did the addition of wedges change the isodose distribution? Include a screen
shot (including axial and coronal) of the isodose distribution before and after the
wedge placement using a plan evaluation/comparison view.

The addition of two wedges with the heel positioned posteriorly helped to eliminate the 110%
dose that was located posteriorly. The wedges helped to push the dose anteriorly and resulted in
better PTV coverage. When selecting a wedge angle, I chose the wedge angle that helped
decrease the warmth posteriorly but did not take away too much dose that the target was losing
prescription coverage on the posterior side of the PTV.
Plan 5 (without wedges) Plan 6 (wedges)
  According to Khan, 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 Khan, 5th ed, Ch. 11.4)

According to Khan, the minimum distance an absorber, such as a wedge, should be placed from
the skin surface is 15 cm. The reason for keeping an absorber at this minimum distance is to
maintain the skin sparing effect of a megavoltage photon beams. The absorber itself can become
a source of electron contamination from the photon beam. Increasing the distance between the
wedge and the skin surface allows for divergence, absorption and scattering of the electrons.1

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?

With a deeply seated target, I chose to use 18 MV from all four beams to achieve deeper
penetration and skin sparing.

 What is the final weighting of your plan?

Posterior beam: 0.300
Left lateral: 0.18
Right lateral: 0.220
Anterior: 0.300

 Did you use wedges? Why or why not?

I did not use wedges. The 4-field technique spread the dose distribution out well and created a
conformal box surrounding the target. There wasn’t any hot areas that would benefit from using
a wedge to smooth the dose gradient.

 Where is the region of maximum dose (“hot spot”) and what is it?
The maximum dose is within the PTV on the anterior and lateral side of the target volume. The
maximum dose is 4759.9 cGy (105.8%).

 What is the purpose of normalizing plans?

Normalization is a tool that dosimetrists can use to scale the dose to a certain percentage and in
turn, all other dose levels are adjusted by the same proportion.2 A situation in which it would be
appropriate to utilize the normalization function is when a plan is just shy of meeting the target
coverage constraints and the organs at risk are well below the constraints. Essentially the whole
plan is either heated up or cooled down by a certain ratio. Although there are a number of
different ways to normalize a plan, it is common to normalize 100% at the isocenter in SAD
techniques.2

 What impact did you see after normalization?  Why? Include a screen shot
(including axial and coronal) of the isodose distribution before and after applying
normalization using a plan evaluation/comparison view.

I noticed the whole plan was a little warmer overall after normalizing the plan. In this plan, I
normalized the plan up by 1.2%. In other words, the planning system took the 98.8% isodose line
and increased that dose to become the 100% isodose line. Thus, to meet the criteria of 95% of the
PTV to receive 100% of the dose the entire plan’s isodose lines increased by 1.2%.

 Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal
and coronal views. Show the PTV and any OAR.

Isodose distribution showing PTV (red) only:

Final isodose distributions with PTV and OARs:
 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).
  Use the table below to list typical organs at risk, critical planning objectives, and the achieved
outcome. Provide a reference for your planning objectives.

The following table lists typical organs at risk for the pelvis. The planning objectives are taken from both the
QUANTEC data and our departmental planning template.3

Many of the planning objectives have not been met. If I was doing this plan in the clinic, I would have a
conversation with the physician about the acceptable doses to the organs at risk given the amount of overlap
between them and the PTV. For example, 64% of the bladder is within the PTV. Therefore, the planning
objective of V45Gy < 35% of the bladder isn’t feasible.

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Bladder Mean Report 45.87 Gy report
Max < 65 Gy Max 47.07 Gy Y
V30Gy Report 100% report
V45 Gy < 35% 91.9% N
V65Gy < 50% 0% Y
V70 ≤ 35% 0% Y
V75 ≤ 25% 0% Y
V80 ≤ 15% 0% Y
Rectum Mean Report 43.56 Gy report
V30 Gy < 60% 93.1% N
V40 Gy < 80% 90% N
V50 Gy < 50% 0% Y
V60 Gy < 35% 0% Y
V65 Gy < 25% 0% Y
V70 Gy < 20% 0% Y
V75 Gy < 15% 0% Y
Small bowel V15 Gy < 120cc 921.66 cc N
V30 Gy < 300 cc 692.87 cc N
V45 Gy < 195 cc 292.90 cc N
V40 Gy < 30% 37.9% N
R Femur V30 Gy < 15% 13.4% Y
V50 Gy < 10% 0% Y
L femur V30 Gy < 15% 12.5% Y
V50 Gy < 10% 0% Y
PTV Max Report 47.60 Gy Report
D95% ≥ 100% 100% Y
V95% > 99% 100% Y
V100% > 95% 95.0 Y
CTV V100 > 99% 99.0% Y
References:

1. Khan FM, Gibbons JP. Khan’s The Physics of Radiation Therapy. 6th Philadelphia, PA: Lippincott
Williams & Wilkins; 2020.
2. Bentel G. Radiation Therapy Planning. 2nd ed. McGraw Hill Professional; 1996.
3. Marks LB, Yorke ED, Jackson A, et al. Use of normal tissue complication probability models in the
clinic. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S10-S19. doi:10.1016/j.ijrobp.2009.07.1754