PELVIS 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.

Plan 1: Calculate the single PA field.

 Describe the isodose distribution.
 Where is the hot spot and what is it?
 What do you think creates the hot spot in this location?
 Using your DVH, what percent 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?
 Using your DVH, what percent of the PTV is receiving 100% of the prescription 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?
 Where is the hot spot and what is it?
 What do you think creates the hot spot in this location?

Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution.
 In your own words, summarize the benefits of using a multi-field planning approach? (Refer to Khan, 5th ed, Ch. 11.5B)
 Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the prescription 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?
 What was your rationale behind your final field weight?

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..)
 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.
 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)

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?

 What is the final weighting of your plan?
 Did you use wedges? Why or why not?
 Where is the region of maximum dose (“hot spot”) and what is it?
 What is the purpose of normalizing plans?
 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.
 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).
 Use the table below to list typical organs at risk, critical planning objectives, and the achieved outcome. Provide a reference for your
planning objectives.

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
PLAN 1

1. The isodose distribution in this first plan with a single PA is spread all the way through the body from the posterior skin surface through the abdominal
wall. The 95%, 98%, 100%, 105%, and 110% are tightly packed together in the middle of the PTV, with the 70%, 60%, and 50% extending in to the
abdominal wall and further spread out.
2. The hotspot for this plan is 172%, or 7742.2 cGy, and is placed on the patient’s posterior just under the skin surface at the level of bottom of L5.
3. The hotspot for this plan is approximately 1.4cm deep into the pelvis on the posterior aspect in the line of the beam. I believe that this is because this is
the where the beam is going, and also because the depth of max dose for a 6MV beam is typically 1.5 cm, so this makes sense for the hotspot to be in
this area.
4. According to the DVH in this plan, approximately 49.84% of the total PTV volume is receiving 100% of the dose.
PLAN 2

1. The isodose distribution in this second plan with a single PA is still spread all the way through the body from the posterior skin surface through the
anterior abdominal wall. The 95%,98%,100%,105%, and 110% are more spread apart now but still in the middle of the PTV. The 70% line is now at the
abdominal wall with the 50% at the skin surface.

2. According to the DVH in this plan, approximately 53.5% of the total PTV volume is receiving 100% of the dose.
PLAN 3

1. The isodose distribution has now split into 3 different distributions at each point of beam entry and has now formed a “box” in the middle of the PTV
with two elongated rectangles on the patient’s sides. The 100% isodose line is now inside the sacrum and moves out to the middle of the PTV as well
as lateral sides of the patient. The 50%, 60% 70% and 80% are no longer spreading out to the abdominal wall and skin anterior to posterior, but
instead are encompassing roughly a 2cm margin about the PTV anterior to posterior. The 50%-80% encompass the lateral isodose lines at the skin
surface where the lateral beam entry points are at.
2. The hotspot is now 114.9%, or 5172.1 cGy , and is approximately 2.9 cm from the right posterior aspect of the PTV.
3. The hotspot is located on the posterior right aspect of the patient. I believe this is because of two different reasons. The first I believe is due to the
three converging beams on the posterior aspect of the patient’s pelvis. The second being that the patient’s right side to midline is smaller in width
than the patient’s left side in relation to the PTV, so the beam is attenuated less on the right side, producing a hot spot.
PLAN 4

1. As compared to the previous plan, the iso dose lines of each beam are still beginning to form a “box” around the PTV. The 50%, 60%, and 70% are still near the
skin surface, but the 100% is covering over half of the PTV, forming a nice box shape posterior to anterior. The 90% isodose line forms a complete box over
almost the whole PTV, with the 95% and 98% covering about 75%.

2. There are two main benefits of using a multi-field approach when treatment planning. These include sparing normal tissue and providing maximum dose to
the tumor volume. When you have a single field, you can get excessive superficial dose, and thus it is not used in many cases except for cancers involving
superficial nodes. By adding a set of parallel opposed fields, you can produce a more homogenous, or “uniform” dose to the tumor volume, but the normal
tissue in the path of the beam and around the tumor may still receive too much dose.1 By increasing the plan to 3 fields or multiple fields, the tumor dose
increases while the dose to the normal tissue is spared.1 Some things to consider when placing multiple fields are the potential organs at risk and normal tissue
volume that are in the path of the beam. This may require adjusting the beam angles until you can produce a plan with maximum tumor volume dose and
minimum normal tissue dose.

3. According to the DVH in this plan compared to the single field in plan 2, 58.3% of the PTV is now receiving 100% of the prescription dose.
PLAN 5

1. The final weight choice for each field is as follows:

a. PA Pelvis: .341 or 31.6%
b. LT Lat Pelvis: .368 or 34.1%
c. RT Lat Pelvis: .371 or 34.3 %
2. The total field weight of the plan was 1.08. I chose to increase the total field weight because I could not achieve adequate coverage of 100% without
making the plan hotter and weighting the overall plan more. I adjusted the RT and LT lateral fields slightly until my isodose lines were a little more
uniform and equally weighted, and then I began adjusting my PA pelvis field weighting. I started by weighting the PA field more than the laterals, but I
had a lot of low dose near the skin surface and not as much PTV coverage as I would like, so began bringing the weighting down. I lowered the weighting
until I had almost a 100% PTV coverage and my lower dose isodose lines became tighter around my PTV “box.” I am sure I will manipulate this a lot more
once I work on plans 6 and 7.
PLAN 6

1. Before I even placed wedges on my lateral fields, I had to turn my collimators to 90 degrees and refit my MLC’s to the PTV structure with margin. This
is because dynamic wedges on our Varian linear accelerators only move in the Y direction as our MLC carriage moves in the X direction. Once I
changed the collimator angles, I recalculated the dose and began adding the dynamic wedges. I placed the wedge with the heel towards the anterior
of the patient with the heel at the posterior part of the patient and toe towards the anterior part of the patient. The Left Lateral Pelvis has a EDW20IN
wedge, and the RT LAT Pelvis has an EDW20OUT wedge.
2. This is because the patient’s body habitus is smaller towards the anterior of the patient, and by putting the toe towards the anterior, it forces the dose
forward to cover the anterior part of the PTV more while cooling down the plan. By adding these wedges, I was also able to reduce the total weight of
all fields to 1.035, while maintaining good PTV coverage.

PLAN 6 WITH EDW PLAN 5 WITHOUT EDW

PLAN 6 (continued…)

3. According to Khan, the minimum distance a wedge or absorber should be placed from the skin’s surface in order to keep skin dose below
50% of dmax is 15cm.1
PLAN 7

1. After taking my original wedges off and placing an AP field, I decided to keep all fields weighted with 23X beams due to the amount of tissue the beams
were going through. This allows for sparing of normal tissue and max dose to the tumor volume.
2. The final weight for the plan is 1.040. The breakdown for this weight is:
a. PA Pelvis: .270 or 26%
b. LT Lat Pelvis: .260 or 25%
c. RT Lat Pelvis: .263 or 25.3%
d. AP Pelvis: .247 or 23.7%
3. I decided to use wedges again because I liked how they cooled the plan down and pushed the 100% dose line forward in plan 6. I placed a EDW10IN
wedge on the LT Lateral Pelvis and a EDW10OUT wedge on the RT Lateral Pelvis. This allowed the plan to be cooled down while pushing the dose
forward to cover the anterior part of the PTV more while cooling down the plan. The heel is placed on the posterior aspect of the patient with the toe
towards the anterior.
4. The hotspot is located in the rt lateral anterior aspect of the PTV and is 114%.
5. The purpose of normalizing a plan is to manipulate the coverage, either increasing or decreasing.
6. After normalizing the plan to 100% covering 95% of the volume, I noticed that the hotspot decreased from 114% to 111.2%. The DVH in this plan went
from approximately 99.2% of the total PTV volume is receiving 100% of the dose to 95% of the total PTV volume is receiving 100% of the dose.

WITHOUT NORMALIZATION WITH NORMALIZATION

PLAN 7 (continued…)

Isodose Distributions
PLAN 7 (continued…)

DVH

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Bladder D50%< 4500-55 cGy D50%= 4630.1 cGy Y
Bladder Max<5000-5700 cGy Max=4844.2 cGy Y
Rectum D60%< 3000-5000 cGy D60%= 4517 cGy Y These dose constraints are a
Rectum D50%<4500-5400 cGy D50%=4542 cGy Y combination of QUANTEC and
Bowel Space D30%<4000-5000cGy D30%=4571.8 cGy Y departmental planning objectives.
RT Femur Max< 5000cGy 4671.7 cGy Y
LT Femur Max< 5000cGy 4753.8 cGy Y
References

1. Gibbons JP. Chapter 11. In: Khan's the Physics of Radiation Therapy. 6th ed. Philadelphia, PA: Wolters Kluwer; 2020:186-191.