Pelvis Clinical Lab Assignment

Use the Pelvis CT data set provided in Canvas to complete the following 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 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 shows dose collecting majority in the posterior of the patient. The highest isodose lines
fall in the most posterior of the PTV and with each centimeter moving anteriorly, the isodose line decreases until
only the 20% isodose line is left covering the most anterior portion of the patients external body contour.
• Where is the hot spot and what is it?
The hot spot is in the patient’s posterior skin just below the tip of the tail bone and a little more superficial than
the gluteus muscles. It is measuring at 171.8% or 7732.1 cGy.
• What do you think creates the hot spot in this location?
The hotspot is falling here because our plan is not normalized and by using our facilities lowest photon energy
(6x), the DMAX is only 1.5cm. This is the exact depth of our hotspot. We also aren’t receiving contribution from
any other fields to alter this positioning.
• Using your DVH, what percent of the PTV is receiving 100% of the dose?
48.685% of the PTV is receiving 100% of the dose.

Figure 1, Plan 1 axial isodose distribution along with a DVH displaying PTV coverage.
Plan 2: Change the PA field to a higher energy and calculate the dose.
• Describe how the isodose distribution changed and why?
The distribution visually looks almost identical. The only difference I found was that the depth of each percent
isodose line was just a little deeper when I changed my energy to 10x compared to the prior 6x energy
distribution.
• Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
50.49% of the PTV is receiving 100% of the dose

Figure 2, Plan 2 axial isodose distribution along with a DVH displaying PTV coverage.

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?
The isodose now is doing the same thing at the lateral borders that it was previously just doing from the
posterior aspect. This creates the hottest isodose lines at the 2 intersection corners at the posterior oblique
corners of the patient. It is at this point that dose overlap occurs from the PA and the respective lateral field.
• Where is the hot spot and what is it?
The hotspot is in the patient’s right posterior. It falls roughly 5cm deep from the patients posterior and 14cm
deep from the patient’s right lateral. It is measuring at 116.6% or 5244.9 cGy.
• What do you think creates the hot spot in this location?
The hotspot is falling in this location due to the overlap of dose from the 2 fields. Because of the smaller 6x
energy, it is closer to that overlapping border edge rather than centrally in the PTV. It is falling on the patient’s
right side as from a quick look, the right side has less skin before reaching the PTV than the left side does.

Figure 3, Plan 3 axial isodose distribution along with a DVH displaying PTV coverage.
Plan 4: Increase the energy of all 3 fields and calculate the dose.
• Describe how this change in energy impacted the isodose distribution.
This change in energy allowed my higher isodose lines to traverse deeper into the patient. The higher dose
collected more centrally unlike before where it was collecting more in that lateral tissue.
• In your own words, summarize the benefits of using a multi-field planning approach? (Refer to Khan, 5th
ed, Ch. 11.5B)
It is beneficial to use a multi-field approach when planning a treatment for a tumor that is more centralized in
the body. The main benefit of this technique is that it helps to not only get maximum dose possible to the target
volume, but also minimize high dose to surrounding organs at risk.
• Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the
prescription dose?
51.36% of the PTV is receiving 100% of the dose.

Figure 4, Plan 4 axial isodose distribution along with a DVH displaying PTV coverage.

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?
G180 (PA): 25%, G90(LL): 38.5%, G270(RL): 36.5%
• What was your rationale behind your final field weight?
I made the decision to reduce my PA field in order to minimize exit dose to my more anterior structures such as
the bowel and the bladder. I was able to then contribute more dose to my laterals to gain more contribution
from them, pulling the hot spot a little more anterior as it was falling very posterior before. I also weighted the
LL beam a percent higher until I felt the hotspot was bouncing back and forth between the two sides since the
patient is thicker on that LL side and there’s just a little more skin to traverse through.

Figure 5, Plan 5 axial isodose distribution along with a DVH displaying PTV coverage.
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..)
The final wedge angle I chose was 15-degree wedges for both lateral fields. Both wedges have the heel posterior
and the toe anterior to push dose that direction.
• 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 isodose distribution changed when I added the wedges by minimizing the high isodose lines in the patient’s
posterior oblique section and pushing higher isodose lines more anterior oblique. The 100% isodose line also
covers more anterior and lateral of the PTV structure.

Figure 6, Plan 6 isodose distribution change before (Left) and after (Right) wedge placement.

• 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 a wedge should be placed from the patient’s skin surface is 15cm. This
ensures that contamination of electrons doesn’t cancel out the skin sparing effect. This distance ensures that
the skin dose stay below 50% of dmax dose.1

Figure 7, Plan 6 axial isodose distribution along with a DVH displaying PTV coverage.
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?
I made the decision to put 15x from both lateral beams and leave a 10x energy from the AP and PA beams. This
was because I feel like the beam must travel much deeper through tissue from the lateral sides. I liked the 10x
for AP and PA. I did try 15 just to see what my dose distribution looked like, and it raised my hot spot and broke
up my 100% isodose a lot more throughout my PTV before normalizing. Because of this, I stuck with 10x.
• What is the final weighting of your plan?
My final weighting was 25.7% from my PA, 27.6% for my RL, 24.3% from my AP, and 22.4% from my RL beam.
• Did you use wedges? Why or why not?
I did not use wedges as I felt there was no concentration of dose in any area of the PTV that needed to be
pushed elsewhere. I felt with adjusting my weighting alone, I was able to scatter my hotspot all around my PTV
and make my dose evenly dispersed.
• Where is the region of maximum dose (“hot spot”) and what is it?
My hot spot is falling central in the patients PTV (when considering AP vs. PA) and falling on the patient’s right
side out of any OAR’s and in the PTV. It measures at 109.6% or 4934.0 cGy.
• What is the purpose of normalizing plans?
The purpose of normalizing plans is to ensure that dose prioritizes covering the PTV. It ensures dose delivery to
the correct target volume we are aiming to treat.
• 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.
After normalizing I noticed my hot spot increased and I had to adjust my weighting back a little bit to ensure an
even dose distribution throughout my PTV structure.

Figure 8, Plan 7 isodose distribution before (Left) and after (Right) normalizing.
 • Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and coronal views.
Show the PTV and any OAR.

Figure 9, Plan 7 final isodose distributions in the axial, sagittal, and coronal views showing the PTV and it's coverage and any OAR structures contoured.

• 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).

Figure 10, Plan 7 final 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)
Femoral Head D50 < 35Gy2 26.1 Gy Yes
Bowel Space D50 < 26Gy2 29.9 Gy No
Rectum (w/ PTV) D60 < 48 Gy2 45.96 Gy Yes
Bladder D50 < 25 Gy2 46.2 Gy No
 References

1. Gibbons JP, Khan FM. Khan's the Physics of Radiation Therapy. Philadelphia, PA: Wolters Kluwer; 2020.

2. Jang, H. et al. (2021) “Effective organs-at-risk dose sparing in volumetric modulated arc therapy using a half-
beam technique in whole pelvic irradiation,” Frontiers in Oncology, 11. Available at:
https://doi.org/10.3389/fonc.2021.611469.