DOS 771 – Pelvis Lab

Bryn Dahms

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 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.
o The isodose levels are centered along the midsagittal line and have a fairly uniform
shape throughout the plan. Isodose lines start almost at the surface of the skin and
travel deeper into the body, closely following the field edge. Towards the lateral edge of
deeper isodose lines, a cold shoulder appears. The greatest distribution of dose along
the central axis occurs about 3 cm from the skin surface.

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Figure 1.1. Isodose distribution for a single PA field using a 6 MV beam. The hotspot is 170.2% of the
prescribed dose, or 7659 cGy.

• Where is the hot spot and what is it?

o The hotspot is located 0.90cm right of the central axis of the beam and 1.30cm from the
surface of the skin. The hotspot has a max dose of 7658.1 cGy (170.2% of prescribed
dose)

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

o The hot spot is likely the result of a large amount of dose being administered through
one field. Additionally, the lower energy of the field has less penetrating power, so the
beam deposits dose more superficially than a megavoltage beam of higher energy.

• Using your DVH, what percent of the PTV is receiving 100% of the dose?
o 48.13% of the PTV receives 100% of the dose

Figure 1.2. Dose volume histogram for Plan 1. Forty-eight point one-three percent of the PTV is
covered by the prescribed 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 isodose distribution remained centered on the midsagittal line but has reduced fall
off beyond the anterior edge of the 100% isodose line. The 50% isodose line almost
reaches the anterior side of the patient and the superficial posterior hotspot has
decreased significantly from Plan 1.

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Figure 2.1. Isodose distribution for a single PA field of 15 MV energy. The hotspot is 153.9% of the
prescribed dose, or 6925.5 cGy.

• Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
o At 15 MV beam energy, 49.49% of the PTV is receiving 100% of the prescribed dose.

Figure 2.2. Dose volume histogram for a single PA field of 15 MV energy. One-hundred percent of the
prescribed dose covers 49.49% of the PTV.

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?
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o The isodose distribution marks three distinct areas of the pelvis. The largest area of dose
is located at the intersection of the three fields and has horns that extend along the
edges of the PA field. Two smaller areas of prescribed dose are located laterally on the
patient and extend from near the skin surface to a few centimeters deep, closely
following the edges of the field and the patient.

Figure 3.1. Isodose distribution of a 3-field pelvis with 6 MV beams weighted equally. The hotspot is
113.4% of the prescribed dose, or 5103 cGy.

• Where is the hot spot and what is it?

o The hottest hotspot is located in the right posterior corner of the treatment fields,
where the PA and Right Lateral beams intersect. This hot spot is 5102.5 cGy or 113.4%
of the prescribed dose.

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

o The intersection of the fields and the lower beam energies likely influence the location
of the hotspot. Though it is interesting that the mirrored corner at the posterior
intersection of the PA and Left lateral field do not have as large of a hotspot. This might
result from anatomical variations between the right and left gluteal muscle groups. The
larger mass of less dense tissue on the right side of the patient attenuates the beam less
resulting in a larger hotspot on the right side.

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Figure 3.2. Dose volume histogram of a 3-field pelvis plan with equally weighted 6 MV fields. Fourty-
seven-point six percent of the PTV is covered by 100% of the prescribed dose.

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 isodose lines have a greater buildup region and lesser fall off. The 100% isodose
line is located only at the intersection of the beams. This centralized dose has horns that
extend along the PA field edges, resulting in a cold spot towards the center of the beam
intersections and into the anterior portion of the PTV. The lateral distributions of dose
that flanked the sides of the patient have broken up and now appear as small pockets of
90% of the prescribed dose.

Figure 4.1. Isodose distribution of a 3-field pelvis with equally weighted 15 MV beams. The hotspot is
113.1% of the prescribed dose or 5089.5 cGy.
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• In your own words, summarize the benefits of using a multi-field planning approach? (Refer to
Khan, 5th ed, Ch. 11.5B)
o Multi-field planning allows dosimetrists to maximize dose to an area of interest while
sparing critical structures and normal tissues. Multiple fields can be set up around OARs
to avoid such from receiving entry and/or exit dose. This use of multiple fields also
allows for increases in plan conformity and dose uniformity throughout the tumor
volume.

• Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the
prescription dose?
o In the single field from plan 2, 49.49% of the PTV is receiving 100% of the dose. Using 2
lateral fields in addition to the PA field, 60.85% of the PTV is receiving 100% of the dose.
With three fields, 11.37% more of the PTV is receiving prescribed dose than the plan
with 1-15 MV beam.

Figure 4.2. Dose volume histogram of a 3-field pelvis with 3-15 MV beams of equal weight. Sixty point
eight percent of the PTV is covered by 100% of the prescribed 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?

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o I decided to use 15 MV beams for each field for which the weightings are 36% PA, 32% R
lateral, and 32% L lateral.

Figure 5.1. Isodose distribution of a three field pelvis with 3-15 MV beams. The right lateral beam is
weighted 32%, left lateral beam 32% and the PA beam 36%. The hotspot is 113.8% or 5121 cGy.

• What was your rationale behind your final field weight?

o At this field weight, the dose is maximized to the PTV while minimizing dose to the
femurs and areas outside of the PTV.

Figure 5.2. Dose volume histogram for a 3-field pelvis. The left and right lateral fields are weighted 32%
each, the PA field is weighted 36%. Fifty-nine point nine percent of the PTV is covered by 100% of the
prescribed dose.

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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..)
o After testing multiple different wedge angles, I decided on 45° wedges, oriented with
the heel towards the posterior of the patient. The updated field weighting is such that
the PA field administers 50% of the dose, and the lateral fields administer 25% of the
dose.

I was torn between 45° and 60° wedges. Sixty degree wedges had better coverage
(92.3% of the PTV was covered by 100% of the dose) but had a significantly higher
bladder dose as well (91.5% received 100% of the dose with 60° wedges, 77.7% of the
bladder received 100% of the dose with 45° wedges). Considering this, the less
aggressive wedges seemed like a better fit.

• 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.
o The isodose levels are distributed deeper into the body. The wedges ‘pushed’ the dose
that was concentrated in the posterior portion of the field intersections towards the
anterior portion of the intersection, evening out the distribution of the 100% isodose
line and breaking up the larger posterior hotspots.

Figure 6.1. Isodose plan comparison. (A) A 3-field plan with 45° wedges on the lateral fields oriented
with the heel towards the posterior of the patient. Field weighting is such that the right and left lateral
fields administer 25% of the dose each, and the PA field administers 50% of the dose. The hotspot is

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110.9% or 4990.5 cGy. 89.56% of the PTV is covered by 100% of the dose. All field use 15 MV beams.
(B) A 3-field plan without wedges. The right and left lateral fields administer 32% of the dose each. The
PA field administers 36% of the dose. The hotspot is 113.8% or 5121 cGy. 58.89% of the PTV is covered
by 100% of the dose. All fields use 15 MV beams.

• 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)
o A wedge or absorber should be placed at least 15cm from the surface of the patient’s
skin to keep the skin dose below 50% of Dmax.

Figure 6.2. DVH of a 3-field pelvis plan with 45° wedges on the right and left lateral fields, oriented with
the heel towards the posterior of the patient, and a PA field. One hundred percent of the prescribed
dose covers 89.56% of the PTV.

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 used 15 MV beams for all 4 fields. Ten MV beams unfortunately did not have enough
penetrating power to sufficiently cover the PTV. I also attempted a mixed energy plan
with 10 MV beams for the AP and PA fields, and 15 MV beams for the lateral fields, but
was not able to sufficiently cover the PTV.

• What is the final weighting of your plan?

o The final weighting of my plan is such that the AP field delivers 12% of the dose, the PA
field 36%, the right lateral field 27%, and the left lateral field 25%.

• Did you use wedges? Why or why not?

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o I used 20° wedges on the lateral fields with the heel positioned towards the posterior of
the patient to shift the dose more towards the anterior portion of the PTV. I used
wedges to achieve sufficient coverage of the PTV while minimizing dose through the AP
field, to avoid as much dose to the bowel space as possible.

• Where is the region of maximum dose (“hot spot”) and what is it?
o The maximum hotspot is located to the right of the midsagittal axis in the posterior
portion of the fields’ intersection, following the field boarders of the PA and R Lateral
fields. The hotspot is 4892.7cGy, 108.7% of the prescribed dose.

• What is the purpose of normalizing plans?

o Normalizing plans is used to define the point at which dose will be prescribed. Plans can
be normalized to different volumes, isodose lines, points, etc., but the general goal of
normalizing is to ensure that the target of interest is sufficiently covered.

• 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.
o After normalization, the PTV was more sufficiently covered superiorly and inferiorly, and
the hot spot increased by 1.8%, from 4810.5 cGy to 4892.7 cGy. This increase in
coverage is because the normalization was set such that 95% of the defined target
volume, the PTV, was to be covered by 100% of the dose. Because the superior and
inferior portions of the PTV were missing the most dose, these areas increased in
coverage most notably after the normalization was applied. The hot spot also increased
as a result of the increase in monitor unit output required to meet the normalization
constraints.

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Figure 7.1. Isodose plan comparison of a four-field pelvis plan (A) prior to normalization, and (B) after
normalizing so that 95% of the PTV in covered by 100% of the prescribed dose.

• 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 7.2. Isodose distribution of the final 4-Field plan in the (A) axial, (B) coronal, and (C) sagittal
view. All fields are centered at the isocenter. The PTV is outlined in red, the bladder in yellow, bowel
space in purple, rectum in brown, right femur in light blue, and left femur in orange.

• 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).

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Figure 7.3. DVH of the final plan. One hundred percent of the dose covers 95.0% of the PTV.

• Use the table below to list typical organs at risk, critical planning objectives, and the achieved
outcome. Provide a reference for your planning objectives.
o Bowel Space constraints are based on the RTOG-0822 protocol. Other constraints are
standard constraints used by the physicists at NM.
▪ Hong TS, Moughan J, Garofalo MC, et al. NRG Oncology Radiation Therapy
Oncology Group 0822: A phase 2 2tudy of preoperative chemoradiation therapy
using intensity modulated radiation therapy in combination with Capecitabine
and Oxaliplatin for patients with locally advanced rectal cancer. Int J Radiat Oncol
Biol Phys. 2015;93(1):29-36. https://doi:10.1016/j.ijrobp.2015.05.005
o Many of these constraints regarding the OAR are quite difficult to meet because a large
portion of each OAR is contained within the PTV. Sparing these organs is possible but it
would come with the trade off of underdosing the target region.

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
CTV_Total V98% > 99-100% 99.888% Y
PTV_Total V100% > 94-95% 95% Y
Bladder V4000cGy < 60% 98.44% N
Rectum V4000cGy < 45% 89.608% N
Bowel Space V4500cGy < 65cc 277.833cc N
V4000cGy < 100cc 390.725cc N
V3500cGy < 180cc 439.315cc N
BiLat Femoral Heads V5000cGy < 5% 0% Y

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