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. The isodose distribution is concentrated primarily in the
posterior region. The prescribed dose is not covering the PTV and most of the dose is being
delivered posterior to the PTV.
 Where is the hot spot and what is it? The hotspot is located in adipose tissue approximately
4.5cm from the posterior edge of the PTV and about 2cm left of midline. It is 172% or
7749cGy
 What do you think creates the hot spot in this location? The hotspot is in this location because
the entire prescribed dose is being delivered by a single, low energy PA field. There is no dose
being delivered by different beam angles and the energy is too low for a patient this size.
 Using your DVH, what percent of the PTV is receiving 100% of the dose? About 47% 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? The isodose distribution is still
concentrated posteriorly. Some of the lower dose isodose lines, such as the 50% line, are
extending more anterior than with the lower energy beam. The maximum dose point is lower
(150%) and moved a couple centimeters anterior due to the higher energy beam. This is
because the dmax depth of the higher energy beam is greater than the lower energy beam,
therefore there is more penetration of the tissue.
 Using your DVH, what percent of the PTV is receiving 100% of the prescription dose? About
50% of the PTV is receiving 100% or the prescribed 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? The isodose lines have shifted
anteriorly and appear to be more conformal around the PTV, however, the lateral beams
have created hot spots of about 105-110% of the prescribed dose on both sides of the
patient. These areas of dose are separate from the dose contributed by the PA field because
of the lower energy used.
 Where is the hot spot and what is it? The hot spot is still posterior to the PTV, but it has
moved anterior a few more centimeters and is much closer to the PTV. It also moved to the
right about 5 centimeters. It is 115% of the prescribed dose.
 What do you think creates the hot spot in this location? The hot spot is in this location because
the weight of the PA and R Lat fields are likely too high. I think the energy is too low as well.
Additionally, the dose distribution may be improved with the use of wedges.

Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution. The dose is significantly
more conformal to the PTV. The lateral hotspots are gone and the PTV appears to be
receiving better dose coverage compared to the previous plan. The 100% isodose line is
covering 54% of the PTV. The 95% isodose line is covering 86% of the PTV. The 90% isodose
line is covering 99% 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) Single megavoltage beam treatments are rarely used and must
produce a plan that does not deliver excessive irradiation to organs at risk, must deliver
reasonably uniform dose, and other important criteria. Typically, a multi-field planning
approach produces plans with more uniform dose distribution, maximum dose within the
tumor volume, and more appropriate doses to the normal tissues surrounding the treatment
volume. This requires using appropriate beam angles, adequate beam energy and weighting,
and beam modifiers (such as wedges).
 Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the
prescription dose? About 56% 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? Adjusting the weighting on this plan did
very little to improve dose distribution/lower the hotspot. My final weighting was PA: 34% L
Lat: 34% R Lat: 32%
 What was your rationale behind your final field weight? When the beams were set to equal
weighting, the hotspot was 5069cGy (113%) and was located approximately 5mm posterior to
the PTV and about 6cm right of midline. I added some weight to the posterior beam, which
lowered the hotspot to 5032cGy. I then took weight from the R Lat beam and added it to the
L Lat beam, which moved the hotspot to the posterior edge of the left side of the PTV.

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..) Heel towards posterior 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. The addition of wedges significantly improved dose
distribution to the PTV. After placing wedges and adjusting the field weighting, 100% of the
dose was covering 73% of the PTV and 95% of the dose was covering about 97% of the PTV.
The hotspot was also lower after the addition of wedges. It went from 113% to 108%.

 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) In order to keep skin dose below 50% of the dmax, absorbers/wedges
should be placed no less than 15cm from skin surface.

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 decided on 15MV for this plan. The PTV
coverage was better and the hotspot was lower than it was with 6MV. The patient’s size was
also a determining factor for this energy selection.
 What is the final weighting of your plan? AP: 19% PA: 28% R Lat: 26% L Lat: 27%
 Did you use wedges? Why or why not? I did not use wedges for this because the dose
distribution was fairly uniform without wedges. When I tried to add even the smallest wedge
we have available here, the area near the toe of the wedge became too hot. Adjusting beam
weighting did not help.
 Where is the region of maximum dose (“hot spot”) and what is it? The region of maximum
dose is located in the right anterior portion of the PTV and it is 4884cGy, or 108.5%.
 What is the purpose of normalizing plans? The most basic reasons for normalizing plan are to
lower the maximum dose or improve PTV coverage.
 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 normalization, coverage of the PTV was improved, but the
maximum dose was higher. Additionally, the OAR doses were slightly higher. In order to
achieve the PTV coverage stated above, the plan was normalized by a factor of 97%. This
means that the 97% isodose line became the 100% isodose line. As a result, all other isodose
lines increased.
 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. QUANTEC

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Bladder V65<50% V65 = 0% Y
V70 < 35% V70 = 0%
 V75 < 25% V75 = 0%
V80 < 15% V80 = 0%
Rectum V50 < 50% V50 = 0% Y
V60 < 35% V60 = 0%
V65 < 25% V65 = 0%
V70 < 20% V70 = 0%
Bowel V45 < 195cc V45 = 313cc N
Femur_R/Femur_L Dmax< 52Gy Femur_R dmax = 47Gy Y
Femur_L dmax = 46Gy
Because GYN external beam radiotherapy is often limited to 45-50Gy, long terms effects are not seen
as often as pelvic irradiation prescribed to higher doses. Therefore, the dose limits to the bladder and
rectum are not as much of a concern3,4. I did find a protocol comparing gynecologic IMRT vs 3D which
listed different constraints than QUANTEC.

References

1. Emami, Bahman. Tolerance of normal tissue to therapeutic radiation. Reports of radiotherapy

and Oncology 1.1 (2013): 123-7.
2. Kavanagh, Brian D. et al. Dose–Volume Effects in the Stomach and Small Bowel
International Journal of Radiation Oncology, Biology, Physics, Volume 76, Issue 3, S101 - S107
3. Klopp AH, Yeung AR, Deshmukh S, et al. Patient-Reported Toxicity During Pelvic Intensity-Modulated
Radiation Therapy: NRG Oncology-RTOG 1203. J Clin Oncol. 2018;36(24):2538-2544.
doi:10.1200/JCO.2017.77.4273Radiation
4. Viswanathan, Akila N. et al. Radiation Dose–Volume Effects of the Urinary Bladder International
Journal of Radiation Oncology, Biology, Physics, Volume 76, Issue 3, S116 - S122
5. Michalski, Jeff M. et al., Radiation Dose–Volume Effects in Radiation-Induced Rectal Injury
International Journal of Radiation Oncology, Biology, Physics, Volume 76, Issue 3, S123 - S129