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 with only a PA beam makes it very hot posteriorly while dose is only
covering half of the PTV. Coverage is lost in the anterior portion of the PTV.
 Where is the hot spot and what is it?
 The hot spot is midline, in the soft tissue completely posterior of the patient’s sacrum, almost
to the surface of the skin. The hot spot value is 170.2%.
 What do you think creates the hot spot in this location?
 The hot spot is created in this location due to the single beam entering posteriorly through soft
tissue then a change in boney anatomy as the beam goes through the patient’s body. This
allows for a lot of dose right at the surface of the
 Using your DVH, what percent of the PTV is receiving 100% of the dose?
 About 62% 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?
 We are able to cover a little more of the anterior aspect of the PTV but not completely. This is
because 18X are able to deliver dose deeper into tissue resulting in more dose being delivered
to the anterior portion of the PTV.
 Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
 Now, about 73% of the volume is getting 100% of the 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 distribution is pushed off the posterior skin and forward covering the anterior area
of the PTV which means the dose is covering more the of the volume now. The 100% isodose
line also seems to have broken up into three areas: the PTV area and on either side of the pelvis
where the lateral beams are coming in.
 Where is the hot spot and what is it?
 The hotspot is now inferior and pushed forward into the right gluteal muscles which is closer to
our PTV but not quite inside of it at 114.2%.
 What do you think creates the hot spot in this location?
 When observing the patients body shape, you can tell that her abdomen is laying more so on the right
side than the left. Therefore there is more tissue to go through with the Right Lateral beam. Since there
is more tissue accumulating dose on that side of the body, the hot spot will be thrown on the right side
of the patient.
Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution.
 The isodose lines are much tighter around the PTV with more coverage of the volume. The
100% line that was broken into the both sides of the pelvis now are gone.
 In your own words, summarize the benefits of using a multi-field planning approach? (Refer to Khan, 5 th
ed, Ch. 11.5B)
 The benefits of using a multi-field planning approach is the ability to spare nearby structures
while delivering a more conformal dose distribution to the treatment volume.
 Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the
prescription dose?
 With this plan, about 60% of the PTV is receiving 100% of the dose. That is less coverage than
Plan 2.
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?
 PA = 18%, LT = 41%, RT = 41%
 What was your rationale behind your final field weight?
 I chose these values because it resulted in the lowest hot spot possible.
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..)
 EDW30IN for both laterals with collimator at 0.
 LT LAT wedge is heel towards inferior of patient and toe towards superior of patient
 RT LAT wedge is heel towards inferior of patient and toe towards superior 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.
 Using my wedge placement, the broken up dose came together and the dose was pushed up
superiorly. The DMax also increased quite a bit from 108.5% to 127.7%.
 If rotating the wedge to EDW30OUT, it does the opposite where the dose is pushed down to
cover the inferior portion of the PTV which loses coverage to half the volume superiorly .

 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, 5 th ed, Ch.
11.4)
 The minimum distance is about 15 cm.

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?
 18x for every field because it gave a better dose distribution and lower hot spot. When I
changed the PA to 6X just to see what would happen, the 105 isodose line sank back to the
posterior area of the PTV and the Dmax increased to 110%.
 What is the final weighting of your plan?
 PA = 33%, AP = 27%
 LT = 19%, RT = 21%
 Did you use wedges? Why or why not?
  I did not use wedges because it threw dose completely out of where I needed it to be. I
considered adding a wedge on the AP beam due to that slant but it brought the hotspot up to
under the toe and very anterior of the patient.
 Where is the region of maximum dose (“hot spot”) and what is it?
 The hot spot is in the posterior left side of the treatment volume but is now within the PTV. The
value is 105.2%
 What is the purpose of normalizing plans?
 The purpose of normalizing plans is to tell the system how much coverage you are wanting to
get within a plan and how much leniency there is when deciding on percentage or isodose line
to normalize to.
 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 the plan where 100% of the dose covers 95% of the volume, I noticed the
Dmax got hotter but the hot spot stayed at almost the same spot. This may have happened
because of the dose being forced to stay within 95% of the volume created hot spots within the
PTV.

 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.
 Mobius3D DVH LIMITS

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

Ou29.3tcome
Bladder 6500 cGy 4740.5 cGy Y
Bowel 5000 cGy 4753.5 cGy Y
Rectum 6000 cGy 4629.3 cGy Y
Femurs 5000 cGy 4769.2 cGy Y