Clinical Pelvis Lab

By: Kristen Eberhard,

University of Wisconsin-LaCrosse

2-22-2023

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Kristen Eberhard
2/22/23

Students were given prompts to complete this Pelvis lab assignment. All plans that were created have
screenshots of the isodose distributions and Dose Volume Histograms (DVH) for review, as instructed.
The objectives are listed and answers below:
Setup:
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.

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Plan 1-PA, 6X
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?
The isodose distribution is shallow in this simple PA field. This is a representation of the beam as a factor
of depth. There is some bowing of the isodose line due to the inhomogeneities shown by distinct horns.
The 100 percent isodose line reaches a depth of 11.58cm. However, only 47.9 percent of the PTV is
receiving 100 percent of the dose according to the Dose Volume Histogram (DVH).
Due to an energy of 6X being used in the plan, the hot spot is expected to be around Dmax (1.5cm). There
is some attenuation of the beam from the table and patient tissue inhomogeneities seen in the isodose
lines. The hot spot is 171.3% and presented posteriorly at a depth of 1.38cm. Because the beam is of
lower energy, as compared to a 10X or 18X beam, the dose is expected to be shallower, and because the
beam is directed from the posterior aspect of the patient, the hot spot lies posteriorly.
Looking at the DVH, 47.9 percent of the PTV is receiving 100% of the prescribed dose in this plan. This
DVH also shows that this plan is not conformal when evaluating and viewing the gradual slopes.

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Plan 2-PA, 18X

Prompt: 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?
The isodose distribution is now more forward peaked, reaching deeper depths in the patient, with a higher
Beam Energy of 18X. The isodose distribution is more homogenous because less absorption of dose
occurs with higher energy beams, as the field size has remained the same and still utilizing SAD
technique.
The hot spot is now 145.8% at 2.95 cm depth which is close to the 3.3 cm Dmax of the 18X Beam. The
beam profile has changed. The horns are less pronounced, and the shoulders are more rounded due to the
flattening filter of the LINAC causing hardening of the beam and using the higher 18MV energy.
Looking at the DVH, 52.6 percent of the PTV is now receiving 100% of the prescribed dose.

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Plan 3-PA with opposing laterals, 6X

Prompt: 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?
By adding more fields, the dose becomes more complicated. There is less uniformity in the Posterior
beam. Isodose lines and hot spots appear on both sides of the patient in the parallel opposed beams
directed laterally. This represents a higher dose to the normal (lateral) subcutaneous tissues. “Uniformity
of the dose depends on three things: beam Energy, beam flatness, and patient thickness,” per Khan. 1
Because this plan is using a low energy 6X beam, the dose to the lateral soft tissue is higher as dose does
not travel deep into the patient. The isodose distribution has greater horns posteriorly, being pulling
posteriorly, as dose is now delivered in overlapping fields. The lateral-posterior portion of the PTV
receive higher doses than the medial-anterior portion of the planning target volume. This creates the “U-
shaped” isodose line representing the 100 percent prescribed dose.
The hot spot has decreased again, now reading 113.3%. The hot spot has also moved, because there is
more dose delivered anteriorly and laterally from the addition of parallel opposed beams, and there is
overlap by the lateral beams with the posterior beam. The hot spot has moved anteriorly, deeper into the
tissue.

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Plan 4- 3 Field, 18X

Prompt: 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?
 Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the
prescription dose?

Increasing the energy of the beam created a more midline uniform dose; and the high dose that was being
delivered to normal subcutaneous tissue decreased laterally. The horns have decreased, and the dose is
still slightly being pulled posteriorly.
By using a multi-field approach at higher energies, the normal tissues are spared because the beam, as a
function of the beam’s energy can travel deeper to the tumor toward midline; and use of multiple fields
allows the dose to be distributed through the body at different points/angles (still directed at the tumor),
instead of being focused on one point of entry/exit dose, thus, sparing normal tissue.
Compared to Plan 2, 56.1 percent of the PTV is now receiving 100 percent of the prescribed dose
although the isodose curve is pulled posteriorly, there is more coverage to the planning target volume
after using multiple fields.

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Plan 5 Weighting 3Field Beams

Prompt: 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?
By weighting beams in the TPS, the dosimetrist can change dose distribution. I placed heavier weight on
the PA field at 37.6% and split the remaining weight between the lateral fields at 31.2 % each. In doing
so, this allowed the imbalance of the lateral fields to be corrected and reduced the dose to the lateral
normal tissue. This also gave the best PTV coverage. If one of the laterals were weighted heavier than the
other, then the isodose distribution would be pulled to the side of greater weight. If the lateral fields are
weighted heavier than the PA field, then the lateral dose increases and the isodose distribution becomes
hourglass shaped with dose pulled inward midline. If the PA field is more heavily weighted, the dose
becomes near the posterior skin surface increasing dose. Thus, the current weighting gave optimal results.

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Plan 6 PA, LT LAT, RT LAT with Wedges

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)

On Plan 6, wedges could be placed in the beam’s path. I chose 45 degree Enhanced Dynamic Wedge
(EDW), with a collimator rotation of 90 degrees, and the wedge heel was at the patient’s posterior aspect.
(Wedge toe is then anterior). I chose this orientation due to patient’s inhomogeneity. Adding the wedges,
in this manner, pulled the isodose lines more anterior which provided more even and adequate tumor
volume coverage. I then weighted the beams (PA-52.5, LLAT-23.9, RTLAT-23.9) to obtain a more even
isodose distribution that almost completely covered the PTV with 95% of the prescribed dose.
The minimum distance a wedge should be from the patient’s skin is 15 cm, per Khan.

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Plan 7-4 Field Pelvis

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.

Using a combination of energies, a 10X for the PA field and 18x for all other beams, allowed for a more
uniform dose. The 10X was used posteriorly as there is less tissue to travel through, and the 18X was used
for the lateral beams due to greater separation and for the AP needing to penetrate deeper into the patient.
Instinctively, one would think using a 6X beam would be useful in the PA Field, but using the lowest

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energy increased the hot spot and dose to the Organs at Risk (OAR). Using a 10X beam helped provide
the best PTV coverage with decreased dose to critical structures.
All fields were equally weighted at 25% and no wedges were used. No wedges were used because with
the addition of an AP field produced a box like isodose distribution. Coverage was adequate and the plan
was acceptable but could be a little better.
There is a hot spot of 105.5 percent located anteriorly and on the left side of the patient before plan
normalization. Plan normalization is used to scale the machines output to reach the desirable dose. After
applying this method, the dose became more uniform making isodose lines appeared smoother. This
happens because the TPS has increased the monitor units ever so slightly to allow more dose to be
produced and provide uniform coverage around the PTV.
Plan comparison of before normalization (left) and after (right).

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As SLHS uses several guidelines for constraints, I used the RTOG protocols that is used in Mobius as a
second check for acceptable planning.

Organ At Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Bladder V80 Gy < 15% 4776.1 cGy Y
Rectum V50 Gy <50% V50=0 Y
Small Bowel Dmax ≤ 55Gy 4817.6 CGy Y
Femoral heads V44 Gy < 5% V44=5.79 N

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REFERENCES:
1.Khan’s The Physics of Radiation Therapy, 6th edition., John P. Gibbons. Chapter 11.

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