Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

Pelvis Clinical Lab Assignment

*Prescription: 4500cGy in 25 fractions to the PTV
*Plan 1: 6X Single PA Field

1. Describe the isodose distribution:

The isodose distribution demonstrates that the majority of the dose is situated on the
posterior surface of the patient’s pelvis. This isodose distribution does not show
conformal coverage of the PTV. The prescription isodose does not reach the anterior or
lateral portions of the PTV, and the dose distribution is providing too much dose to the
posterior pelvis.
2. Where is the hot spot and what is it?
The hot spot is located on the posterior surface of the patient’s pelvis, near the sacrum
and coccyx. The 3D dose max for this plan is 7704.5 cGy. Additionally, the rectum is
receiving a mean dose of 5451.8 cGy and max dose of about 68 Gy, which is more than
the prescription of 45 Gy. I believe this hot spot is created because there is only one beam
targeting the PTV and entering the patient posteriorly. I think if additional beams were
added it would help distribute the dose more evenly and provide more dose in the
direction of the additional beams.
3. Percent of the PTV receiving 100% dose:
From viewing the DVH for this plan, it shows that only 48.7% of the PTV is receiving
the prescription dose of 45 Gy.
Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

*Plan 2a: 10X Single PA Field

1. How did the isodose distribution change and why?

Increasing the energy of the single posterior beam increased the coverage anteriorly and
reduced the hot spot in the posterior pelvis near the skin surface. The 3D dose max with
the 10 MV beam is now 6950.5 cGy, demonstrating a slight skin-sparing effect.
Additionally, the 50-90% isodose lines with the 10 MV beam reach further anteriorly. I
believe this is because of increased forward scatter with the higher energy beam.
Although, there is not much difference in the prescription isodose line, it is still not
covering the anterior or lateral aspects of the PTV.
2. Percent of the PTV receiving 100% dose?
After viewing the DVH for the 10 MV posterior beam, there is 49.9% of the PTV
receiving the prescription dose of 45 Gy.

*Plan 2b: 18X Single PA Field

Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

3. How did the isodose distribution change and why?

Raising the energy of the posterior beam even further to 18 MV shows the 50-90%
isodose lines move even more anteriorly from the effects of forward scatter. The hot spot
on the posterior surface of the pelvis is now reduced to 6573.7 cGy, demonstrating even
further skin sparing with the 18 MV beam.
4. Percent of the PTV receiving 100% dose?
After evaluation of the DVH for the 18 MV posterior beam, it shows that 53.6% of the
PTV is receiving the prescription dose of 45 Gy.

*Plan 3: 6X, 3 Field (PA, R Lat, L Lat)

1. Describe the isodose distribution and change:

After adding the two lateral beams at 6 MV the isodose distribution changed
significantly. The PTV is covered laterally with the prescription dose, but there are now
Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

hot spots of about 105% (47.25 Gy) on each lateral surface of the pelvis. The 50% (22.5
Gy) isodose line is more conformal to the anterior aspect of the PTV, and it does not
reach out into the small bowel as much. The extreme hot spot on the posterior surface has
almost been removed, with only a couple spots of about 110% (49.5 Gy) in the posterior
pelvic muscles. Additionally, most OAR dose has been reduced, the rectum having the
greatest reduction of dose. Although, the femurs are receiving more dose with the lateral
fields added.
2. Where is the hot spot and what is it?
The hot spot is still in the posterior pelvis, but with the three fields the hot spot is no
longer on the coccyx or sacrum, it is in the posterior pelvic muscles. The 3D dose max is
now only 5119.1 cGy, occurring in the right posterior pelvic muscles. Adding the lateral
fields has created areas of 47.25 Gy (105%) on the lateral superficial surfaces of the
pelvis.
3. What creates the hot spot in this location?
The lateral hot spots are created from skin dose from the 6 MV beams. The posterior hot
spot occurs where there is overlap between the three fields, and it is more posterior
because of the posterior beam.
*Plan 4a: 10X, 3 Field (PA, R Lat, L Lat)

1. Describe how the change in energy impacted the isodose distribution:

The increase in beam energy to 10 MV for the three fields shows significant skin sparing.
The prescription isodose line with the 10 MV beams is no longer present on each lateral
surface of the pelvis. The 3D dose max is reduced to 50.23 Gy instead of 69.51 Gy with
just the posterior 10 MV beam. Also, the hot spot in the posterior pelvic muscles has been
reduced slightly in comparison with the three field 6 MV plan.
2. Summarize the benefits of using a multi-field approach:
Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

The use of multiple fields offers a few benefits to dosimetry. One of the benefits is when
multiple beams are used the dose to the subcutaneous tissue is reduced. In using one or
two beams the dose to the tissue where the beam(s) enter is greater. By adding multiple
beams, the planner is able to reduce the skin dose by distributing the dose over multiple
fields. Another benefit with multiple beams is the reduction in dose to OAR surrounding
the tumor while increasing tumor dose. Multiple fields have better potential of providing
a more conformal plan. Furthermore, multiple fields allow the planner more capabilities
of customizing the dose distribution with MLCs, wedges, and field weighting. If there is
only one beam, then there are not as many choices for the planner to work with.
3. Compared to Plan 2, what percent of the PTV is receiving 100% dose?
In plan 2a, 10 MV plan with only the posterior beam, 49.9% of the PTV was receiving
the prescription dose of 45 Gy. After adding the lateral fields to the posterior 10 MV
beam plan, 49.2% of the PTV is receiving 45 Gy. This occurred because the lateral
beams, being equally weighted, caused the prescription isodose line to bulge laterally
instead of just projecting anteriorly.

*Plan 4b: 18X, 3 Field (PA, R Lat, L Lat)

4. Describe how the change in energy impacted the isodose distribution:

Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

After increasing the energy of the three fields to 18 MV, additional skin sparing is
noticed on each lateral surface of the pelvis. The isodose lines project more anteriorly
covering more of the PTV with the 18 MV beams because the lateral beams have
increased penetration as well. Although, there are slightly larger hot spots in the posterior
pelvic muscles from increased penetration of the lateral beams and their overlap with the
posterior beam.
5. Compared to Plan 2, what percent of the PTV is receiving 100% dose?
Plan 2b, 18 MV posterior beam only, had 53.6% of the PTV receiving 45 Gy. The DVH
for the 18 MV with three fields shows 57.4% of the PTV receiving 45 Gy. An increase
because the lateral beams have caused the prescription isodose to cover more of the
anterior and lateral borders of the PTV.

*Plan 5: 18X, 3 Field (PA, R Lat, L Lat) Weighted

1. What was the final weighting choice for each field and the rationale?
Pictured above is how I chose to weight the three 18 MV fields (PA at 40.9%, Laterals at
29.5%). I thought it would be best to weight the posterior field the most with the laterals
at equal contribution. I know this adds a hot spot in the posterior pelvis and increases the
Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

rectal dose. I tried to balance the hot spot in the posterior pelvis with the lateral beams to
not have anything greater than 110% dose. My thought process was that I would
eventually add wedges on the lateral fields to reduce dose to the hot spot and increase the
dose anteriorly. I also did not like weighting the laterals too heavily because it caused
prescription dose to appear at each lateral surface of the pelvis, which does not contain
any PTV and would cause unnecessary increased dose to the femurs and skin tissue.
*Plan 6: 18X, 3 Field (PA, R Lat, L Lat) 30 Degree Wedge, Weighted

1. What was the final wedge angle and orientation?

I thought that the 30-degree wedge angle with the heel towards the patient’s posterior
surface and the toe pointing anteriorly looked the best. In my opinion, it attenuated
enough dose on each lateral surface of the patient and the posterior pelvis while not
increasing the dose too much anteriorly and adding hot spots in the bowel. I did notice
that there was a hole created in the center of the PTV, but thought this could be fixed
with normalization or adding an anterior beam. Knowing I would eventually add an
anterior beam, I did not want the wedges to increase the dose too much anteriorly and
then have a hot spot when the anterior field is added. I also adjusted the weighting of the
lateral beams because the left lateral was creating an anterior spot of 105% dose. I know
there are still areas of 105% dose in the posterior pelvis, but thought when an anterior
beam was added those spots would be reduced. I also liked that the 105% dose in the
posterior pelvis was mostly avoiding the rectum.
2. How did the wedges change the isodose distribution?
After adding the wedges, the isodose distribution changed drastically. As pictured below,
in the axial view the anterior dose was increased significantly with the 30-degree wedges
on the lateral fields allowing more dose on the toe side anteriorly. Now the prescription
isodose line covers the anterior portion of the PTV. Additionally, the area of 110% dose
Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

in the posterior pelvis is no longer present with the wedges added to attenuate the dose in
the heel section of the wedge. Furthermore, the dose on each lateral surface of the pelvis
has been decreased because the wedges have absorbed some of the dose.

3. 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?
According to Khan, the minimum distance a wedge or any other absorber should be
placed from the skin surface is 15 cm. This distance from the skin helps make sure the
skin-sparing effect of MV beams is not compromised with electron contamination from
the absorber.
*Plan 7: 18X, 4 Field Box, 30-Degree Wedge, Weighted, Normalized

1. What energy and why?

After discussing the best plan options with my preceptor and creating plans with different
energies, wedges, and weighting we decided on this plan. We thought 18 MV was the
optimal beam energy for a pelvis plan of this thickness to get the proper penetration.
Additionally, the higher energy offers better skin-sparing and since the tumor is deep in
the pelvis we felt that this was a better option.
2. What is the final weighting of the plan?
Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

The final weighting of the plan has the posterior beam contributing the most at 39.3%,
the laterals are almost even at 25.7% for the right and 25.0% for the left, and the anterior
beam is only at 10%. This arrangement was chosen to avoid excess dose to the bowels
with the anterior beam, and decrease dose to the lateral pelvis from the lateral fields.
3. Were wedges used, why or why not?
For this plan 30-degree wedges were used on the laterals with the heel at the posterior
surface and the toe at the anterior surface. This enabled the laterals to decrease the
posterior 110% dose and increase the anterior dose to make it more conformal to the
PTV. Without wedges the plan had areas of dose above prescription either anteriorly or
posteriorly. Also, if the laterals did not have wedges and were increased to reduce the
spots of dose over the prescription it caused more dose to each lateral surface of the
pelvis.
I tried many different wedge arrangements and had a hard time choosing between the
plan with 45-degree wedges or 30-degree wedges. I decided I liked the DVH statistics
better for the rectum and CTVs with the 30-degree wedges. I also liked the visual of
where the 105% isodose spots were with the 30-degree wedges, but the other OAR doses
were just slightly higher with the 30-degree wedges than the 45.
4. Where is the region of maximum dose and what is it?

The 3D dose max for this plan is 109.5% (49.05 Gy). The area of maximum dose is on
the anterior and left side of the PTV. There are also multiple spots of 105% dose,
somewhat balanced between the four corners (anterior left and right, posterior left and
right) of the PTV in the axial view. I tried to minimize any dose above prescription to any
OAR while not letting dose increase outside of the PTV too much. Unfortunately, parts of
the rectum, bowel space, and bladder are receiving 105% dose because they are in or near
the PTV.
5. What is the purpose of normalizing plans?
Normalizing a plan is another way to alter the dose distribution by scaling the dose to a
desired level. There are multiple ways to normalize, dose can be normalized to different
locations such as a point or volume. The planner can also choose how to normalize.
Whether that is a certain amount of dose covering a point or volume or to a specific
isodose line. The basic goal of normalizing a plan is to alter the dose to a desired level to
achieve optimal coverage. Below is an example of normalizing the plan so that 95% of
the PTV receives 45 Gy.
Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

6. What impact did normalization have and why?

After normalizing the plan, the cyan line (100% isodose line representing 45 Gy) is
shown to cover more of the PTV. As seen above in the transverse and coronal images, the
plan that was not normalized did not have prescription dose coverage of the anterior,
inferior, or superior aspects of the PTV. Once the plan was normalized to have 95% of
the PTV receiving 45 Gy, more of the PTV was covered by the prescription dose. The
impact of normalizing on this plan caused the dose to increase to provide better coverage
to the PTV. This alters every isodose line, as seen above the areas of 105% dose also
increase along with the other isodose lines.
Dosimetry Clinical Internship-Pelvis Lab Kearla Bentz

*RTOG 1203 (Pelvis Gyn 45 Gy) Planning Objectives

OAR Planning Objective Objective Objective Met?
Outcome
Bladder D35% < 4500 cGy 4634.76 cGy No
Bowel D190cc < 4500 cGy 4642.32 cGy No
Bowel D30% < 4000 cGy 4380.21 cGy No
Lt Femur Maximum dose < 4700 cGy 4688.4 cGy Yes
Rectum D80% < 4000 cGy 4537.51 cGy No
Rt Femur Maximum dose < 4700 cGy 4665.2 cGy Yes