Jamie Robinson

Clinical Practicum 1
July 2, 2023

Plan 1: Calculate the single PA field.

Figure 1: Single PA field

• Describe the isodose distribution (be specific in your description of depth, location,
etc).
When I first calculated the single PA beam with 6MV, the isodose lines were all posterior and
barely past midline. Figure 1 shows the 100% isodose line represented in yellow which is
equivalent to the 4500cGy that was prescribed. However, it only reached the green crosshair
which is represented as the isocenter. It does not cover past that. When measuring from the
posterior of the patient, the yellow 100% isodose line stops at 12.2 cm. The PTV is unfortunately
not shown well in the image, however, regardless of that it is not even covered by the 80% line
represented in navy blue. The 50% isodose line in white, however, does cover the PTV and totals
2700cGy. The minimum dose being received to the PTV is 2687.2cGy

• Where is the hot spot (max dose) and what is it?

The hot spot is displayed in red and represents the dose maximum of 171.4% which is equivalent
to 7712.3cGy. Since 6 MV has a Dmax of 1.5 cm, the maximum dose is deposited closer to the
surface, which in this case is the posterior aspect of the patient.

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

The hot spot is created in this location because 6 MV has a Dmax of 1.5cm. The maximum dose
is deposited at that point creating a hot spot.
• Using your DVH, what percent of the PTV is receiving 100% of the dose?
Remember to describe or show how you read this.
Less than 50% of the PTV is receiving 100% of the dose, specifically 49.258%. To find this
exact total in Eclipse, I used the cross-hair tool, and placed it at the intersection of graph where
the red PTV line intersected the total dose of 4500cGy and then followed the intersecting grid
line on the Ratio of Total Structure Volume (%) shown in figure 2.
 Figure 2: DVH of Plan 2 showing coverage of PTV at 100%

Plan 2: Change the PA field to a higher energy and calculate the dose.

Figure 3: 10 MV PA Calculated Plan

Figure 4: 18 MV PA Calculated Plan

• Describe how the isodose distribution changed and why?
The isodose lines changed for both the 10 MV and 18 MV photon beams. With higher energy,
the beams were able to penetrate further into the body. The coverage is better; however, it still
fails to fully cover the PTV. When going back into the plan, the 70% isodose line fully covers
the PTV which totals 3150 cGy

• Using your DVH to confirm, what percent of the PTV is receiving 100% of the
prescription dose?
The 10 MV beam resulted in 50.298% receiving 100% of the prescription dose. The 18 MV
beam resulted in 53.4736% of the PTB receiving 100% of the prescription 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.

Figure 5: 3 Field Calculated Plan

• Describe the isodose distribution. What change did you notice?
On the third plan, shown in figure 3, the isodose distribution changed drastically as dose was
now displaying on the right and left laterals of the patient. The 100% isodose line is more
centralized and pronounced on the laterals as well resulting in excess dose outside of the PTV.
The superior and inferior coverage shown on the coronal image has also decreased.

• Where is the hot spot and what is it?

The hot spot on plan 3, shown in figure 6, is indicated by a red dot on each image and is
considered the global dose maximum totaling 114.6% which is equivalent to 5157.3cGy.

Figure 6: Hot Spot Location

 • What do you think creates the hot spot in this location?
When beams are created, the number of treatment beams, energy used, and field size are
just some of the factors that come into play and can impact the dose distribution. It is important
to consider when creating a plan how the dose distribution affects the prescribed target volume
and normal surrounding tissues. In this plan, equal field weighting was used and equaled 0.333
for all three fields. In some instances, unequal doses need to be assigned to a beam, which is
considered beam weighting.2 Modifying the beam weighting can be of benefit to reduce dose
outside of the planned tumor volume especially when multiple beams are used. 2

Plan 4: Increase the energy of all 3 fields and calculate the dose.

Figure 7: 10 MV Calculated Plan

Figure 8: 18 MV Calculated Plan

• Describe how this change in energy impacted the isodose distribution.
With a higher energy, the 100% isodose distribution expanded anteriorly, superiorly, inferiorly
as well as laterally. On the 10 MV plan, the entire PTV is covered by the 80% isodose line
equaling 3600cGy. The dose to the laterals has also decreased compared to the 6 MV allowing
for less dose to normal tissue. The 18 MV plan shows similar coverage with the 100% isodose
line except for the coronal view. On the coronal view, the 100% isodose line covers the inferior
portion of the PTV better. The entire PTV is now covered by the 90% isodose line. Although that
coverage is tight, the higher energy allows 4050cGy to get to the PTV. The dose to the patient’s
laterals were also decreased. Only the 80% isodose line shows on the 18 MV plan compared to a
combination of 80% and 90% with the use of 10 MV. With higher energy, the beam is able to
travel further through the body depositing its dose closer to the PTV.
 • In your own words, summarize the benefits of using a multi-field planning
approach? (Refer to Khan Ph.ysics for benefits of multiple fields)
Using a multi-field planning approach has many benefits when completing 3D treatment
planning. By using multiple fields, a lower energy (6 MV or 10 MV) can be used. As the lower
energy beams are delivered from multiple fields, dose is distributed around the PTV over a larger
surface area.3

• Compared to your single field in plan 2, what percent of the PTV is now receiving
100% of the prescription dose? Use a DVH to show how you obtained this response.
The 10 MV plan is receiving 50.5563% to 100% of the prescription dose and the 18 MV plan is
receiving 56.3737% to 100% prescription dose.

Figure 9: DVH with Comparison of Plan 2 and Plan 4 Receiving 100% of Prescription 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?
The final weighting chosen for plan 5 was 0.233 for the PA and 0.383 for both the right and left
laterals.

Figure 10: Field Weighting for PA, Right Lateral, and Left Lateral Fields
• What was your rationale behind your final field weight? Be specific and give details.
I wanted to try to minimize the dose to the patient’s laterals, so I weighted the beam heavier on
both the right and left. I did not see any benefit to weighting the right more than the left or vice
versa. Although weighting the PA beam higher would have decreased dose to the laterals, it
compromised coverage to the PTV and created more hot spots in the posterior aspect of the
patient and overall, a hotter plan. With lower beam weighting on the PA beam, my plan dose
max was 109.8%, as opposed to 115.1% with a higher weighted beam on the PA.

Figure 11: Final Field Weighting

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..)
The final wedge angle that I chose was a 25 enhanced dynamic wedge. In this plan, the heel of
the wedge was placed towards the posterior of the patient in order to absorb the hot spot in the
posterior aspect of the patient in hopes to even out the dose distribution.

Figure 12: 25 EDW

 • 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.
Figure 11 shows the coronal and axial view of what my plan looked like prior to the addition of
any wedges. In order to determine the true effect of the wedges, I created a plan for each
electronic wedge that is offered in my clinic-10 EDW, 15 EDW, 20 EDW, 25 EDW, 30 EDW,
45 EDW, and 60 EDW. All of these plans with the respective wedges are shown below in figures
13-18, except for the 25 EDW which is shown above in figure 12.
For all the wedges that were placed, the heel of the wedge was placed posteriorly with the intent
to minimize the hot spot in the posterior aspect of the pelvis and to even out the dose
distribution. As you look through the images, you can see how the isodose lines change primarily
on the patient’s laterals as well as the 100% isodose line, shown in yellow on the coronal image.
The 100% line showed better coverage with each wedge added as the isodose line moved
anteriorly on both the coronal and axial images as well as gave better inferior coverage to the
PTV. The 50% isodose line shown in white covered on the lateral minimized with each wedge
application. However, as the wedge angle increased, the plan did become “over wedged.”
Looking at figures 16-18, one can see on all images that as the wedge increased, the isodose lines
gave worse coverage anteriorly, superiorly, and inferiorly.

Figure 13: 10 EDW Figure 14: 15 EDW

Figure 15: 20 EDW Figure 16: 30 EDW

Figure 17: 45 EDW Figure 18: 60 EDW

 • According to your Khan Physics book, 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 absorber should be placed from the patient’s
skin surface in order to keep the skin dose below 50% of dmax is 15 cm.3

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?
In my final plan, I chose 18 MV. This energy showed the best dose distribution due to the size of
the patient. When showing my plan to my preceptor, she recommended using EZ fluence and
generating a plan so that the AP and PA were the fields with beam modifiers as opposed to the
laterals.

• What is the final weighting of your plan?

The final weighting of my plan was 1.0 for both the AP and PA fields, 0.248 for the right lateral
field and 0.240 for the left lateral field.

Figure 19: Final Field Weighting for Plan 7

• Did you use wedges? Why or why not?
I decided not to use wedges for my final plan. Instead, I used the 3D automated planning
software, EZ fluence. After trying all the available EDW available in Eclipse, my preceptor
recommended to see what EZ fluence would create and how it would compare to my current
plans. EZ fluence created two fluences on the AP and PA fields of my treatment plan. A wedge
on the AP and PA fields was not something that I had considered. With the EZ fluence added, I
saw a reduction in dose to the patient’s anterior which eliminated dose to the bowel.
• Where is the region of maximum dose (“hot spot”) and what is it?
The region of the maximum hot spot is located centrally within the PTV and is 105% with no
normalization and 106.6 with normalization of 100% covers 100% of the target volume.

• What is the purpose of normalizing plans?

Normalization can be rather complex in 3D and IMRT treatment planning as there are multiple
ways to normalize a plan. Options of normalization include normalizing to an isocenter, a defined
point other than the isocenter, a minimum target absorbed dose, an isodose value, and to the dmax
of the beams.1 When a plan is normalized, the dose to the planned tumor volume (PTV) is being
adjusted or “forced” to 100% at Dmax for a SSD plan or 100% to the isocenter for a SAD treatment
plan.2 This results in dose to all surrounding areas to adjust or change by the same ratio.2

• 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.
Prior to normalization, the Eclipse software defaulted to the ISO receiving 100% of the dose.
The maximum dose to the treatment plan was 105%, with a minimum of 98.5% to the PTV and a
mean of 102.4% to the PTV. The yellow 100% isodose line in figure 20 was evenly distributed
throughout the PTV.
When the plan was normalized so that 95% covers the 100% target volume, shown in figure 21,
the maximum dose changed to 106.6%, the minimum dose to the PTV was 95% and the mean
was 100.8% Normalizing my plan decreased the dose overall to the PTV.

Figure 20: No Normalization-Defaults to ISO getting 100% of the Dose.

Figure 21: After Normalization-95% covers 100% of the Target Volume-98.5% Plan
Normalization

• 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 22: Final Plan’s Isodose Distributions
• Include a final DVH with PTV and OARs. 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).
This is my final DVH with the PTV and OARs shown.

Figure 23: Final DVH and OARs

Figure 24: A plan comparison was ran to compare the two different plans with and without
normalization. When looking at this DVH, the lines from both plans overlap showing little to no
difference between them.
• Use the table below to list typical organs at risk, critical planning objectives, and the
achieved outcome. Provide a reference for your planning objectives and a rationale
for the objectives chosen. Organ at Risk (OAR) Planning Objective Objective
Outcome Objective Met? (Y/N)
Per our department’s ClearCheck, constraints are listed and can be customized based of what is
being treated and the prescription dose. For a patient being treated to 4500cGy to the pelvis the
following constraints are used and are shown in the table below. QUANTEC values were also
listed as a reference and comparable to our department’s standards.
Our guidelines and my results are as follows:
Less than or equal to 30-70% of the bowel can receive 4000cGy.
Less than or equal to 35-70% of the bladder can receive 4500cGy and 0.03cc can receive
6500cGy.
Less than or equal to 80-100% of the rectum can receive 4000cGy and 0.03cc can receive
6500cGy.
Less than or equal to 15-20% of the femoral heads can receive 3000cGy and 0.03cc can receive
5500cGy.
All of the criteria for this plan was met with the exception of V4500cGy≤35-70%. Unfortunately,
since the pelvis was treated with a 4 field box technique, there was no way to minimize dose to
the bladder especially when taking into consideration its location to the PTV. The final outcome
for the bladder was 92.762% which was 22.762% over the planning objective limit. On our
department template, it states that 20-30% of treatment plans will not meet criteria.
 Organ at Risk Planning Objective Objective Outcome Objective Met (Y/N)
(OAR)
Bowel (BO) V4000cGy≤30-70% 37.616% Y
V65 < 50%
(QUANTEC)
Bladder (BL) V4500cGy≤35-70% 92.762% N
V6500cGy≤0.03cc 0cc Y
V 65 < 50%
(QUANTEC)
Rectum (R) V4000cGy≤80-100% 90.876% Y
V6500cGy≤0.03cc 0cc Y
V50 < 50%
(QUANTEC)
Femoral Heads V3000cGy≤15-20% 14.555% Y
(F) V5500cGy≤0.03cc 0cc Y
V50 < 5%
(QUANTEC)
Figure 25: Objectives and Outcomes for OARs
Sources:
1. Pickett B, Altieri G. Normalization: What does it really mean? Science Diet.
1992;17(1):15-27. https://doi.org/10.1016/0958-3947(92)90004-Y.
2. Bentel G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hills; 1992.
3. Gibbons JP. Khan's The Physics of Radiation Therapy, 6th Edition. Philadelphia, PA:
Lippincott, Williams, and Wilkins; 2020.