Ben Lemieux

Clinical Practicum Clinical Lab Assignment

July 28, 2015
Plan #1
1. Chart listing all critical structures and their respective TD 5/5.
Organs at Risk
(OR)

Spinal Cord
Brain Stem
Brain
Lt Lens
Rt Lens
Mandible
Oral Cavity
Lt Parotid

Constraint
Dose (cGy)

Plan #1
Dose
(cGy)

4500
5000
4500
1000
1000
6500
6000
3200

3027.3
2783.7
5903.0
59.6
65.6
6626.3
5986.0
222.5

Met
Constrain
t (Yes or
No)
Yes
Yes
No
Yes
Yes
No
Yes
Yes

2. Axial images showing 100% (6000 cGy), 95% (5700 cGy), 75% (4500 cGy)
and 40% (2400 cGy)

3. Plan 1 DVH and statistics

4. This plan included three different beams. The first two beams are wedge pair
fields with a prescription of 200 cGy per day for 30 fractions to a total of 60
Gy and the other was a straight AP beam covering the anterior neck nodes
with a prescription of 180 cGy per day for 28 fractions to a total of 50.4 Gy. A
1cm bolus was used to cover the entire treated area of the 1a and 1b beams.
No bolus was used for the 1c beam.

a. The 1a RAO field beam energy is 6MV photons directed at 320 degrees
with 0 collimator and couch angles. The field size is 8.6cm (X1:4.3,
X2:4.3) x 8.8cm (Y1:4.4, Y2:4.4) with MLC blocking to a margin of 1cm
around the Rt Parotid PTV. This field uses a 45 degree wedge. The toe
of the wedge faces right in the machine. The source to skin distance
for beam 1a RAO is 97.2 cm. The monitor units given from this field are
246 MU.
b. The 1b RPO field beam energy is 6MV photons directed at 230 degrees
with 0 collimator and couch angles. The field size is 8.2cm (X1:4.1,
X2:4.1) x 8.8cm (Y1:4.4, Y2:4.4) with MLC blocking to a margin of 1cm
around the Rt Parotid PTV. This field uses a 45 degree wedge. The toe
of the wedge faces left in the machine. The source to skin distance for
beam 1b RPO is 97.45 cm. The monitor units given from this field are
227 MU.
c. The 1c AP beam is matched to the inferior portion of both 1a and 1b
beams to treat the nodes in the right neck. It is independently jawed
down so the Y2 jaw has no divergence. The beam energy is 6MV
photons directed at 0 degrees with 0 collimator and couch angles. The
field size for this field is 8.2cm (X1:6.0, X2:2.2) x 10.1cm (Y1:10.1,
Y2:0) with MLC blocking the larynx on the superior medial portion of
the field. The source to skin distance for beam 1c AP is 95 cm. The
monitor units given from this field are 227 MU.
d. There are shifts from the simulation isocenter. The 1a and 1b treatment
isocenter is shifted 10.10cm out, 0.04cm up and 5.24cm right. The 1c
treatment isocenter is 5.67cm out, 0.21cm up and 2.83cm right.
5. Plan Evaluation
a. In this data set the patient was setup with their chin extended. The
chin extension helped with pulling the parotid glands forward to help
avoid critical structures and can also help decrease mandible dose.
This plan was constructed using two wedged pair fields with the beams
90 degrees apart. 45 degree wedges were used to create a
homogeneous dose distribution. 1 cm bolus was used to cover the
surface of the PTV. An anterior field was used and matched to the
inferior of the wedged pair to treat the right neck nodes. A clinic
standard of 5cm deep was used for this beam. A block was used to
protect the larynx from this beam.

Plan #2
1. Chart listing all critical structures and their respective TD 5/5.
Organs at Risk
(OR)

Spinal Cord
Brain Stem
Brain
Lt Lens
Rt Lens
Mandible
Oral Cavity
Lt Parotid

Constraint
Dose (cGy)

Plan #2
Dose
(cGy)

4500
5000
4500
1000
1000
6500
6000
3200

4723.4
4333.1
5832.1
40.3
30.0
6788.7
6250.2
3464.4

Met
Constrain
t (Yes or
No)
No
Yes
No
Yes
Yes
No
No
No

2. Axial images showing 100% (6000 cGy), 95% (5700 cGy), 75% (4500 cGy)
and 40% (2400 cGy)

3. Plan 2 DVH and statistics

4. This plan included two different beams. The first beam was an 18MV photon
field and the second beam was a 20MeV electron field. A 1 cm bolus was
used to cover the entire treated area.
a. The 2a Rt Lateral field beam energy is 18MV photons directed at 270
degrees with 0 collimator and couch angles. The field size is symmetric
and is 8.8cm x 9.0cm with MLC blocking to a margin of 1.3cm around
the Rt Parotid PTV. No wedges were used for this field. The source to

skin distance for beam 2a Rt Lateral is 97.36 cm. The monitor units
given from this field are 209 MU.
b. The 2b Rt Lateral electron field beam energy is 20MeV electrons
directed at 270 degrees with 0 collimator and couch angles. The field
size is symmetric and is 10cm x 10cm using a 10cm x 10cm cone with
custom block. The block was made creating a 1.3cm block around the
Rt Parotid PTV. The source to skin distance for beam 2a Rt Lateral is
100 cm to the top of the bolus and 101 cm to skin. The monitor units
given from this field are 215 MU.
c. There are shifts from the simulation isocenter. The 2a Rt Lateral
treatment isocenter is shifted 10.10cm out, 0.04cm up and 5.24cm
right. The 1c treatment isocenter is 10.10 cm out, 0.04cm up and
9.28cm right.
5. Plan Evaluation
a. This plan was constructed with two lateral beams. One was a photon
beam to cover the deeper portions of the tumor and the other was an
electron field used to cover the shallow portion of the tumor. In order to
get coverage, a 1cm bolus was used for both beams. I started with
lower energy electrons and photons but was having trouble getting
coverage of the tumor at deeper depths. I ended up going with 20 MeV
electrons and 18 MV photons to get 100% coverage of the tumor. This
plan differed from the wedged pair plan in left parotid dose, oral cavity
dose and also max hotspot dose. The left parotid in dose was the
biggest difference between the two plans. The left parotid mean dose
for the wedge pair was 138.5 cGy compared to the mixed beam that
was 2889.8 cGy. This is because of the exit dose with both beam
directed lateral toward the target. Although doses to the oral cavity
were much lower for the mixed beam plan. The max hotspot for the
two plans was 6846 cGy for the wedge pair fields and 7201 cGy for the
mixed beam and also did end up outside the PTV.

Plan #3
1. Chart listing all critical structures and their respective TD 5/5.
Organs at Risk
(OR)

Spinal Cord
Brain Stem
Brain
Lt Lens
Rt Lens
Mandible
Oral Cavity
Lt Parotid

Constraint
Dose (cGy)

Plan #3
Dose
(cGy)

4500
5000
4500
1000
1000
6500
6000
3200

1909.6
1955.2
4471.4
38.3
41.2
6301.8
5507.8
1434.4

Met
Constrain
t (Yes or
No)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

2. Axial images showing 100% (6000 cGy), 95% (5700 cGy), 75% (4500 cGy)
and 40% (2400 cGy)

3. Plan 3 DVH and statistics

4. This plan included 5 different IMRT beams. All beams were a 6MV photon
fields. A 0.5cm bolus was used to cover the entire treated area.
a. The 3a-e beam energy was 6MV photons directed at angles of 200,
240, 280, 320 and 0 degrees with 0 collimator and couch angles. The
field size is shown in the chart below. No wedges were used for these
fields. The source to skin distance and monitor units for each beam are
also in the chart below.
Beams
MU
X1
X2
3a 200
63
3.0
4.0
RPO
3b 240
84
3.5
4.0
RPO
3c 280
64
4.0
4.0
RAO
3d 320
53
4.0
3.5
RAO
3e 0 Ant
72
4.0
3.5
**SSD does not include depth of bolus

Y2
4.5

Y1
4.0

SSD
94.98

4.5

4.0

96.52

4.0

4.0

97.44

4.0

4.0

97.20

4.0

4.0

93.39

5. Plan Evaluation
a. This plan turned out the best between all three plans as far as PTV
coverage, hotspot and organ sparing. The plan was constructed with 5
beams. I started at 0 degrees and used 40 degrees between beams to
decrease overlap. This beam orientation worked great for organ
sparing giving multiple angles to deposit dose and allowed me to
reduce dose to structures but not lose coverage on the PTV. The
hotspot for this plan was 6304 cGy with 100% coverage of the PTV with

the 95% isodose line. As shown in the composite DVH below, the
doses for most critical structures were much lower than that of either
the wedged pair or mixed beam techniques.

Plan 1 = Thin Solid, Plan 2 = Thin Dashed, Plan 3 = Thick dashed