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Planning Assignment (3 field rectum)

Use a CT dataset of the pelvis. Create a CTV by contouring the rectum (start at the anus and stop
at the turn where it meets the sigmoid colon). Expand this structure by 1 cm and label it PTV.

Create a PA field with the top border at the bottom of L5 and the bottom border 2 cm below the
PTV. The lateral borders of the PA field should extend 1-2 cm beyond the pelvic inlet to include
primary surrounding lymph nodes. Place the beam isocenter in the center of the PTV and use the
lowest beam energy available (note: calculation point will be at isocenter).

Contour all critical structures (organs at risk) in the treatment area. List all organs at risk (OR)
and desired objectives/dose limitations, in the table below:

Organ at risk Desired objective(s) Achieved objective(s)

Small Bowel V20 <50% V20 = 7.17%
V45 <10% V45 = 0
V50 <0% V50 = 0
Max <50Gy Met
Femoral Heads and Neck V45 <20% V45 = 0
Met
Bladder V50 <30% V50 = 0%
Met
* All constraints listed are outlined in procedural guidelines set by my clinical institution

a. Enter the prescription: 45 Gy at 1.8 /fx (95% of the prescribed dose to cover the PTV).
Calculate the single PA beam. Evaluate the isodose distribution as it relates to CTV and
PTV coverage. Also, where is/are the hot spot(s)? Describe the isodose distribution, if a
screen shot is helpful to show this, you may include it.
After adding a PA field as described above with a 6MV photon beam there was
significant hot spots around the posterior surface of the patient. The max point dose is
currently at 73.55 Gy or 163% (Figure 2). The Max point dose is very near the skin
surface which I suspect is due to the fact that we account for the density of the treatment
table in our plans. In addition, there are several slices of the CT where the 95% line is
not covering the PTV anteriorly.
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Figure 1 - 6MV PA Beam

Figure 2 Isodose Line

Color Key

Figure 3 - 15MV PA Beam

b. Change to a higher energy and calculate the beam. How did your isodose distribution
change?
When changing this field to a 15 MV beam the isodose lines moved anteriorly as is
expected with a more penetrating beam (Figure 3). The max point dose also dropped to
65.32 Gy or 145%. This point has moved anterior by about 1.25 cm due to the increase
in energy in comparison with the 6MV beam. The small bowl and bladder however are
now receiving a higher dose due to the increased penetration of the beam. Previously the
Small bowel was covered minimally by the 31.5 Gy line but now has some coverage with
the 36 Gy line. This patient is positioned supine however the use of a prone belly board
would improve the amount of dose to the small bowel as the stomach would be pulled out
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of the field more. With the 15 MV Beam the 95% line is still not completely covering the
anterior portion of the PTV though it is improved from the 6MV beam energy.

c. Insert a left lateral beam with a 1 cm margin around the ant and post wall of the PTV.
Keep the superior and inferior borders of the lateral field the same as the PA beam. Copy
and oppose the left lateral beam 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 beams.
Describe this dose distribution.
The 95% line is now forming a box around the rectum which has eliminated the posterior
hot spot however the lateral beams are now showing increased dose superficially on the
right lateral beam which is seeing full prescription dose at a depth of 1.5 cm. The dose to
the bowel and bladder have been significantly improved with the bowel as compared to
the single field plan (figures 3 &4). The max point dose has also decreased to 51.5 Gy or
114%. The femurs are now getting significantly more dose as well as opposed to the
single field 6MV plan.

Figure 4 - Single field 6 MV beam

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Figure 5 - 3 field equal weighted 6 MV beams

d. Change the 2 lateral fields to a higher energy and calculate. How did this change the dose
distribution?
The superficial dose to the lateral beams has reduced significantly to 40.5 Gy being the
highest superficial dose (figure7). The max point dose for this plan is now 50.3 Gy or
111.7%. It is now located deeper to the patient but just lateral and posterior to the PTV.
The max point dose to the small bowel and bladder were again reduced (figure 6).

Figure 6 - 3 field plan showing lateral beams with 15 MV and PA beam with 6MV
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Figure 7 - Isodose distribution for 3 field plan with 15 MV lateral fields and 6MV PA
field

e. Increase the energy of the PA beam and calculate. What change do you see?
The lateral beams have cooled off and the 40.5 line has been eliminated superficially.
The max point dose did increase very slightly to 50.5 Gy or 112.2%. This point is located
lateral and posterior to the PTV.
f. Add the lowest angle wedge to the two lateral beams. What direction did you place the
wedge and why? How did it affect your isodose distribution? (To describe the wedge
orientation, you may draw a picture, provide a screen shot, or describe it in relation to the
patient. (e.g., Heel towards anterior of patient, heel towards head of patient.)
The collimator was changed to 90 degrees for both laterals and field sizes were adjusted
to match their previous orientation to accommodate the use of a 10 degree EDW for
either field. The max point dose for the plan has dropped to 49.8 Gy or 110.7%. The
hotspots that were located lateral and posterior to the PTV have decreased in size but are
still present (figure 8). Coverage has also been maintained over the PTV with the 95%
line. Some of the lower energy dose areas are beginning to pinch in near the box of
coverage around the target.
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Figure 8 Isodose distribution after addition of 10 degree wedge

g. Continue to add thicker wedges on both lateral beams and calculate for each wedge angle
you try (when you replace a wedge on the left, replace it with the same wedge angle on
the right). What wedge angles did you use and how did it affect the isodose distribution?
Utilizing 45 degree wedges with heels oriented posteriorly dropped the max point dose to
47.5 Gy or 105.5%. The posterior side of the box formed by the 95% line has now
pinched in slightly and coverage of the PTV has been maintained throughout.
The max dose to the femurs has increased in this plan quite notably. The bladder max
dose has also increased but the small bowel doses have decreased (figure 9).

Figure 9 - 3 field plan utilizing 45 degree wedges with heels posterior

h. Now that you have seen the effect of the different components, begin to adjust the
weighting of the fields. At this point determine which energy you want to use for each of
the fields. If wedges will be used, determine which wedge angle you like and the final
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weighting for each of the 3 fields. Dont forget to evaluate this in every slice throughout
your planning volume. Discuss your plan with your preceptor and adjust it based on their
input. Explain how you arrived at your final plan.
I started with a 2:1:1 weighting for this plan with all 15 MV beam energies because of the
depth of the PTV and then added weight to the lateral beams to reduce a posterior
hotspot. My final weighting was 46% to the PA field and 27% to each lateral field. I
utilized 60 degree wedges laterally with the heels posterior. The max point dose for the
final plan was 47.5 Gy or 105.5%. This point was just lateral to the PTV and just
superior to the right femoral head (figure 10).
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Figure 10 - Axial, Sagittal, & Coronal views of final plan

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Figure 11 - DVH of final Plan

i. In addition to the answers to each of the questions in this assignment, turn in a copy of
your final plan with the isodose distributions in the axial, sagittal and coronal views.
Include a final DVH.

See Figures 10 & 11

4 field pelvis

Using the final 3 field rectum plan, copy and oppose the PA field to create an AP field. Keep the
lateral field arrangement. Remove any wedges that may have been used. Calculate the four fields
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and weight them equally. How does this change the isodose distribution? What do you see as
possible advantages or potential disadvantages of adding the fourth field?

The AP Beam could benefit from a wedge with the heel superior to reduce the dose to the small
bowel and bladder (figure 12). While the max point dose/hotspot near the anus does increase
with the use of the increased wedge size this is still within the acceptable limits of my clinical
internship sites limits for the 25-degree wedge (figure 12, 13, and 14) and could be considered to
reduce side effects with increase dose to the small bowel. As stated earlier the use of a prone
belly board would likely have improved this setup as well to minimize the dose to the small
bowel. The main disadvantage is there is significantly more normal tissue being treated in this 4-
field plan.

Figure 12 - No Wedge, Max Point Dose 47.8 Gy (106.2%)

Figure 13 - With AP 25-degree wedge heel superior, Max Point Dose 48.1 Gy (106.9%)
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Figure 14 - With AP 45-degree wedge heel superior, Max Point Dose 48.9 Gy (108.7%)

In comparison to the final 3 field plan the femurs are getting less dose in the 4-field plan which is
advantageous. The 3-field plan, however, does have higher doses to some of the tissues of the
small bowel but overall less is being treated than is seen in the 4-field plan (figure 12). Both
plans adequately cover the PTV but overall the 3-field plan is treating less normal tissue and is
therefore the preferred plan for treatment. In addition, the max point dose for the 4-field plan
with no wedges is 47.8 Gy or 106.2% as opposed to the preferred 3-field plan which is slightly
cooler at 47.5 Gy or 105.5%.
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Figure 15 - DVH Comparision of 3 field (dashed line) and 4 field with 25 degree AP wedge
(solid line) plans