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Veronica Laird

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).

I got my desired objectives for the constraints from Beaumont Hospital Standards
and their Boarding pass
Organ at risk Desired objective(s) Achieved objective(s)
Small Bowel Max Dose- 55 Gy Max Dose- 11.91 Gy
30% can get 40-45 Gy 0% is getting 40 Gy
Bladder Max Dose 55 Gy Max Dose- 45.21 Gy
30 % can get 45-50 Gy 0.02% is getting 45 Gy
Femoral Heads Max Dos 55 Gy Rt Max- 28.01 Gy - 0% is
50 % may receive 45 Gy getting 45Gy
Lt Max- 43.01 Gy - 0% is
getting 45Gy
Isodose distribution key
Enter the Isodose Color Dose % of prescription:
45 Gy at 1.8 /fx Grey 6525 145% (95% of the
prescribed dose Light Orange 5850 130% to cover the
PTV). Calculate Red 4950 110% the single PA
beam. Evaluate Yellow 4725 105% the isodose
distribution as Green 4500 100% it relates to
CTV and PTV coverage. Also
Light Blue 4275 95%
where is/are the hot
Pink 4050 90%
spot(s)? Describe the
Sky Blue 3600 80%
isodose distribution, if
Lavender 3150 70%
a screen shot is helpful to show
Orange 2700 60%
this, you may include it.
When calculating Forest Green 2250 50% the PA beam to
have 95% of the prescribed dose to cover the PTV, then my plan becomes
very hot. I had to prescribe the isocenter to the 87% isodose line to get
100% coverage of 95% of the dose to my PTV. To be able to push the dose
that is needed to get 4275 cGy to the PTV, my hot spot is 6646 cGy
(155% hot). Using the 6MV beam, my hotspot is around
Figure 1
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1.5 cm into the patient (1.5 cm dmax).


Because of the bone in the pelvis, the
beam is attenuated, which accounts for
the jaggedness in the isodose
distribution anterior in the patient. I
overrode my density for my rectum and
small bowel to 1 because the amount of
air is going to be different every day for
treatment (overrode for whole lab). As
for my constraints, my small bowel dose
is very low at maximum dose of 2723
cGy. This is because I only have the one
beam coming from the posterior, and my
small bowel is very anterior in the
patient. Figure 1 is my isodose
distribution for a 6 MV PA beam.
Change to a higher energy and calculate the beam. How did your
isodose distribution change?
Once I changed to an 18 MV beam the isodose distribution looks similar but
my plan has cooled down. My hot spot is now at 5614 cGy (125% hot). On
this plan in order to get 95% of the PTV* covered by 100% of the dose, I had
to prescribe the isocenter to the 92% isodose line instead of 87% with the
6MV. Although my isodose lines look similar, the dose distributes deeper into
the patient. My isodose lines have elongated into the patient more, and at
the anterior portion the lines arent so jagged because there is less
attenuation with the 18 MV beam. My small bowel is 170.4cGy hotter in the
18 MV plan. Below is the trial comparison between the 6 MV and 18 MV. In
figure 2 below, the left image is 6 MV, Right image is 18 MV Both calculated
to cover 95% of the dose to the PTV and are covered by the Light Blue thick
isodose line.
Figure 2
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*PTV showed in color wash blue


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.
Figure 3
The isodose distribution is now a box
around the PTV, however, with the
lower dose and the larger patient I
have hot spots at the entrance of each
beam. I prescribed to the 90% isodose
line for the isocenter to get 95% of the
dose to cover 100% of the PTV. My
overall hotspot is 5953.7 cGy (132%).
The 3 field has a similar maximum
dose for the bladder, but the mean
dose has gone from 3236 cGy for the
18 MV PA beam plan to 1393.2 cGy for
the 3 field. My small bowel max dose
has gone from 2893.9 to 917.0. In
figure 3 to the right is my isodose
distribution for my 3 field 6 MV plan.

a. Change the 2 lateral fields to a higher energy and calculate. How


did this change the dose distribution?
When changing the lateral fields to 18 MV, my isodose distribution looks
better. The plan has cooled down, and where my lateral beams are
coming in is not as hot as on the 6MV plan. The hotspot has decreased to
5540 cGy (123.1%). The plan is still very hot from the posterior beam
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because of the 6MV that is being used on the PA. With the 6MV all plan
where the lateral beams were coming in were getting 4950 cGy. With the
18 MV there is just a little spot of 4275 cGy, but mostly 4050 cGy. Below
in figure 4 is the comparison between the 6 MV all fields (left), and the 18
MV laterals with 6 MV PA beams (right).
Figure 4

b. Increase the energy of the PA beam and calculate. What change


do you see?
When changing the PA beam to 18 MV, the plan looks even better. The
hotspot has come down to 5390 cGy (119.8%). My doses to my OARs are
similar, but a little hotter with the 18 MV plan because of the deeper
dispersion in the patient. Below in Figure 5 is a comparison of the all 6 MV
plan (left) and the all 18 MV plan (right).

Figure 5
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c. 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..)
With Elekta machines, the wedges are Universal so I can choose any
wedge angle. Because a lot of machines only come with 15, 30, 45, and
60 degree wedges I chose to use 15 Degree wedge for both lateral
beams. I placed the heels of the wedges posterior on the patient. This
helped to even out the dose distribution in the ant/post direction of the
patient. Before I added the wedge, my plan was very hot posterior. This
helps to bring the dose more anterior in my patient because a lower dose
is getting through the heel of the wedge, and more through the toe. This
has also brought down my max dose to 5076 cGy (112.8% hot), while
having the same coverage on the PTV. Below in figure 6 shows a sagittal
view on how my dose distribution has cooled down in the ant/post
direction. My dose is still not even in the sup/inf direction, which I think
would help by adding a wedge to the PA beam with the heel inferior. On
the left is my plan without wedges and on the right is the plan with 15
degree wedges on both lateral beams.
Figure 6

d. 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?
As I increased my wedge angles, the isodose distribution pushes more
anterior in the patient. I ended up getting the best coverage with 35
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degree wedge angles on the lateral beams. By doing this, I was able to
cool down my plan to 4768 cGy (105.9% hot), which is a much more
reasonable hot spot. My isodose distribution is still falling hotter inferior.
The only problem with using the higher wedge angles is I have a hotter
dose in the entrance dose of the lateral beams on the anterior aspect of
the beam. Below in Figure 7 shows the new isodose distribution with the
35 degree wedges.
Figure 7

e.

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 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.
18 MV is the perfect energy to use for this plan because it keeps my
entrance dose lower, and my overall plan lower. The pelvis is a thick area
and this patient has thicker anatomy so the 18 MV beams are needed. I
adjusted the PA beam to 39% of the dose which helped to bring my
entrance dose on my lateral beams down. The right and left lateral beams
are even weighted at 30.5%. I added a 12 degree wedge to my PA beam
with the heel inferior to help the dose distribution to be more even in the
sup/inf direction. I also changed my lateral wedge angles to 42 degrees.
This helped me to get 95% of the dose to 99.94% of the PTV while
keeping my hot spot to 4672 (103.8% hot). Now my plan has a nice even
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dose distribution throughout the fields. I like that I was able to keep the
hot spot down while getting coverage on my PTV. As for my OARS, all of
the doses met the constraints set by the Beaumont standards. After
showing my clinical instructor, he agreed with my decisions.

f. 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.
Below are the isodose distributions in the transverse, sagittal, and coronal
views. Also below is the final DVH.
Transverse View at CAX

Sagittal View at CAX Coronal View at CAX


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DVH

summary of treatment plan

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 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?
After adding the AP beam I still have great coverage of the PTV. The
advantage is that my dose distribution is more like a box around the PTV,
and is very conformal without having to add any wedges. I would still add a
wedge to the PA beam with the heel inferior to bring the dose further
superior because I am hot inferior. I have lower doses on the entrance of my
lateral beams. My femoral head dose has decreased from 43.01 Gy max dose
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for the 3 field to 38.63 Gy for the 4 field. The disadvantage to this is that I
am now giving my bladder and some of my small bowel much more dose.
Another disadvantage is that I am treating a lot more normal tissues than I
did with the 3 field plan. I think for a patient that isnt as thick and if we were
treating an area more central in the body such as the prostate, then the 4
field box would be a great choice, but for this plan, the 3 field wedged plan is
a better option. Below in figure 8 shows a transverse comparison of my 3
field plan on the left compared to my 4 field plan on the right. In figure 9, I
also have the DVH summary that compares the dose to my bladder and
small bowel for the two different plans. The solid lines are the 3 field trial,
and the dashed lines are the 4 field.

Figure 8
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Figure 9

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