Ian Zoller

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:

Immobilization: Patient is positioned head-first prone on the belly board. The hands are
holding on to a handle on the board above the patients head. An ankle sponge is used for
patient comfort.

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

Small Bowel No more than 150cc to V35: 0 cGy
exceed 35 Gy V40: 0 cGy
No more than 70cc to V45: 0 cGy
exceed 40 Gy Max dose: 1421 cGy
No more than 35 cc to
exceed 45 Gy
No point dose above 50 Gy
Femoral Heads No more than 50% to Left
exceed 30 Gy V30: 37.6%
No more than 30% to V40: 0.8%
exceed 40 Gy Max Dose: 4517 cGy
None to exceed 50 Gy Right
V30: 30.1%
V40: 0.3%
Max Dose: 4397 cGy
Bladder Mean dose < 40 Gy Mean: 1722 cGy

Planning objectives for prone rectum retrieved from Arthur G. James Cancer Hospital

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.
 Ian Zoller

In order to get 95% of the dose covering the PTV using 6 MV photons, the plan needed to be
normalized way down to 87.74%. With the plan already being extremely hot before, after
renormalizing, the hotspot increased to 161.4%. The isodose lines are more forward pointed in
the center of the beam and towards the inferior portion of the field due to the amount of bone
in the beam path. The hot spot is close to the surface of the patient and is left sided.

Single PA beam: 6 MV

Axial

Coronal
 Ian Zoller

Sagittal

b. Change to a higher energy and calculate the beam. How did your isodose distribution
change?

The plan is much cooler when using 10 MV photons. The hot spot changed from 161.4% to
149.3%. The isodose distribution looks similar to the 6 MV plan, however, the isodose lines
penetrate deeper into the patient with the higher 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.

To make a 1 cm anterior and posterior margin while keeping the same superior and inferior
borders, I used the ellipse function when shaping the MLCs. The hot spot using three fields is
significantly reduced to 123.7%. The isodose lines around the PTV are rectangular in shape,
with the higher isodose lines such as the 105% located toward the patients posterior. There
are also pockets of high dose located laterally at the entry of the lateral beams. Some exit dose
can be seen at the anterior of the patient from the PA beam.
 Ian Zoller

3 field: 6 MV

MLCs of lateral fields

Axial
 Ian Zoller

Coronal

Sagittal

d. Change the 2 lateral fields to a higher energy and calculate. How did this change the
dose distribution?

With 10 MV photons, the hot spot is slightly reduced to 121.4%. Using a higher energy from
the laterals helped reduce the pockets of high dose located on the sides of the patient. Most of
the high dose is still located posteriorly with the hot spots being located at the intersections of
the PA and lateral beams.
 Ian Zoller

e. Increase the energy of the PA beam and calculate. What change do you see?

After changing the energy of the PA beam to 10 MV, the hot spot is reduced to 120.8% and
there is an increase in exit dose.

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..)

I placed the toe of the wedge pointing toward the anterior of the patient in order to help drive
dose anteriorly. Once again, the hot spot is further reduced to 117.1%. Using 10 EDWs, the
isodose distribution was not changed much the plan is still hot posteriorly. The pockets of
dose located laterally were shifted toward the anterior of the patient.

3 field: 10 EDW: 10 MV

Lateral field showing wedge orientation

 Ian Zoller

Axial

Coronal
 Ian Zoller

Sagittal

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?

As I increased the wedges on the lateral fields, the hot spot kept getting smaller and smaller
and gradually moved toward the anterior of the patient. Once I got to the 45 EDW, the higher
isodose lines had shifted toward the anterior of the patient. I gradually stepped up from 10, 15,
20, 25, 30, and 45 degree EDWs.

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
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.

For the final plan, I used the highest energy available at my clinic for the lateral beams which is
15 MV. I used this energy because the PTV is deep in the body, and the beams are opposed.
For the PA beam, I used 10 MV because the PTV again is at depth but at the same time I was
worried about exit dose through the small bowel and bladder. I used 45 wedges so that I
could weight the PA beam more than the lateral fields. With the PA beam being weighted
more, it helped me to achieve the dose constraints for the femoral heads. I renormalized the
 Ian Zoller

plan so that 95% of the PTV is covered by the 100% isodose line. The final weighting that I used
was 0.430, 0.281, and 0.289 for the PA, Left Lateral, and Right Lateral beams respectively.

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.

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?

Adding the fourth field helps with coverage of the PTV and helps to reduce the high dose that
collects at the sides of the patient when using 3 fields. A major disadvantage of using this field
arrangement is that we are now entering through a lot of normal tissue such as the bladder and
small bowel. This will most likely cause the patient to have side effects that could be prevented
by delivering the tumor dose with a 3 field arrangement.

4 field: 10 MV

Axial
 Ian Zoller

Coronal

Sagittal
External Beam Planning
External Beam Planning 13.6.30 OSUCCC - James, Columbus OH

Patient: Dosimetry Program, Student 2

Patient IDs: 2000000000
Comment:

Plan Plan Course Plan Status Plan Last Modified

3fld,10X,EDW2 Pelvis Lab Unapproved: Tuesday, March 28, 2017 2:14:36 PM by zoll07 Tuesday, March 28, 2017 2:59:21 PM by zoll07

DVH Structure Structure Status Coverage [%/%] Volume Min Dose Max Dose Mean Dose Modal Dose Median Dose Std Dev
Rectum Unapproved 100.0 / 100.0 44.8 cm 4468.8 cGy 4800.4 cGy 4603.7 cGy 4639.6 cGy 4603.6 cGy 56.4 cGy
Femoral Head Rt Unapproved 100.0 / 100.0 152.5 cm 116.2 cGy 4397.5 cGy 1656.3 cGy 291.0 cGy 1194.0 cGy 1257.3 cGy
Femoral Head Lt Unapproved 100.0 / 100.0 153.0 cm 118.5 cGy 4516.6 cGy 1919.4 cGy 3283.1 cGy 1702.5 cGy 1275.2 cGy
Bladder Unapproved 100.0 / 100.0 418.3 cm 1135.2 cGy 4661.9 cGy 1722.4 cGy 1401.2 cGy 1510.1 cGy 714.9 cGy

Patient: Dosimetry Program, Student 2 (2000000000) Printed Tuesday, March 28, 2017 3:14:56 PM by zoll07
Course: Pelvis Lab
Plan: 3fld,10X,EDW2 - Unapproved Page: 1/2
External Beam Planning
External Beam Planning 13.6.30 OSUCCC - James, Columbus OH

DVH Structure Structure Status Coverage [%/%] Volume Min Dose Max Dose Mean Dose Modal Dose Median Dose Std Dev
Small Bowel Unapproved 100.0 / 100.0 1421.0 cm 49.8 cGy 1421.0 cGy 488.7 cGy 105.3 cGy 229.3 cGy 406.8 cGy
PTV Rectum Unapproved 100.0 / 100.0 189.3 cm 4405.0 cGy 4911.7 cGy 4616.3 cGy 4654.7 cGy 4617.1 cGy 70.7 cGy

Plan prescription

Total Dose
Plan Prescription Dose per Number of at Primary Prescribed Normalization Nor...
Plan Sum Plan Sum Course Weight Plan Plan Course dose Fraction Fractions Ref. Point Percentage Mode Value
- - - 3fld,10X,EDW2 Pelvis Lab 4500.0 cGy 180.0 cGy 25 4500.0 cGy 100.0 % Plan Normalization Value: 99.14 99.1 %

Patient: Dosimetry Program, Student 2 (2000000000) Printed Tuesday, March 28, 2017 3:14:56 PM by zoll07
Course: Pelvis Lab
Plan: 3fld,10X,EDW2 - Unapproved Page: 2/2
Patient Name: Dosimetry Program, Student 2 (2000000000) Course: Pelvis Lab Plan normalization value: 99.1 %
Hospital: OSUCCC - James, Columbus OH Plan: 3fld,10X,EDW2 Calculation grid: 2.0 mm
Plan last modified: Tuesday, March 28, 2017 2:59 PM by zoll07 Image: Pelvis Lab Maximum dose: 4911.7 cGy
Save Status Not saved! Maximum dose in PTV Rectum: 4911.7 cGy
Minimum dose in PTV Rectum: 4405.0 cGy
Mean dose in PTV Rectum: 4616.3 cGy

Fields in plan '3fld,10X,EDW2' of course 'Pelvis Lab'

Field ID Technique Machine Energy Scale Wedge ID Weight X1 X2 Y1 Y2 Gantry Rtn Coll Rtn Couch Rtn X Y Z SSD MU
[cm] [cm] [cm] [cm] [deg] [deg] [deg] [cm] [cm] [cm] [cm]
1 PA STATIC-I TB_SD_2023 10X Varian IEC 0.430 +7.5 +6.7 +8.5 +11.0 0.0 0.0 0.0 -0.5 -2.5 -7.0 91.9 80
2 L LAT STATIC-I TB_SD_2023 15X Varian IEC EDW45IN 0.281 +8.5 +11.0 +5.6 +4.1 270.0 90.0 0.0 -0.5 -2.5 -7.0 81.1 85
3 R LAT STATIC-I TB_SD_2023 15X Varian IEC EDW45OUT 0.289 +8.5 +11.0 +4.1 +5.6 90.0 90.0 0.0 -0.5 -2.5 -7.0 81.7 85

Patient Name: Dosimetry Program, Student 2 (2000000000) Z: -7.00 cm External Beam Planning 13.6.30
Course: Pelvis Lab Scaling Factor: 50% Printed Tuesday, March 28, 2017 3:14 PM by zoll07
Plan: 3fld,10X,EDW2 - Unapproved Head First-Prone Page 1/1
User origin DICOM offset = (0.36cm, -9.75cm, 0.00cm)
Patient Name: Dosimetry Program, Student 2 (2000000000) Course: Pelvis Lab Plan normalization value: 99.1 %
Hospital: OSUCCC - James, Columbus OH Plan: 3fld,10X,EDW2 Calculation grid: 2.0 mm
Plan last modified: Tuesday, March 28, 2017 2:59 PM by zoll07 Image: Pelvis Lab Maximum dose: 4911.7 cGy
Save Status Not saved! Maximum dose in PTV Rectum: 4911.7 cGy
Minimum dose in PTV Rectum: 4405.0 cGy
Mean dose in PTV Rectum: 4616.3 cGy

Fields in plan '3fld,10X,EDW2' of course 'Pelvis Lab'

Field ID Technique Machine Energy Scale Wedge ID Weight X1 X2 Y1 Y2 Gantry Rtn Coll Rtn Couch Rtn X Y Z SSD MU
[cm] [cm] [cm] [cm] [deg] [deg] [deg] [cm] [cm] [cm] [cm]
1 PA STATIC-I TB_SD_2023 10X Varian IEC 0.430 +7.5 +6.7 +8.5 +11.0 0.0 0.0 0.0 -0.5 -2.5 -7.0 91.9 80
2 L LAT STATIC-I TB_SD_2023 15X Varian IEC EDW45IN 0.281 +8.5 +11.0 +5.6 +4.1 270.0 90.0 0.0 -0.5 -2.5 -7.0 81.1 85
3 R LAT STATIC-I TB_SD_2023 15X Varian IEC EDW45OUT 0.289 +8.5 +11.0 +4.1 +5.6 90.0 90.0 0.0 -0.5 -2.5 -7.0 81.7 85

Patient Name: Dosimetry Program, Student 2 (2000000000) X: -0.50 cm External Beam Planning 13.6.30
Course: Pelvis Lab Scaling Factor: 50% Printed Tuesday, March 28, 2017 3:14 PM by zoll07
Plan: 3fld,10X,EDW2 - Unapproved Head First-Prone Page 1/1
User origin DICOM offset = (0.36cm, -9.75cm, 0.00cm)
Patient Name: Dosimetry Program, Student 2 (2000000000) Course: Pelvis Lab Plan normalization value: 99.1 %
Hospital: OSUCCC - James, Columbus OH Plan: 3fld,10X,EDW2 Calculation grid: 2.0 mm
Plan last modified: Tuesday, March 28, 2017 2:59 PM by zoll07 Image: Pelvis Lab Maximum dose: 4911.7 cGy
Save Status Not saved! Maximum dose in PTV Rectum: 4911.7 cGy
Minimum dose in PTV Rectum: 4405.0 cGy
Mean dose in PTV Rectum: 4616.3 cGy

Fields in plan '3fld,10X,EDW2' of course 'Pelvis Lab'

Field ID Technique Machine Energy Scale Wedge ID Weight X1 X2 Y1 Y2 Gantry Rtn Coll Rtn Couch Rtn X Y Z SSD MU
[cm] [cm] [cm] [cm] [deg] [deg] [deg] [cm] [cm] [cm] [cm]
1 PA STATIC-I TB_SD_2023 10X Varian IEC 0.430 +7.5 +6.7 +8.5 +11.0 0.0 0.0 0.0 -0.5 -2.5 -7.0 91.9 80
2 L LAT STATIC-I TB_SD_2023 15X Varian IEC EDW45IN 0.281 +8.5 +11.0 +5.6 +4.1 270.0 90.0 0.0 -0.5 -2.5 -7.0 81.1 85
3 R LAT STATIC-I TB_SD_2023 15X Varian IEC EDW45OUT 0.289 +8.5 +11.0 +4.1 +5.6 90.0 90.0 0.0 -0.5 -2.5 -7.0 81.7 85

Patient Name: Dosimetry Program, Student 2 (2000000000) Y: -2.50 cm External Beam Planning 13.6.30
Course: Pelvis Lab Scaling Factor: 50% Printed Tuesday, March 28, 2017 3:14 PM by zoll07
Plan: 3fld,10X,EDW2 - Unapproved Head First-Prone Page 1/1
User origin DICOM offset = (0.36cm, -9.75cm, 0.00cm)