Pelvis Clinical Lab Assignment

Use the Pelvis CT data set provided to complete the following assignment:

Prescription: 45 Gy in 25 Fractions to the PTV

Planning Directions: Place the isocenter in the center of the designated PTV (note: calculation
point will be at isocenter). Create a PA field with a 1 cm margin around the PTV. Use the lowest
beam energy available at your clinic. Apply the following changes (one at a time) as listed in
each plan exercise below. After adjusting each plan, answer the provided questions. Tip: Copy
and paste each plan after making the requested changes so you can compare all of them as
needed.

Plan 1: Calculate the single PA field.

 Describe the isodose distribution.
The isodose distribution is shifted posteriorly and the 100% IDL covers about half of
the PTV.
 Where is the hot spot and what is it?
Hotspot (8064 cGy) is in adipose tissue posterior to coccyx.
 What do you think creates the hot spot in this location?
Hotspot is likely located in this area due to PA beam configuration, 6MV beam (1.5
dmax), and the presence of bony anatomy to soft tissue interface.
 Using your DVH, what percent of the PTV is receiving 100% of the dose?
Approximately 60% of PTV receives 100% dose.

Plan 2: Change the PA field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed and why?
The isodose curves cover more of the patient separation; the 100% IDL covers slightly
more PTV with lower intensity IDL’s covering the entire separation; whereas with low
energy beam approximately ¾ of the patient separation was covered in isodose
distribution.
 Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
A little more than 60% of PTV is covered by 100% IDL. This value did not change much
between energies.

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.
 Describe the isodose distribution. What change did you notice?
Dose distribution is broader and covers more lateral separation (mid ilium to mid
liium), low energy IDLs are contained within the pelvis and the entire distribution
 creates a box shape. The 100% IDL bows posteriorly slightly toward the sacrum and
may be due to the presence of sacrum since the box does not bow in areas without it.
 Where is the hot spot and what is it?
Hotspot (5123 cGy) is surprisingly in the posterior right corner of the IDL in a right
gluteal muscle.
 What do you think creates the hot spot in this location?
I think there is a wedging effect present due to the shape of the tissue on the right
side.

Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution.
The IDL distribution is contained within a slightly smaller box area within the pelvis.
 What are the benefits of using a multiple-field planning approach? (Refer to Kahn, 5th
ed, Ch 11.5B)
Multiple field use allows the dose to be distributed across a greater area. This could be
beneficial in that it allows for greater PTV coverage and it coois the plan down. A
cooler plan means less dose at the hotspot. Multiple beams also allows for greater
dose conformality.
 Compared to your single field in plan 2, what percent of the PTV is now receiving 100%
of the prescription dose?
About 57% of the PTV receives 100% dose in this plan.

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?
PA = 33%; LLAT = 33.5%; RLAT = 33.5%
 What was your rationale behind your final field weight?
I changed the weighting in this way because a slight increase in lateral weighting
pulled the IDLs anterior for greater PTV coverage. If I weighted the laterals too much
higher the femoral heads began and lateral tissues began to receive more dose, and if
I weighted the PA beam more then it pulled the 100% IDL down and reduced coverage
while creating a hotspot posterior to the PTV. The hotspot for my weighting is within
the PTV.

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.
 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..)
RLAT wedge = 15 deg., heel cephalad; LLAT wedge = 15 deg., heel posterior.
 How did the addition of wedges change the isodose distribution?
 I used the toes of the wedges to pull dose to areas that needed a little more coverage.
The RLAT wedge provided for slightly more inferior PTV coverage while the LLAT
pulled the IDL anterior. Mostly, this patient was very boxy and wedges did not
accomplish a whole lot in any configuration. If greater than 15 deg wedge were used
the middle of the IDL in the PTV began to break down and coverage was lost.
 According to Kahn, 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?
(Refer to Kahn, 5th ed, Ch. 11.4)
About 15 cm.

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?
All 18MV to reduce dose to superficial tissues and create better conformality around
PTV.
 What is the final weighting of your plan?
PA = 30%; AP = 20%; LLAT = 24%; RLAT = 26%
 Did you use wedges? Why or why not?
I did not use wedges because they were not super useful in shaping the beam since
the patient was box shaped and the PTV was somewhat boxy.
 Where is the region of maximum dose (“hot spot”) and what is it?
The hotspot (4989 cGy, 10%) is within the PTV, it is midway between the cephalad and
caudal borders but is a little posteror and lateral (it is anterior to the rectum).
 What is the purpose of normalizing plans?
Normalization allows the planner to dictate how much dose is received to a point. The
planner can dictate that a certain area of the plan receive 95% instead of 100% and
this may cause the rest of the plan to get hotter since the calculation point is cooler, or
it may cause the plan to get hotter. It depends on the placement of the calculation
point.
 What impact did you see after normalization? Why?
My plan got a little cooler because the norm point was placed centrally and was to
receive only 95% of the dose.
 Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and
coronal views. Show the PTV and any OAR.
 Include a final DVH. 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).
  If you were treating this patient to 45 Gy, use the table below to list typical organs at
risk, critical planning objectives, and the achieved outcome. Please provide a reference
for your planning objectives.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Rectum 50% <60 Gy Not met (within PTV)
Bladder 50% <65 Gy Not met (Within PTV)
Femoral head <50Gy met
Bowel <65cc 45Gy Maybe not met (in PTV)

*From Mobius