Pelvis Clinical Lab Assignment

Use the Pelvis CT data set provided in Canvas 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. Each plan will build in complexity off of the previous one. After adjusting each plan,
answer the provided questions. Include a screen shot for each plan to show the isodose distribution along with a DVH clearly
displaying your PTV coverage. Note: Make sure that your plan shows the absolute dose levels and that each view is large enough to
clearly read the needed details. You may want to screenshot each view separately. Describe and/or show how you read the PTV dose
on the DVH. Only provide the PTV when asked for PTV coverage. When asked for field weighting, show the field weighting for that
plan. Embed the question and then your answers with any associated visuals within your completed assignment. A good visual
image and a thorough description of the isodose distribution in each plan are critical components. The reader should be able to
follow your planning process/outcome using your visuals and explanations.
· Important: Please do not normalize your plan when making these adjustments until instructed to do so in the final plan.
· 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 (be specific in your description of depth, location, etc).
o When looking at the isodose distribution I noticed that the isodose lines are coming in from the posterior matching
the beam arrangement, getting to isocenter with a quick falloff after passing through isocenter. Prior to isocenter
there is a large quantity of high dose area.
· Where is the hot spot (max dose) and what is it?
o My hot spot of 7689.4cGy is to the right of the field axis in the superior portion of the PTV, at a depth of roughly 1.14
cm from the patient's posterior surface.
· What do you think creates the hot spot in this location?
o I believe the reason for the hot spot being in this location is due to the dmax of a 6MV beam being considered roughly
1.5 cm depth.
· Using your DVH, what percent of the PTV is receiving 100% of the dose? Remember to describe or show how you read this.
o In evaluating the DVH, I found that 48.29 percent of the PTV is receiving the prescription dose of 4500cGy. I found this
by looking at the x axis, finding 4500cGy, seeing where the PTV line intersected and tracing it to the Y-axis.
 Plan 2: Change the PA field to a higher energy and calculate the dose.
· Describe how the isodose distribution changed and why?
o I was able to increase my PA field from a 6 MV beam to a 15 MV beam. In doing so, my isodose lines penetrated
further into the anatomy, decreasing my hot spot to 6762.3cGy. While the isodose lines look like those from the 6 MV
beam, the key difference is seen on the 70 and 50 percent lines. On those lines the dose fall off is not as rapid due to
the increased penetration.
· Using your DVH to confirm, what percent of the PTV is receiving 100% of the prescription dose?
o According to the DVH the portion of the PTV receiving 100% of the prescription has increased to 53.9 percent.
 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?
o In this three-field arrangement overall the isodose distribution is much more conformal than a single posterior beam,
but with the lower energy there are still large hot spots superficially on the laterals and the posterior. Another
observation is that the isodose lines do not push as far anteriorly as they did, and the largest hot spots are where the
lateral beams overlap with the PA beam on the posterior surface.

· Where is the hot spot and what is it?

o The hot spot is on the posterior surface at the corner overlap of the Rt lateral and PA beams. The hot spot is
5107.6cGy which is a substantial improvement from the single PA beam arrangement.
· What do you think creates the hot spot in this location?
o I believe the hot spot is created by the dmax dose from the PA being superficial and the contribution of dose from the
Rt lateral beam.
 Plan 4: Increase the energy of all 3 fields and calculate the dose.
· Describe how this change in energy impacted the isodose distribution.
o After increasing the energies to 15 MV the hot spots on the lateral portions have been minimized, while also
improving dose to the PTV.
· In your own words, summarize the benefits of using a multi-field planning approach? (Refer to Khan Physics for benefits of multiple
fields)
o While using a multi-field arrangement, someone can make a more conformal plan, sparring normal tissue when
possible. It also allows one to use optimal beam arrangements to pull and push dose where needed.
· Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the prescription dose? Use a DVH to show
how you obtained this response.
o In comparison to the single field plan described above (plan two), the percentage of the PTV receiving 100% of the
dose was able to increase from 53.9 percent to 59.6 percent.
 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?

o PA 35%, Rt Lat 32.2%, and Lt Lat 32.8%
· What was your rationale behind your final field weight? Be specific and give details.
o Overall, for my weighting I did not change it much from them all being equally weighted. I ended up weighing the PA
slightly more (35%) to minimize the hot spots on the laterals, after that I then played with the weighting of the laterals
until my hot spots were evenly distributed on either side of the patient (Rt Lat 32.2% and Lt Lat 32.8%).
 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. Also, if you
desire to adjust the field weights after wedge additions, go ahead and do so.
· 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..)
o For this three-field orientation I decided the best arrangement for the wedges was to insert 25-degree wedges with
an ant/post orientation with the heels facing posteriorly.
· How did the addition of wedges change the isodose distribution? Include a screen shot (including axial and coronal) of the isodose
distribution before and after the wedge placement.
o The addition of these wedges provided the ability to push the 100% isodose line more anteriorly to provide better
coverage for the PTV.
· According to your Khan Physics book, what is the minimum distance a wedge or absorber should be placed from the patient’s skin
surface to keep the skin dose below 50% of the dmax?
o 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?
o With how deep the PTV was I decided that 15MV would be the best energy to use.
· What is the final weighting of your plan?
o My weighting ended up being PA 28.8%, LT Lat 21.5%, Rt Lat 24.5%, and AP 25.2%.
· Did you use wedges? Why or why not?
o In this plan I decided not to use wedges. My reasoning behind not using wedges was because of how well the dose
distribution was after adding the fourth field. I was able to get my hot spots evenly distributed in the four corners on
the treatment field. I did consider adding a wedge going sup/inf, with the heel inferior, to help push the 100% line
superior, but if I did that it would then cool off the inferior portion of the PTV.
· Where is the region of maximum dose (“hot spot”) and what is it?
o My global maximum dose of 4832.3cGy is in the left anterior portion of the PTV.
· What is the purpose of normalizing plans?
o Normalizing plans is an effective way to heat up or cool off your treatment plans. It is also a good way to manipulate
dose coverage.
· What impact did you see after normalization? Why? Include a screen shot (including axial and coronal) of the isodose distribution
before and after applying normalization.
o When I normalized my plan, it then created a plan with higher hot spots, but also better coverage. It was able to do that
by normalizing “down” and making a lower isodose line equate to the 100% isodose line. Which in turn did not change
the shape of the isodose lines but raised them to a higher percentage.
o Screen shots in order no normalization then normalized
· 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 with PTV and OARs. 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).
· Use the table below to list typical organs at risk, critical planning objectives, and the achieved outcome. Provide a reference for your
planning objectives and a rationale for the objectives chosen.
o For my critical planning objectives, I referenced QUANTEC.
o I chose my OARs based upon structures that were near my PTV and provided in my given data set.

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Bladder Dmax <65 Gy 47.42 Gy Yes
Rectum V50 <50% 0% Yes
Rectum V70 <20% 0% Yes
Bowel Space V45 <195cc 294.3cc No