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.

Transverse view at isocenter showing the large area of 110% of the prescription dose (red isodose line).

1
Coronal view at isocenter.

Sagittal view showing the hot spot.

 Describe the isodose distribution (be specific in your description of depth, location, etc).
o All of the dose is coming from the PA beam, which makes the plan hotter in the
posterior region of the PTV. With the prescription set to the calculation point in the
middle of the PTV, the 100% isodose line just reaches that point, the 90% isodose line is
just anterior and the 105% line is just posterior. The 110% isodose line (the highest
isodose line set) extends from the posterior surface of the patient to about 2cm
posterior of our calculation point (using the ruler at the bottom of the image).
 Where is the hot spot (max dose) and what is it?

2
 o The hot spot is located posterior to the PTV close to the surface of the patient. The hot
spot is 76.85 Gy, which is 170.7% of our prescription dose.
 What do you think creates the hot spot in this location?
o The hot spot is created in this area due to the attenuation of the beam, as the Dmax of a
6MV beam is 1.5 cm, which is about where our hot spot is measured to be from the
posterior surface of the patient. As the dose transverses through tissue beyond this
point, more is attenuated which requires a larger amount of dose to reach our
prescription calculation point. The higher amount of attenuation that results from
needing a higher dose to prescribe to the middle of the PTV gives a large area of tissue
receiving ≥ 110% of the prescription dose.
 Using your DVH, what percent of the PTV is receiving 100% of the dose? Remember to describe
or show how you read this.
o Looking at the DVH, the bottom portion states the dose and the while the side states the
volume. Looking at our red PTV line, the line intersects the 45 Gy point, and looking at
the left this occurs at the 48 percent volume. This means that 48% of the PTV is
receiving 45 Gy, which is 100 percent of our prescription dose.

DVH with statistics showing colors for each organ.

3
Close up of the DVH showing that at the at 45 Gy, our PTV is at the 48 percent volume mark, meaning
that 48 percent of our PTV is receiving 100% of the prescription dose.

Plan 2: Change the PA field to a higher energy and calculate the dose.

Transverse view at isocenter showing the dose distribution.

4
Sagittal view of dose distribution at isocenter.

Coronal view of dose distribution at isocenter.

 Describe how the isodose distribution changed and why?

o Using 10MV, the isodose lines did not shift much within/near the PTV. The isodose lines
are slightly more separated from one another (more space for each region) which is due
to the higher penetration power of the beam which makes the dose transverse more
tissue before becoming attenuated. This helps push the isodose lines further as the 90%
and 80% isodose lines now cover more area anteriorly. This can also be seen on the
posterior surface of the patient on the sagittal view where there is now less dose being
delivered right at the surface.

5
  Using your DVH to confirm, what percent of the PTV is receiving 100% of the prescription dose?
o Using the same method as before, our PTV line intersects the 45 Gy point at the 49.8%
volume mark, so 49.8% of our PTV is receiving 45 Gy.

Close up of the DVH showing that 49.8 percent of our PTV volume is receiving the prescription dose.

DVH and plan 2 statistics

6
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.

Transverse view of the isodose distribution at isocenter for plan 3.

Sagittal view of the isodose distribution at isocenter for plan 3.

7
Coronal view of the isodose distribution at isocenter for plan 3.

 Describe the isodose distribution. What change did you notice?

o Using three fields, the isodose lines are now shifted and located in different spots. There
is a much smaller amount of the ≥ 110% isodose line which is located in the posterior
corners of the PTV. There is much less surface dose from the posterior beam, and there
is now surface dose at each lateral side. The isodose lines are now also located in the
lateral aspects of the body, where the 80, 90, 100, and 105% isodose lines are now
pushing towards the PTV, decreasing in dose from the surface until reaching the PTV
area where all 3 beams overlap. In some areas where there is more tissue to transverse
for the beam, the higher isodose regions are larger due more dose being delivered
through those points to achieve the prescription dose at isocenter.
 Where is the hot spot and what is it?
o The hot spot is outside the posterior right corner of the PTV, and has a value of 51.31
Gy.

8
 Hot spot in the transverse view marked by the point where the two yellow lines cross.

Hot spot in the sagittal view.

 What do you think creates the hot spot in this location?

o This hot spot is created through the overlap of the PA and the lateral beam, as on both
sides this is where the area of ≥ 110% accumulates. This point receives dose from both
beams, and being on the outside edge of the PTV it is receiving a higher dose through
attenuation.

9
Plan 4: Increase the energy of all 3 fields and calculate the dose.

Transverse isodose distribution at isocenter for plan 4.

Sagittal isodose distribution at isocenter for plan 4.

10
  Describe how this change in energy impacted the isodose distribution.
o The isodose distribution outside of the PTV has dramatically changed due to the higher
penetration power of the beam. The lateral regions only have the 70 and 80 isodose
values (70 being the lowest set to be seen) except the PTV region, which is much
different from seeing the 80-105% values when using the 6MV energies. There is also
less area being covered by the 110% isodose line with the higher penetrating power.
 In your own words, summarize the benefits of using a multi-field planning approach? (Refer to
Khan Physics for benefits of multiple fields)
o By using multiple fields, dose to the surface and superficial tissue can be lowered
significantly by delivering a conformal dose to the target from multiple angles. This
approach can help lower dose to critical structures and tissue outside the target while
still achieving optimal target dose.
 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 While plan 4 has a larger area of the patient being irradiated, the area of ≥ 110 % of the
prescription dose is smaller. The PTV line on the DVH intersects the 45 Gy point near the
50% volume mark. This means that 50% of our PTV volume is receiving 100% of the
prescription dose (45 Gy).

Plans 2 and 4 compared (4 on top). DVH and statistics for plan 4.

11
A closeup of plan 4’s DVH showing 50 percent of the volume is receiving 45 Gy.

Plan 5: Using your 3 high energy fields from plan 4, adjust the field weights until you are satisfied with
the isodose distribution.

Plan 5 transverse dose distribution at isocenter.

12
Plan 5 sagittal dose distribution at isocenter.

 What was the final weighting choice for each field?

o For this plan setup the final weighting was 36% for both the right and left lateral beams
and 28% for the PA beam.

Beam weighting for plan 5 (weighting is in column after slider bar).

 What was your rationale behind your final field weight? Be specific and give details.
o After discussing with a dosimetrist, this weighting was chosen due to the optimal
distribution that resulted from lowering the PA beam. When the PA beam was weighted
heavier, our posterior hotspot greatly increased in size so it was lowered to decrease
the hot value for the plan. By doing this, the lateral weighting increased which made the
plan look more conformal. While this did make PTV coverage better, it also pushed more
dose to the small bowel (anterior of 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. Also, if you desire to adjust the field weights after
wedge additions, go ahead and do so.

13
  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 The final wedge orientation chosen were 45 degree wedges with the heel facing the
posterior side of the patient on both lateral beams.
 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 wedges pushed the isodose lines towards the anterior portion of the volume,
decreasing the hot spot. This is done with an enhanced dynamic wedge, moving the Y
jaw while the beam is on. The jaw attenuates dose as it moves, which pushes the dose
distribution so that more dose in the heel portion is attenuated and the toe portion
receives more dose. The pictures were taken with the same weighting, before and after
the addition of wedges.
Pre wedge-

14
 Addition of 45 degree wedges on both lateral beams-

 According to your Khan Physics book, 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?
o The general rule of thumb is that wedges are kept 15cm from the surface to keep the
skin dose below 50 percent of Dmax.

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.
15
  What energy(ies) did you decide on and why?
o 15MV was used for each beam because it had the most penetrating power and
produced a lower hot spot for the plan. This significantly decreases surface dose and
helps deliver dose to target volumes while sparing critical structures.
 What is the final weighting of your plan?
16
 o After the plan was normalized and checking with a dosimetrist, the final weighting was:
 PA: 28%
 L Lat:25%
 R Lat: 26%
 AP: 21%
o This weighting was achieved after dosimetrist feedback after normalizing the plan.

 Did you use wedges? Why or why not?

o No wedges were used for the final plan. With the 15MV dose distribution, it would not
be optimal to push the dose more anterior because the hot spot was acceptable and
pushing the dose anteriorly would give more dose to the small bowel and bladder,
structures we want to spare as much as possible. This was discussed with the
dosimetrist after normalizing the plan, as with the AP beam the bladder and small bowel
were already receiving a large amount of the prescription dose.
 Where is the region of maximum dose (“hot spot”) and what is it?
o The hot spot is posterior to the PTV on the right side of the patient with a value of 48.91
Gy (this was achieved after applying the dosimetrist feedback). This makes sense with
the beam weighting we currently have, as the PA is weighted the most and the right
lateral is the second highest weighted beam.
 What is the purpose of normalizing plans?
o Normalizing plans can help scale the dose to provide adequate coverage to an area. This
can be done to a volume to ensure that the whole volume can be accounted for when
applying goals and objectives to a plan. The normalization can be changed to make a
plan hotter or cooler while keeping a similar distribution of isodose curves that increase
or decrease depending on the change.
 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 After normalizing to the entire PTV instead of the middle calculation point, the plan got
hotter to achieve the 100% of the prescription dose to 95% of the volume objective.
Before normalizing, our plan was much cooler superiorly, so to account for that section
of the volume the dose had to increase.
o All OARs are selected for these images, and small bower and bladder can be seen within
them.
o Note- these images were taken right after normalization (before modifying plan and
dosimetrist input) to see the direct effect after normalization. The post
modification/dosimetrist input images are at beginning of the plan 7 section.

17
Pre-normalization images- taken at isocenter

18
Post-normalization images-

 Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and coronal
views. Show the PTV and any OAR.
o All OARs are selected for these images, and small bower and bladder can be seen within
them.
o This shows the changes after the dosimetrist feedback with the normalization (same
images that are at the start of the plan 7 section)

19
20
  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).

Unlabeled final plan DVH and statistics image.

21
  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.

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
PTV 95 percent receiving 95% Y
45 Gy
Rectum Dmax ≤ 49.5 Gy 48.32 Gy Y
Bladder Dmax ≤ 49.5 Gy 48.06 Gy Y
Right femur Dmax ≤ 47.25 Gy 45.97 Gy Y
Left femur Dmax ≤ 47.25 Gy 46.54 Gy Y
Bowel space Dmax ≤ 49.5 Gy 47.76 Gy Y
External Dmax ≤ 49.5 Gy 48.90 Gy Y

These clinical goals are common ones for 3D cases in our clinic that MDs will either ask for on the
treatment planning order or will look to see when evaluating a plan. Even when a MD does not
specifically ask for these, our dosimetry team will try to stick to these objectives. The objectives include
95% of our PTV volume receiving 100% of the prescription dose, which plan 7 asks for and is the main
starting point in our dosimetry department for any 3D plan. For OARs, if the structure is within the PTV,
we aim to have a max dose point of 110% of the prescription dose. If the structure is on the outside of
the PTV or is only slightly decide, we will use max dose of 105% or 110% of the prescription dose
depending on what the doctor wants the clinical goal to be. In this case, the femurs did meet the lower
than 105% of the prescription dose goal. For external goals, our clinic will set a max dose of 120% of
the prescription dose goal (in this case 54 Gy) as a general goal but will aim to get the overall hot spot
much lower.

22