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Pelvis Clinical Lab Assignment

Plan 1: Calculate the single PA field.
 Describe the isodose distribution (be specific in your description of depth, location,
etc).
o Looking at the isodose distribution, the PTV is not getting adequate coverage on
the anterior portion. The 100% isodose line is covering less than half of the PTV
and is only covering the posterior portion of it. The 95% line is covering about
half of the PTV but is still not covering anteriorly. The PTV is only getting full
coverage from the 59.5% isodose line.
 Where is the hot spot (max dose) and what is it?
o The hot spot is located posteriorly in the patient, close to the skin surface, and it
is 174.8%.
 What do you think creates the hot spot in this location?
o The hot spot is in this location because there is only one PA beam entering
posteriorly and it’s 6MV (the lowest energy), so it’s not penetrating as deep into
the tissue as a higher energy beam would. The dmax for 6MV is only 1.5 cm, so
this is where we’re getting the most dose build up and it’s located posteriorly in
the patient because that’s where the beam is entering from.
 Using your DVH, what percent of the PTV is receiving 100% of the dose? Remember to
describe or show how you read this.
o 48.28% of the PTV is receiving 100% of the dose. If I follow the dose on the x-axis
over to 45Gy, this point intersects with 48.28% on the y-axis, which is the ratio of
total structure volume, or the percentage of the PTV being covered with that
dose.

Plan 1
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Plan 1

Plan 1
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Plan 1

Plan 1 DVH showing PTV coverage

Plan 2: Change the PA field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed and why?
o I changed the PA field from 6X to 15X. The isodose lines shifted more anteriorly
so that more of the PTV is being covered. I noticed a bigger difference/more of a
shift in the lower isodose lines compared to the 95% or 100% lines. This is
because with a higher energy, the dose is being pushed deeper into the body.
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The dmax for 15MV is 3.0 cm. The hot spot was also reduced from 174.8% to
154.0%.
 Using your DVH to confirm, what percent of the PTV is receiving 100% of the
prescription dose?
o 54.35% of the PTV is receiving 100% of the prescription dose.

Plan 2

Plan 2
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Plan 2

Plan 2
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Plan 2 DVH showing PTV coverage

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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 The isodose distribution around the PTV expanded even more anteriorly, giving
the PTV more coverage with the higher dose levels. However, the isodose
distribution has spread out more laterally in the patient, so there’s more dose at
the sides of their body and around the femoral heads.
 Where is the hot spot and what is it?
o The hot spot went down to 113.8% and it’s located posteriorly in the patient,
about 6 cm from the skin surface, which is deeper in the body than it was before.
It’s gotten closer to the PTV but is still outside of it.
 What do you think creates the hot spot in this location?
o The hot spot is still very posterior in the patient because the beams are only
entering from the posterior and lateral angles and since they’re the lowest
energy, the dose isn’t penetrating as far. To push the hot spot more anteriorly
towards the PTV, I think we’d need to add a beam entering from the AP or we
would have to increase the energy on the existing beams so that more dose is
being deposited at a greater depth.

Plan 3 hot spot location

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Plan 3

Plan 3
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Plan 3

Plan 3
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Plan 3 DVH showing PTV coverage

Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution.
o The isodose distribution changed so that the higher doses are covering more
anteriorly and medially in the patient. Essentially, the dose got pushed deeper
into the body. More of the PTV is being covered with the higher isodose lines.
The higher doses that were in the lateral parts of the patient near the hips also
got pushed more medially, so it cooled down the sides of the body.
 In your own words, summarize the benefits of using a multi-field planning approach?
(Refer to Khan Physics for benefits of multiple fields)
o Using multiple fields is beneficial in distributing the dose more evenly to the
treatment area. The more fields you have, the lower the weighting is for each
field (each field is individually contributing less) and the dose build-up is highest
where the fields meet. In comparison, with just one field, the dose is only being
distributed from one angle. This creates more of a hot spot at the surface of the
skin where the beam is entering and PTV coverage will not be as sufficient.
 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 61.9% of the PTV is receiving 45 Gy, compared to 54.3% of the PTV receiving 45
Gy in plan 2.
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Plan 4

Plan 4
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Plan 4

Plan 4
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Plan 4 DVH comparison with Plan 2 showing PTV coverages

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: 0.308
o Lt Lat: 0.346
o Rt Lat: 0.346
 What was your rationale behind your final field weight? Be specific and give details.
o Weighting the PA more heavily decreased the PTV coverage and created more of
a hot spot posteriorly by the sacrum. Weighting the laterals more heavily
decreased the hot spot, pushed it more into the PTV, and increased the PTV
coverage overall, but it also increased the dose in the sides of the body and near
the femoral heads. I tried to find a good balance between maintaining good PTV
coverage but not getting the 95% and 100% isodose lines in the sides of the body
near the skin surface. Weighting the PA just slightly lower than the laterals
looked like the best balance to me.
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Plan 5 with weighting

Plan 5
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Plan 5

Plan 5
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Plan 5 DVH showing PTV coverage

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 30IN on the left lateral and 30OUT on the right lateral. The heel for both is
towards the posterior side of the patient.
 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 isodose lines expanded to cover more of the anterior portion of the PTV
because dose is being forced anteriorly by the wedge. I could tell when I had too
much of a wedge because I started to lose coverage posteriorly.
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Plan 6 before wedges

Plan 6 after wedges

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Plan 6

Plan 6
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Plan 6

Plan 6 DVH showing PTV coverage

 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 15 cm is the minimum distance it should be from the patient’s skin to keep the
skin dose below 50% of dmax.
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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 15MV on all fields gave the best coverage of the PTV. The pelvis is a thicker area
of the body so this plan required a higher energy to obtain the ideal dose
distribution at the depth of the PTV.
 What is the final weighting of your plan?
o PA – 0.280
o Lt Lat – 0.236
o Rt Lat – 0.255
o AP – 0.228
 Did you use wedges? Why or why not?
o No, with the four fields the dose was already pretty conformal and adding
wedges just caused me to lose coverage in areas and made the plan hotter.
 Where is the region of maximum dose (“hot spot”) and what is it?
o The hot spot is 107.3% and is located within the PTV (left anterior corner when
viewing axially).
 What is the purpose of normalizing plans?
o Normalizing gets dose coverage to the desired area by shifting the isodose lines
to force coverage. The treatment planning system will do whatever it needs to
do to obtain the coverage you are telling it to (i.e. 100% of the prescription dose
covering 95% of the treatment volume), however, this will usually make the plan
hotter. The advantage, though, is that you know you’re getting your desired PTV
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 It improved coverage of the PTV where it wasn’t getting covered with the 100%
dose, superior and inferiorly. This is because I told the planning system to make
it so that the 100% isodose level covers 95% of the target volume and it will do
whatever it has to do to the plan to force/maintain that coverage.
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Plan 7 before normalization

Plan 7 after normalization

 Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and
coronal views. Show the PTV and any OAR.
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Plan 7

Plan 7 Axial
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Plan 7 Coronal

Plan 7 Sagittal

 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).
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Final DVH showing PTV and OARs

 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.

I used the ClearCheck application at my clinic to see if the OARs met the planning objectives. I
used a GI/Pelvis long course constraints template since the prescription is 45 Gy in 25 fractions.
In this case, the bladder and bowel did not meet the planning objectives because the PTV is
relatively large and it includes both of those structures in it. I’ve attached a copy of the
ClearCheck report that I ran to this assignment.
Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Bladder Mean≤4000-4400cGy Mean=4597.3cGy no
Rectum Max≤5440-5540cGy Max=4761.6cGy yes
Lt Femur D5%≤4500-5000cGy D5%=4363.9cGy yes
Bowel D120cc≤3500-3850cGy D120cc=4663.5cGy no