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.
o The isodose distribution is U shaped towards the posterior surface. The PTV is
not getting adequate coverage as the PTV is more in the center of the patient
and most of the dose is posterior. The PTV covered by the 100% isodose line is
47.37%. The isodose line that is giving the PTV 100% coverage is the 60% isodose
line.
Where is the hot spot and what is it?
o The max dose is located posteriorly and under skin surface. The max dose is 7618
cGy which is 169%.
What do you think creates the hot spot in this location?
o I think using 6 MV beam is the reason for the hot spot in this location. A 6 MV
has a dmax of 1.5 cm. The dose is delivered more towards the surface with a
lower energy beam.
Using your DVH, what percent of the PTV is receiving 100% of the dose?
o 47.37% of the PTV is receiving 100% of the dose.
Plan 2: Change the PA field to a higher energy and calculate the dose.
Describe how the isodose distribution changed and why?
o The isodose distribution is still U shaped towards the posterior surface. The dose
distribution for the 100% line looks similar to the 6 MV. However, the 50 and
60% isodose lines are deeper into the patient and stretch more to the anterior
surface. This is because higher energy will penetrate deeper into the patient.
Another change in isodose distribution is the hot spot. It is still posterior, but
deeper into the patient. It has also decreased from 169% to 144%.
Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
o 47.12%
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 is no longer U shaped towards the posterior. It is now a
rectangular shape around the PTV. The PTV is now covered by the 80% isodose
line. The plan is now hot on the laterals as well. The PTV coverage by the 100%
isodose is still low at 46.57%.
Where is the hot spot and what is it?
o The hotspot is still located posteriorly and right of the PTV. The max dose is now
5081 cGy and is 113%.
What do you think creates the hot spot in this location?
o I think that the beam weighting is creating a hot spot at this location. If the
weighting was decreased on the right lateral and increased on the left this could
balance it out. The beam energy could also be increased on the laterals to
penetrate deeper and cool down the dose delivered near the surface.
Plan 4: Increase the energy of all 3 fields and calculate the dose.
Describe how this change in energy impacted the isodose distribution.
o This change in energy pushed the dose more towards the PTV on the laterals.
With the lower energy the 100% isodose lines were appearing on the right and
left sides of the patient and now is more central. The hot spot is still in a similar
location however it has decreased to 108%.
What are the benefits of using a multiple-field planning approach? (Refer to Kahn, 5th
ed, Ch 11.5B)
o Reduction of dose to subcutaneous tissue and normal tissue surrounding the
tumor. It can also increase dose uniformity, and help to better spare critical
organs
Compared to your single field in plan 2, what percent of the PTV is now receiving 100%
of the prescription dose?
o Compared to the single field in Plan 2, 44.12% of the PTV is getting 100% of the
dose which is less than what Plan 2 was receiving.
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: 40%
L Lat: 30.05%
R Lat: 29.95%
What was your rationale behind your final field weight?
o My rationale for the beam weighting was to decrease the dose to the laterals by
weighting them less than the posterior beams. My PTV coverage increased
slightly to 46.64% but no adjustments that I made was able to increase this value
by much more so I focused on decreasing the dose to the sides while still keeping
my hot spot under 110%.
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..)
o I chose heel towards posterior of patient and 20 degree wedge. I tried to push
more of the dose to the anterior portion of the PTV.
How did the addition of wedges change the isodose distribution?
The isodose lines were pushed more anterior. The 49.62% of the PTV is now being
covered by the 100% isodose line compared to the 46%. In plan 5, only 71.5% of the PTV
was being covered by the 95% isodose line. With the addition of wedges, that number
jumped to 90.41%. My hot spot also decreased from 110% to 104%. However, the plan
is also hotter more anterior, especially on the laterals due to the wedge.
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)
o According to Kahn,the minimum distance a wedgeor absorber should be placed from
the patients skin surface is 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 I decided on 18 MV because of the size of the patient as well as the location of
the PTV. The PTV was located in the center of the patient. The 18 MV beam was
able to peneterate deeper and give a better coverage than a 6 MV beam
What is the final weighting of your plan?
PA: 32.79%
AP: 27.21%
L Lat 20%
R Lat 20%
Did you use wedges? Why or why not?
o No, I did not use a wedge. I attempted a plan using an AP wedge, heel inferior,
toe superior, to help try to push dose more superiorly. It did help to push dose
more superior but inferiorly it started missing coverage. The plan still adequately
covered the PTV, however, dose to the bowel space was increased. Therefore, I
ended up choosing a plan with no wedge.
Where is the region of maximum dose (“hot spot”) and what is it?
o 4898 cGy- 108% This hot spot is located anterior to the isocenter, on the left side
of the PTV
What is the purpose of normalizing plans?
o The purpose of normalizing a plan can be to either make it hotter or cooler.
What impact did you see after normalization? Why?
o I could not get adequate coverage with my 100% isodose line. I was only getting
57% of my PTV being covered by my 100% line. However, my 95% isodose line
was covering over 95% of the PTV. Renormalizing to 95% caused my 95% isodose
line to now be 100% giving adequate coverage to the PTV.
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
Bowel Max dose <50 Gy for small Max dose 48.75 Gy
bowel (RTOG 0822)*
Rectum V50 <50% (QUANTEC) 0%
Femurs V50 <5% (RTOG GU Consensus) 0%
Bladder V65 <50% (QUANTEC) 0%
*Because large and small bowel were contoured together, I used the more conservative dose constraint
for the small bowel.
