Kelli Braith

Dos771: Clinical Internship I

Spring 2024

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.

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Plan 1: Calculate the single PA field.
 Describe the isodose distribution (be specific in your description of depth, location, etc).
o The prescription is coming from the posterior only. The distribution is very posterior and
hot. This is a typical distribution for a single field plan. The anterior is cool because of
the low exit dose. The coverage of the PTV is not ideal. 100% of the dose is only covering
a portion of the PTV. Due to using a 6 MV beam, the dose is greatest at any depth along
the central axis of the beam. With a one field approach the beam’s intensity portrays a
direction projecting to the beam’s direction.1

 Where is the hot spot (max dose) and what is it?

o The maximum hot spot is very posterior and near the skin surface. The location is to be
expected as the Dmax for a 6 MV beam is 1.5 cm1. The maximum hot spot measures
7650.5 cGy. The hot spot is also not in the PTV.

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  What do you think creates the hot spot in this location?
o All the dose enters the patient through a single beam in one location, creating a
clinically meaningful hot spot.2
o The hot spot is expected to be about 1.5 cm from the surface due to D max of a 6 MV
being around 1.5 cm.1

 Using your DVH, what percent of the PTV is receiving 100% of the dose? Remember to
describe or show how you read this.
o The percentage of PTV receiving 100% of the dose is 51.37%.
o The x axis of the DVH reads the dose in cGy is read. The y axis reads the percentage of
the volume of the total structure.

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Plan 2: Change the PA field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed and why?
o The distribution changed due to the change of energy. An 18 MV beam is now being
used.
o The dose is being deposited deeper into the patient. The isodose lines are shifted more
anterior and covering more of the PTV. There is also less skin dose because the hot spot
is more anterior as Dmax of 18 MV is around 3.5 cm.1

 Using your DVH to confirm, what percent of the PTV is receiving 100% of the prescription
dose?
o The percentage of the PTV receiving 100% of the prescription dose is 55.80%.

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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 By adding right and left lateral beams, the dose becomes more conformal to the PTV but
also added prescription dose to the lateral aspect of the body. The added posterior
beam assists with less bowel dose, but then adds to the integral dose throughout the
body. Integral dose is a measure of total energy absorbed in the treated volume. 1 The
dose on the lateral aspect of the body comes from the lateral beams being weighed the
same as the posterior beam. The hot spot is closer to the PTV but more lateral.

 Where is the hot spot and what is it?

o The hot spot has improved in location, it is getting closer to the PTV. It is located
posterior and lateral to the PTV, in soft tissue. The maximum hot spot measures 5095.6
cGy.

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  What do you think creates the hot spot in this location?
o The maximum hot spot is located at the intersection of all 3 beams. The energy used 6
MV, is unable to penetrate as deep into tissue. The hotspot is also slightly lateral
towards the right due to the unequal tissue distribution. The right side of the patient has
less tissue to penetrate than that of the left side.

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 increased energy positively impacted the dose distribution. The 18 MV beams assist
with making the dose more conformal. The dose penetrates deeper into the body. The
lateral prescription dose was decreased.

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  In your own words, summarize the benefits of using a multi-field planning approach? (Refer
to Khan Physics for benefits of multiple fields)
o According to Khan, the main goal of planning is to deliver maximum dose to the tumor
and to minimize dose the surrounding tissues. It is important to consider uniformity
within the tumor volume and sparing critical structures when planning. 2 When choosing
angles to deliver dose through, critical structures are considered. The dose is most ideal
when uniform, but other structures are studied as well. A multi-field planning approach
increases the dose distribution uniformity. Uniformity can be achieved by using field
that are an appropriate size, increasing the number of fields, selecting appropriate beam
directions, and adjusting the beam.1
 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 plan 2, the percentage of the PTV that received 100% of the prescribed dose is
55.80%.

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 o In plan 4, the percentage of the PTV that received 100% of the prescribed dose is
61.42%.

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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 POST: 0.435
o LT LAT: 0.282
o RT LAT: 0.282
 What was your rationale behind your final field weight? Be specific and give details.
o When choosing the weight of each beam, I focused on achieving the best target dose
and limiting dose to other structures. I chose to weigh the post beam slightly more due
to the target being more posterior. The posterior beam being weighted a bit more
assists with getting more dose to the target. The lateral beams are weighted equal to
balance both sides to try to reduce the integral dose to the anterior of the body and into
the bowel. Limiting dose towards the anterior will limit side effects for the patient. The
coverage of the target improved from Plan 4 to Plan 5, but the global max hot spot also
increased.

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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 Left Lateral= EDW30IN: Heal towards to posterior of the patient, heal towards the feet
of the patient
o Right Lateral= EDW30OUT: Heal towards the posterior of the patient, heal towards the
feet of the patient
o The collimator also needed to be turned on the two fields to orientate the wedges
correctly.

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  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.

Before wedge placement: axial

Before wedge placement: coronal

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After wedge placement: axial

After wedge placement: coronal

o The use of the wedges assisted with pushing dose more anterior into the PTV. The dose
became more box like and is more conformal. The wedges also helped with the PTV
being covered by 100%.

 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 minimum distance is around 15 cm between the wedge and the surface. This is to
keep the skin dose below 50% of Dmax.1

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 o Electron contamination can occur if the wedge is too close to the patient. It is vital to
have an adequate distance from the skin surface to limit the electron contamination
produced by the absorber facing the surface doesn’t harm the skin sparing effect of the
mV photon beam.2

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 Posterior field: 10 MV. 10 MV was chosen because the target is more posterior and
more superficial on the posterior field. 10 MV Dmax is 2.5 cm1 and the separation
between the surface and target shows that the distance of 2.5 cm would be desired.
o Left lateral, right lateral, and anterior field: 18 MV. 18 MV was chosen because the
target is deeper when considering these angles. 18 MV Dmax is around 3.5 cm1 the
distance from the lateral beams and the anterior beams needs a larger distance to
achieve dose to the target.
 What is the final weighting of your plan?
o Posterior field: .300
o Left lateral: .180
o Right lateral: .220
o Anterior field: .300
 Did you use wedges? Why or why not?
o I did not use any wedges. If I would have used wedges the dose would have been
pushed more anterior, but with adding an anterior beam, the anterior aspect of the
body would have been hot.

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  Where is the region of maximum dose (“hot spot”) and what is it?

o The hot spot is anterior in the PTV. The maximum hot spot measures 106.2%.

 What is the purpose of normalizing plans?

o Normalization gives the ability to rescale the dose to the isodose line of interest. If 100%
is desired to cover the target, it can be requested, and the dose will be adjusted to
achieve this request. Normalization will assist with hot or cold plans. The dose can be
adjusted up or down by a certain percentage to achieve the coverage needed.
Normalization can be done with two methods. The methods are a fixed SSD treatment
or an isocentric method.1 The isocentric method is used for SAD treatments. SAD
treatments are performed at my clinical site. SAD treatments will normalize the 100%
isodose line at the point of the isocenter.

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  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 Before normalization: Before normalization the PTV was not covered as well by 4500
cGy. As seen on the DVH, 100% of the dose (4500 cGy) was covering 86.8772 % of the
target volume. This plan was not normalized; therefore, dose was not adjusted to cover
more of the PTV.

o After normalization: After normalization the plan became hotter. The PTV was
covered by 100% better. As seen on the DVH, 100% of the dose was covering 95% of
the target volume.

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  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 Isodose distribution with PTV only:

o Final isodose distribution with PTV and OARs:

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  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 The OARs in the table use planning objectives from departmental standards and the
QUANTEC data.4 The PTV coverage is achieved in the final plan. The bladder and small
bowel are not achieved. This case would require a conversation with the physician to be
aware of the priority of the plan. It is important to be aware of sensitive tissues. The PTV
has acceptable coverage, but some of the sensitive tissue objectives are not achieved.
The physician will give insight into what the goal of the plan is.

Organ at Risk Planning Objective Objective Outcome Objective Met? Reference?

(OAR) (Y/N)
BLADDER V45Gy < 45% 91.5 % N Per
departmental
standards
SMALL BOWEL V20Gy < 50cc 849.781cc N Per
departmental
standards
V26.5Gy < 0.03cc 773.691 N Per
departmental
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 standards
V28.75Gy < 0.03cc 727.897 N Per
departmental
standards
LEFT FEMUR V20Gy < 64% 57.936% Y Per
departmental
standards
V25Gy < 5% 15.826% N Per
departmental
standards
RECTUM V50Gy < 50% 0% Y QUANTEC

V60Gy < 35% 0% Y QUANTEC

V70Gy < 25% 0% Y QUANTEC

V75Gy < 15% 0% Y QUANTEC

RIGHT FEMUR V20Gy < 64% 62.015 Y Per

departmental
standards
V25Gy < 5% 17.452 N Per
departmental
standards

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References:
1. Washington CM., Leaver, D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO:
Mosby; 2010.
2. Gibbons, JP. Khan’s The Physics of Radiation Therapy. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2020.
3. Bentel GC. Radiation Therapy Planning. 2nd ed. McGraw Hill; 1996.
4. Marks LB, Yorke ED, Jackson A, et al. The use of normal tissue complication probability (NTCP)
models in the clinic. International journal of radiation oncology, biology, physics. 2010;76(3
0):S10-S19. doi:https://doi.org/10.1016/j.ijrobp.2009.07.1754

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