Planning Assignment (3 field rectum)

Use a CT dataset of the pelvis. Create a CTV by contouring the rectum (start
at the anus and stop at the turn where it meets the sigmoid colon). Expand
this structure by 1 cm and label it PTV.
Create a PA field with the top border at the bottom of L5 and the bottom
border 2 cm below the PTV. The lateral borders of the PA field should extend
1-2 cm beyond the pelvic inlet to include primary surrounding lymph nodes.
Place the beam isocenter in the center of the PTV and use the lowest beam
energy available (note: calculation point will be at isocenter).
Contour all critical structures (organs at risk) in the treatment area. List all
organs at risk (OR) and desired objectives/dose limitations, in the table
below:
Organ at risk
Bladder

Desired objective(s)
D40 < 4000 cGy
D15 < 4500 cGy
Dmax 5000 cGy

Achieved objective(s)
D40 = 3141 cGy
D15 = 4360 cGy
Dmax = 4555.8 cGy

Small Bowel

Dmax < 5000 cGy

V35 < 180 cc
V40 < 100 cc
D40 < 4000 cGy
D25 < 4500 cGy
Dmax 5000 cGy
D40 < 4000 cGy
D25 < 4500 cGy
Dmax 5000 cGy

Dmax = 1921 cGy

V35 = 73.42 cc
V40 = 1.97 cc
D40 = 2291 cGy
D25 = 2882 cGy
Dmax = 4467 cGy
D40 = 1890 cGy
D25 = 2764 cGy
Dmax = 4327 cGy

Left Femoral Head

Right Femoral Head

a. Enter the prescription: 45 Gy at 1.8 /fx (95% of the prescribed dose to

cover the PTV). Calculate the single PA beam. Evaluate the isodose
distribution as it relates to CTV and PTV coverage. Also where is/are
the hot spot(s)? Describe the isodose distribution, if a screen shot is
helpful to show this, you may include it.
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The dose distribution is very hot in the posterior region. The image is
shown below. The plan is normalized to 100%. If it is normalized to
have the 95% isodose line cover, then the plan gets even hotter in the
posterior area. The plan has a classic distribution of a single field plan.

b. Change to a higher energy and calculate the beam. How did your
isodose distribution change?
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The plan became less hot in the posterior area and the isodose lines
were pushed more anterior, which allows for better CTV and PTV
coverage.

c. Insert a left lateral beam with a 1 cm margin around the ant and post
wall of the PTV. Keep the superior and inferior borders of the lateral
field the same as the PA beam. Copy and oppose the left lateral beam
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
beams. Describe this dose distribution.
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The distribution is spread out much more uniformly and the hot spot is
only around 5%, as opposed to the single field plans which had greater
than 10%. The coverage to the PTV is a bit better with this distribution;
however with the addition of the lateral beams, there is now some
dose in the lateral areas. The image of the distribution is shown below.

d. Change the 2 lateral fields to a higher energy and calculate. How did
this change the dose distribution?
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The distribution looks similar to what is shown above, however the

distribution became a little bit better as far as coverage is concerned.
The dose that was in the lateral areas from the lateral beams also
become reduced with the higher energy, which is good. The 95%
isodose line is still a bit shy however.

e. Increase the energy of the PA beam and calculate. What change do you
see?
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The coverage became just a bit better since the isodose lines were
pushed a bit anterior. The 5% hot spot was also drastically reduced.

f. Add the lowest angle wedge to the two lateral beams. What direction
did you place the wedge and why? How did it affect your isodose
distribution? (To describe the wedge orientation you may draw a
picture, provide a screen shot, or describe it in relation to the patient.
(e.g., Heel towards anterior of patient, heel towards head of patient..)
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I placed the wedge on both lateral beams with the toe towards the
anterior of the patient on both beams. I placed it this way because the
hot spot was in the posterior region and so I wanted the heel to be

placed towards the posterior in order to reduce dose in that area. I also
wanted my isodose lines to shift anterior in order to get better PTV
coverage and this wedge orientation was appropriate in order to
achieve that. I started with a 15 degree wedge and that helped a bit,
but I still had a hot spot and not 95% coverage to my PTV.
g. Continue to add thicker wedges on both lateral beams and calculate for
each wedge angle you try (when you replace a wedge on the left,
replace it with the same wedge angle on the right) . What wedge
angles did you use and how did it affect the isodose distribution?
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I then added a 30 degree wedge. The distribution became better but I

still had a hot spot. Next I tried a 45 degree wedge. This was the
perfect wedge. It got rid of my 5% dose and the 95% isodose line was
fully covering the PTV. I also went ahead and tried a 60 degree wedge
to see what would happen. This resulted in my plan being overwedged, as the hot spot shifted more towards the anterior from the
posterior.

h. Now that you have seen the effect of the different components, begin
to adjust the weighting of the fields. At this point determine which
energy you want to use for each of the fields. If wedges will be used,
determine which wedge angle you like and the final weighting for each
of the 3 fields. Dont forget to evaluate this in every slice throughout
your planning volume. Discuss your plan with your preceptor and
adjust it based on their input. Explain how you arrived at your final
plan.
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For my final plan I chose 15 MV energy and a 45 degree wedge for both
lateral beams. Since I wanted to reduce dose to the lateral areas, I
weighted my posterior beam 50% and the laterals 25%. I showed the
plan to the dosimetrist and she was happy with the plan that I created.
The 95% isodose line was covering the PTV fully and my max dose was
4699 cGy, which was just under 5% hot. All of my organ at risk
objectives were also being met.

i. In addition to the answers to each of the questions in this assignment,

turn in a copy of your final plan with the isodose distributions in the
axial, sagittal and coronal views. Include a final DVH.
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(See final plan below)

4 field pelvis
Using the final 3 field rectum plan, copy and oppose the PA field to create an
AP field. Keep the lateral field arrangement. Remove any wedges that may
have been used. Calculate the four fields and weight them equally. How does
this change the isodose distribution? What do you see as possible
advantages or potential disadvantages of adding the fourth field?
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After adding an AP beam, the coverage to the PTV was almost the
same as my final plan, only the 100% isodose line was covering a little
bit more with the additional field. However, with the addition of the AP
beam, the 50% isodose line was in the anterior area of the patient. This
dose was not there without this beam. Since my final plan had
comparable PTV coverage to this plan, I do not see any advantage to
having the extra field. When I added this field and evaluated the DVH,
the dose to my small bowel and bladder had increased. This is to be
expected since the AP beam is going thru those structures. However, in
certain cases where the PTV may be extending more anterior, the
addition of the AP field may be necessary in order to get adequate PTV
coverage.