Pelvis Clinical Lab 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 0.5 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 beam.

 Describe the isodose distribution as it relates to PTV coverage. If a screen shot is helpful
to show this, you may include it.
o The isodose lines are what one might expect. The posterior aspect of the PTV is
receiving the full dose, but the anterior portion is not. In fact, the anterior PTV
is only getting 50% of the dose. The 3D min for the PTV is 58.8%.
 Where is the hot spot and what is it?
o The hot spot is horrible. It is 171.3% of the dose or 7710.4 cGy. It is
understandably located in the patient’s posterior tissue very close to the skin
surface.
 What do you think creates the hot spot in this location?
o The hot spot is located here because I am only using one field to pump dose to
my PTV. Given the fact that my PTV is located in the middle of the patient, and
I am using a 6 MV field; the hot spot’s position is logical.

Plan 2: Change the field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed.
o The dose distribution is much better than the previous plan. Much more of the
PTV is covered by the 100% isodose line. The 3D min for the PTV is 66.9%.
There is also less concentrated dose at the patients posterior surface. This is an
improvement over Plan One.
 Where is the hot spot and what is it?
o Even with the increase in beam energy, the hot spot is still located near the
posterior surface of the patient’s body. It is 151.2% of the dose or 6805.9 cGy.
 What do you think creates the hot spot in this location?
o The hot spot is located here due to the fact that I am still only using one beam
to treat this patient. Since this beam is entering the patient posteriorly, it
makes sense that the hot spot would be on the posterior edge of the patient.
Plan 3: Insert a left lateral beam with a 0.5 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 beams.
 Describe the isodose distribution.
o The isodose distribution understandably looks quite different from the
previous two plans. Given the addition of the two lateral fields, there are not
hot areas on the patients left and right sides. However, there is no longer a
large area of high dose near the posterior surface. It is still receiving dose, but
not as much as before. The 3D min for the PTV is 77.3% of the dose.
 Where is the hot spot and what is it?
o The hot spot is located anterior to the coccyx and slightly to the patient’s right
side. The 3D dose max is 11.7% of the dose or 5028.1 cGy. This is a substantial
improvement from the previous plans.
 What do you think creates the hot spot in this location?
o There are hot areas in the two junctions where the posterior field collides with
the left lateral and the right lateral. Both areas are receiving a lot of dose. The
hot spot is on the posterior/right lateral connection. This makes sense due to
the fact that this space, in essence, is being treated twice as much as other
areas.

Plan 4: Change the 2 lateral fields to a higher energy and calculate the dose.
 Describe the impact on the isodose distribution.
o With this plan, the dose has been brought more to the center of the patient.
The right and lateral edges of the patient’s body are no longer receiving a
ridiculous amount of dose. The posterior edge has stayed relatively the same in
comparison with Plan Three. The 3D min for the PTV is 78.4% of the dose.
 Where is the hot spot and what is it?
o The hot spot is in almost the exact same location as the previous plan. It is
112.4% of the dose or 5056.2 cGy.
 What do you think creates the hot spot in this location?
o The logic is the same as it was for plan three. There are hot areas in the two
junctions where the posterior field collides with the left lateral and the right
lateral. Both areas are receiving a lot of dose. The hot spot is on the
posterior/right lateral connection. This makes sense due to the fact that this
space, in essence, is being treated twice as much as other areas.

Plan 5: Increase the energy of the PA beam and calculate the dose.
 What change do you see?
 o With the increase in energy for the PA beam, the 100% isodose line has been
pushed anteriorly. More of the PTV is receiving dose. The 3D min for the PTV is
80.8% of the dose.
 Where is the hot spot and what is it?
o The hot spot is still located at the junction between the posterior and right
lateral fields. However, it has moved anteriorly from its previous location. The
hot spot is 110.8% of the dose or 4984.9 cGy.
 What do you think creates the hot spot in this location?
o Not to sound like a broken record, but I believe the logic is the same as I
previously stated for the last two fields. There are hot areas in the two
junctions where the posterior field collides with the left lateral and the right
lateral. Both areas are receiving a lot of dose. The hot spot is on the
posterior/right lateral connection. This makes sense due to the fact that this
space, in essence, is being treated twice as much as other areas. The only
difference with this field is that the hot spot has been moved anteriorly. This is
due to the increase in beam energy.

Plan 6: Add the lowest angle wedge to the two lateral beams.
 What direction did you place the wedge and why?
o I used two ten degree wedges. These were the lowest angle wedges available.
They were both placed so the heel of the wedge was towards the posterior of
the patient. I did this due to the location of my previous hot spots. I wanted to
push the dose anteriorly.
 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..)
o It helped my dose distribution substantially. The 3D min for the PTV went up to
82.0% of the dose. The isodose distribution is more spread out than before.
There are no longer enormous hot spots on the right lateral and left lateral
edges of the patient. The 100% isodose line is almost completely kept within
the bony anatomy of the patient’s pelvis. The anterior edge of the PTV is still
not getting complete coverage.
 Where is the hot spot and what is it?
o The hot spot is located in the exact same place as the previous plan. However,
it is lower. The hot spot is 108.4% of the dose or 4876.3 cGy.
 What do you think creates the hot spot in this location?
o The hot spot is located here due to the junction of the posterior and right
lateral fields. Even with the wedge, there is still more dose going here than
other areas.
Plan 7: 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). You may weight your fields to get a better dose distribution.
 What final wedge angles and weighting did you use?
o I chose two 20 degree wedges for my lateral fields. As for weighting, I tried
many different combinations. However, I settled on an evenly weighted
distribution of:
 AP - .33
 Lt Lat - .33
 Rt Lat - .33
 How did each change affect the isodose distribution?
o I started out with two 10 degree wedges. I first increased wedge size to 15. This
brought down my hot spot and increased the minimum dose my PTV was
receiving. The same happened when I changed wedge angles again to 20.
However, when I attempted to further increase my wedge size to 25, the hot
spot went up and the PTV minimum coverage decreased.
 Where is the hot spot and what is it?
o The hot spot is still located at the intersection of the posterior and right lateral
fields. It continues to move more anteriorly. The 3D dose max for the PTV is
105.9% of the dose or 4765.6 cGy.
 What do you think creates the hot spot in this location?
o The hot spot continues to move in the anterior direction. Its not a lot, but it is
enough to notice. This, I believe, is due to the fact I am increasing the wedge
angles for my lateral fields. Since the heels of these wedges are posterior, the
dose would understandably be pushed anteriorly.

Plan 8: Copy and oppose the PA field to create an AP field and adjust the collimators to keep a
0.5 cm margin around the PTV. Keep the lateral field arrangement. Remove any wedges that
may have been used. Calculate the four fields and weight them equally. Adjust the weighting of
the fields, determine which energy to use on each field, and, if wedges will be used, determine
which angle is best. Evaluate your plan in every slice throughout your planning volume. Discuss
your plan with your preceptor and adjust it based on their input. Normalize your final plan so
that 95% of the PTV is receiving 100% of the dose.
 What energy(ies) did you decide on and why?
o I decided on 16 MV for my beam energies. My site only has the option of 6 MV
or 16 MV for photon beams. I experimented with 6 MV beams or a mix of the
two, but it didn’t equal the coverage I had with 16’s alone.
 What is the final weighting of your plan?
o After conversing with my preceptor and analyzing all of the option, I decided to
make my plan an eight field plan. This spread the dose around and reduced my
hot spot substantially. The weights for the fields are as follows:
 PA - .097
  RPO – .129
 Rt Lat - .129
 RAO - .129
 AP - .129
 LAO - .129
 LPO - .129
 Did you use wedges? Why or why not?
o With the eight field plan I decided against utilizing any wedges. I experimented
with wedges on different angles, but it didn’t improve the plan.
 Where is the region of maximum dose (“hot spot”) and what is it?
o The hot spot is 106.1% of the dose or 4773.5 cGy. It is located in the posterior
left aspect of the PTV. I am satisfied that the hot spot resides within my PTV
volume.
 What do you think caused the hot spot in this location?
o Considering the fact that I have eight beams and all of them are focused on the
PTV, it makes sense that the hot spot would reside inside the volume. Its
location in the posterior aspect is due to the fact the patient has much more
tissue anteriorly. This makes it easier for beams to reach the PTV from the
posterior than anterior.
 What is the purpose of normalizing plans?
o Normalizing plans tells the machine where you want 100% of the dose. At my
site, this is typically done with a calc point. This calc point can then be moved
to help the dosimetrists adjust their dose distribution.
 What impact did you see after normalization? Why?
o After normalizing my PTV coverage improved. However, this also increased my
hot spot. Both of these results go hand in hand. Due to the fact that my pre-
normalization plan was just short of providing optimal coverage, normalizing
pushed more dose to the PTV and thus increased the hot spot.

Disclaimer:
I had a remarkably difficult time reducing the doses to my OARs. This is due to the
fact that most of these organs are in the PTV volume. However, with the prescription (45
Gy) being a lower dose, the tolerances for these organs was not exceeded.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Rectum V75 < 15%, V60 < 50% V75 = 0%, V60 = 0%
Bladder V80 < 15%, V65 < 50% V80 = 0%, V65 = 0%
Femurs Max Dose 50 Gy Max Dose – 4669.8 cGy
Bowel Space Max Dose 50 Gy Max Dose – 4767.5 cGy

Reference: Mobius 3D Dose Volume Histogram Limits. Mobius Medical Systems, LP. 2014.
Figure One: Transverse View of Pelvis Lab
Figure Two: Coronal View of Pelvis Lab
Figure Three: Saggittal View of Pelvis Lab
Figure Four: Dose Volume Histogram (DVH) of Pelvis Lab