PLAN 1: Calculate the single PA field.

Because there is only a single beam contributing to the isodose distribution it looks like a
percent depth dose curve. The hot spot is 178% and is located on the central axis of the beam on
the posterior of the patient. The location of the hot spot is explained by the fact that the dose is
being pushed from a single PA beam and the Dmax for a 6 MV beam is only 1.5 cm, while the
depth of the calc point is 11.6 cm. With this plan only 51.3% if the PTV is receiving 4,500 cGy.

Figure 1.0. Plan 1 isodose distribution in axial, sagittal and coronal planes, displaying hot spot.

Figure 1.1. Plan 1 DVH, displaying 51.3% PTV coverage.

PLAN 2: Change the PA field to a higher energy and calculate the dose.
Between plan 1 and this plan there is no change in shape to the isodose distribution.
However, the 18 MV beam is more penetrating so the isodose lines reach farther. With this plan
54.1% of the PTV is getting 4,500 cGy.

Figure 2.0. Plan 2 isodose distribution in axial, sagittal and coronal planes.

Figure 2.1. Plan 2 DVH, displaying 54.1% PTV coverage.

PLAN 3: Insert a left lateral field with a 1 cm margin around PTV. Create opposed lateral
to create a right lateral field. Use the lowest energy available for all 3 fields. Apply equal
weighting and calculate dose.

With the addition of two lateral fields there is a lot less exit dose towards the anterior of
the patient. The 100% isodose line has not changed much since that is to our calc point, which is
the same as the previous plans. There is more coverage of the PTV in the 80-95% isodose range,
which is being contributed because of the lateral fields. Where the three fields intersect the shape
of the isodose dose lines is somewhat of a trapezoid shape. With the addition of two lateral fields
the hot spot has decreased to 116%. With the contribution of the lateral fields the hot spot is now
located 4.2 cm from the patient's posterior surface and is located to the right of the central axis.
The patient has a larger separation and more muscle on the left so the dose most likely does not
penetrate as deeply compared to the right. In addition, there is a contribution of exit dose from
the left lateral field. With no dose coming from the AP direction the hot spot should also still be
more posterior.

Figure 3.0. Plan 3 isodose distribution in axial, sagittal and coronal planes, displaying hot spot.
Figure 3.1. Plan 3 DVH.
PLAN 4: Increase the energy of all 3 fields and calculate dose.

Because the 18 MV is more penetrating, more of the dose is able to be pushed towards
the PTV. Increasing the dose increased the coverage of the PTV by pushing all the 95% and 90%
isodose lines in toward the PTV, and more of the 80% as well. Just increasing to 18 MV the plan
dropped to 113% as well. With plan two 54.1% of the PTV is receiving 4,500 cGy, whereas with
this plan 54.8% of the PTV is receiving 4,500 cGy. There is only a small difference in coverage
because the calc point remains the same for both plans. One of the best and easiest ways to
increase conformality of a plan while sparing critical structures is to use multiple fields.1

Figure 4.0. Plan 4 isodose distribution in axial, sagittal and coronal planes.

Figure 4.1. Evaluation between Plan 4 and Plan 2.

PLAN 5: Using your 3 high energy fields from plan 4, adjust the field weights until you are
satisfied with the isodose distribution.

I ended up with the following weighting on my plan: PA field 50%, left lateral 25%, right
lateral 25%. I chose this weighting because it gave the best isodose distribution; 70% and above
is pushed centrally around the PTV. The reason the PA is weighted heavier is because it alone is
giving dose to the PTV in that direction. The lateral fields contribute exit dose to each other, so
they do not need as much weighting.

Figure 5.0. Plan 5 isodose distribution in axial, sagittal and coronal planes.

Figure 5.1. Plan 5 DVH.

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, do so.

I chose 15-degree wedges with the heel towards the posterior of the patient; not to
account for the tissue difference in the patient but rather to adjust the isodose lines. By doing this
the wedge is allowing more dose to be pushed toward the anterior of the patient, while shielding
the posterior portion, which is receiving dose from the PA beam. The addition of wedges
completely took the 110% dose away, dropping to hot spot to 109% versus 117% from plan 5. I
also changed the weighting a little with the addition of wedges, giving the PA field 38% and the
lateral fields each 31%. This pulled some of the 70% and 80% laterally, but overall, there is a
more conformal dose distribution around the PTV with the addition of wedges. According to
Khan,1 a wedge should be placed at a minimum distance of 15 cm from the patient’s skin to keep
skin dose below 50% of Dmax.

Figure 6.0. Plan 5 axial and coronal before wedges compared to Plan 6 axial and coronal with
wedges.
Figure 6.1. Plan 6 isodose distribution in axial, sagittal and coronal planes.

Figure 6.2. Plan 6 DVH.

PLAN 7: Insert an AP field with a 1 cm margin around the PTV. Remove wedges from
previous plan. Calculate dose to the four fields. At your discretion, adjust the weighting
and/or energy of the fields and if wedges will be used. 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 based on their input.

For the final four-field plan I used 18MV because it gives more penetration power and a
more homogenous plan. The final weighting of the plan is 26% PA, 24% AP, 24% left lateral,
26% right lateral. The addition of the AP beam gave a pretty good dose distribution without
needing wedges, the plan was 105% but I didn’t have full coverage on my PTV. This is where
normalization came into play. By normalizing, the TPS forces the dose to cover the PTV, which
gives more heat to the edges of the PTV. You can’t completely cover the PTV without also
heating the center of the treatment plan. After normalizing, I ended up adding a 3-degree wedge
on the anterior beam with the heel to the patient’s left to cool the hot spot that was overlapping
with the bowel space. My final region of maximum dose was 107.4% located posteriorly and to
the patient's left.

Figure 7.0. Plan 7 axial and coronal comparison before normalization and after normalization.
Figure 7.1. Final plan, axial isodose distribution.

Figure 7.2. Final plan, sagittal isodose distribution.

Figure 7.3. Final plan, coronal isodose distribution.

Figure 7.4. Final DVH and clinical goals.

Table 1. Planning Objectives from Embrace II

 Organ at Risk (OAR) Planning Objective2 Objective Outcome Objective Met (Y/N)
Rectum V30 <95% 93% Y
Bowel Space V40 <70% 38% Y
Rt Femur Max dose 5000 4637 cGy Y
Lt Femur Max dose 5000 4665 cGy Y
Bladder Max dose 4800 4794 cGY Y

References
1. Gibbons JP. Khan’s the Physics of Radiation Therapy. Sixth. Wolters Kluwer; 2020:185,
189-190.
2. Pötter R, Tanderup K, Kirisits C, et al. The EMBRACE II study: The outcome and prospect
of two decades of evolution within the GEC-ESTRO GYN working group and the
EMBRACE studies. Clinical and Translational Radiation Oncology. 2018;9:48-60.
doi:https://doi.org/10.1016/j.ctro.2018.01.001