Carly Bernhard

Pelvis Lab
Plan 1: Calculate the single PA field.
 Describe the isodose distribution (be specific in your description of depth, location, etc).
o The dose is much hotter in the posterior part of the body. The dose gets colder
the more anteriorly it travels because it’s being attenuated by tissue.
 Where is the hot spot (max dose) and what is it?
o The hotspot is located posteriorly and is 174.6%
 What do you think creates the hot spot in this location?
o I think the hotspot is located posteriorly because the beam is entering the body
posteriorly, and as the beam is attenuated by positioning devices and patient
tissue, the dose gets progressively cooler the more anterior it travels. I also think
it is hot posteriorly because the energy chosen (6MV) is too low to penetrate any
farther into the body so it stay superficial.
 Using your DVH, what percent of the PTV is receiving 100% of the dose? Remember to
describe or show how you read this.
o If you look at the PTV isodose curve represented in red on the DHV, you can
follow the line up from the bottom of the graph, labeled “Relative dose” that
says 100%, that line intersects with a line coming from the left side of the DVH
labeled “Ratio of total structure volume”. The PTV isodose curve intersects with
100% dose line at 48.2% of the structure volume.
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 changed in that the lines are penetrating the body
deeper or more anteriorly. I believe this is because the energy of the beam was
increased to 15MV which has a deeper dmax and the beam can penetrate
further into the body.
 Using your DVH to confirm, what percent of the PTV is receiving 100% of the
prescription dose?
o 100% of the dose is now reaching 54.3% of the PTV.
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 With adding the two low energy lateral fields, the isodose lines start to spread
laterally, as opposed to the isodose lines going farther and farther anterior in the
pelvis with the single PA field. Because of the equal weighting, all 3 fields are
giving the same amount of dose, but the lateral beams have farther to travel to
reach the target.
 Where is the hot spot and what is it?
o The hotspot is still located posteriorly and it is 113.8%.
 What do you think creates the hot spot in this location?
o I believe the hotspot is located where it is because all 3 fields are overlapping in
that area.
Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution.
 o Increasing the dose on all 3 fields moved the isodose anteriorly slightly and there
is much less dose spreading laterally in the body.
 In your own words, summarize the benefits of using a multi-field planning approach?
(Refer to Khan Physics for benefits of multiple fields)
o Using multiple fields means you can spare more healthy tissue in the body by
splitting up the dose among all fields instead of just blasting through one area of
the body. It also helps shape or conformalize the fields, which is also beneficial
to the healthy tissue in the body.
 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 this multi-field plan, 100% of the dose is reaching approximately 61.8% of the
PTV, as opposed to the PTV in plan 2 receiving 54.3%.I included a screenshot of a
DVH comparing the 2 plans below.
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 I ended with a weighting of 56% on the PA field and 22% on each of the lateral
fields .
 What was your rationale behind your final field weight? Be specific and give details.
o My rationale behind my weighting is that I wanted to put a heavier weight on the
PA than the laterals because the laterals have 2 fields pushing dose to the target
and the PA only has one. Also, keeping the PA at a heavier weight keeps the hot
spot posterior and out of the anterior bowel.
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 I tried all wedge sizes and ended up using a 45 degree wedge on both laterals.
The heel is towards the posterior side of the patient and the toe towards the
anterior side.
 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.
o The addition of wedges pushed the dose anteriorly to improve coverage of the
target exponentially. As you can see by the DVH, 100% of the dose is now getting
to 91.6% of the target, as opposed to before the wedges were added, where
 only 60.5% was being covered. Also, the hotter areas are now smaller and in all 4
corners which is ideal.
 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 textbook states that the wedge tray is always positioned at a distance at
least 15 cm away from the patient’s skin surface in order to avoid destroying the
skin sparing effect of an MV beam.

BEFORE WEDGES WERE ADDED:

AFTER WEDGES ARE ADDED:

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 used 15X for all fields because I wanted to keep dose out of the anterior bowel
if possible and 15X has a deeper dmax than the lower energies.
 What is the final weighting of your plan?
o My final weighting is 29% on the PA, 25% on each lateral, and 21% on the AP.
 Did you use wedges? Why or why not?
o I did not use any wedges. I thought about using one wedge on each lateral to
push dose a little more anteriorly, but even a 10 degree wedge pushed the hot
spot into the anterior bowel, which I did not want.
 Where is the region of maximum dose (“hot spot”) and what is it?
o My hot spot is positioned posteriorly in the body and it is 107.7%
 What is the purpose of normalizing plans?
o Normalization allows for better coverage of the target. It’s another way to move
dose within the patient when you’ve exhausted all other resources such as
energies, weighting, and wedges.
 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 After normalization, the plan got a little hotter. This is because when
normalizing, it shifts the isodose lines to achieve coverage.
o Before normalization:
 o After normalization:

 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 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.

I used the GYN Pelvis clearcheck constraints to verify my OAR doses. Unfortunately, none of the
OARs successfully met the constraints listed in this template. This was not surprising to me
considering the PTV encompassed most of the pelvis. I attached a screenshot of the clearcheck
constraints below.
Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Bladder Mean < 4000-4400cGy Mean=4601.8cGy No
Bowel D120cc<3500-3850cGy D120cc=4649.8cGy No
Left Femur Max < 4500-5000 Max=4713.6cGy No
Right Femur Max < 4500-5000 Max=4627.3 No