Pelvic Lab

Prescription: 45 Gy in 25 Fractions to the PTV

Plan 1: Calculate the single PA field.

 Describe the isodose distribution
- The isodose lines are distributed in an arc shape. The low doses isodose lines are
covering the anterior portion of the patient. In the image below the 50% isodose line
is in light blue and extending anteriorly. The 100% percent line is covering a little less
than half of the PTV. The 50% line is covering all of the PTV and extends anteriorly.
 Where is the hot spot (max dose) and what is it?
- The hot spot is on the posterior right side of the patient, the hot spot on this plan is
168.9%.
 What do you think creates the hot spot in this location?
- I believe the hotspot in this location is created by the PA field and low energy used. In
this plan the energy was 6x. The low energy beam is less penetrating and has lowered
skin sparing.
 Using your DVH, what percent of the PTV is receiving 100% of the dose? Remember to
describe or show you read this.
- 47.83% of the PTV is receiving 100% of the prescription dose. I was able to
determine this by looking at my DVH chart and going to 45 Gy and looking at where
the line was at for the volume. I have attached a screenshot to show this.
Plan 1.
This image shows my isodose lines as well as my hot spot.

This image shows that 47.83% of the PTV is receiving 100% of the dose.
Plan 2: Change the PA field to a higher energy and calculate the dose.
 Describe how the isodose distribution changed and why?
- My isodose distribution in this plan is still in arc shape but they are now reaching
more anteriorly. The 50% line is now touching the patients surface. My isodose
distribution changed in this plan due to the energy increase, the energy on this plan is
15x, and is more penetrating. My 90% line is now covering more of the PTV
anteriorly.
 Using your DVH to confirm, what percent of the PTV is receiving 100% of the
prescription dose?
- 52.52 % of the PTV is now receiving 100% of the prescription dose. I was able to
determine this by looking at my DVH chart and going to 45 Gy and look at
where the line was at for the volume. I have attached a screenshot to show this.

Plan 2.
This image shows my isodose lines with 15x energy.

This image shows that 52.52% of the PTV is receiving 100% of the dose.
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?
- In this plan the isodose distribution now creates a capitol T half way through the body
as I now have 2 lateral fields entering the body. At the lateral aspect of my fields
there are now spots of 105% caused by the low energy lateral beams.
 Where is the hot spot and what is it?
- The hot spot is now more anterior but continues to be on the right side of the patient.
The hot spot is 111.3%.
 What do you think creates the hot spot in this location?
- I believe the hotspot in this location is created as we are now using an additional 2
lateral beams. However, the hot spot is not able to be moved more anteriorly due to
the low energy being used.

Plan 3.
This image shows my isodose lines.

Plan 4: Increase the energy of all 3 fields and calculate the dose.
 Describe how this change in energy impacted the isodose distribution.
- The isodose distribution continues to have a capitol T shape. The change of energy on
this plan impacted the isodose distribution as the isodose lines moved more anteriorly
due to more penetration. More of the PTV is getting 95% coverage anteriorly. The
lateral fields no longer have areas of 95 or 100%.
 In your own words, summarize the benefits of using a multi-field planning approach?
(Refer to Khan Physics for benefits of multiple fields)
- According to Khan some of the benefits of using a combination of parallel opposed
fields as well as multiple fields is to deliver the maximum dose to the target area as
well as having dose uniformity around the target. Khan addresses that using 3 or more
fields can significantly reduce the dose to healthy surrounding tissue; essentially you
want your target to get full dose and the surrounding tissue as low dose as possible.
 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.
- Compared to the single field in plan 2 the PTV is now receiving 58.48% of the
prescription dose.
Plan 4.

This image shows my isodose lines.

This image shows that 58.48% of the PTV is receiving 100% of the dose.

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?
- The final weighting choice for each field was: RL: .350, LL: .340, PA: .310
 What was your rationale behind your final field weight? Be specific and give details.
- The rationale behind my final field weight was that I wanted to break up the high
dose that was posterior. I also only made it a minimal weight change as I did not
like the amount of 110% was outside my PTV. I also agreed on this final beam weight
as now my 59.66% of the PTV is getting 100% of the prescription dose.
Plan 5.

This image shows my isodose lines.

This image shows that my PTV coverage increased to 59.66%.

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..)
- The final wedge angle and orientation I choose was 20 degree wedges and the
orientation for both right lateral and left lateral beams was heel towards the posterior
of the patient.
 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.
- The addition of the wedges moved my isodose lines more anteriorly. The 90%
isodose line covers the entire PTV as opposed to the plan with no wedges.The
addition of the wedges removed the amount of 110% coverage that was present
in the plan without wedges. The hot spot also decreased to 106.5%.
 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?
- According to Khan, as a rule of thumb the minimum distance a wedge or absorber
should be placed from the patients skin surface is 15 cm in order to keep the skin dose
below 50% of the dmax.
This is the plan with no wedges.

This is the plan with 20in wedges.

Plan 6 with 20in wedges.
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?
- I decided to use 15x as my energy for all beams as I wanted to obtain the appropriate
coverage of my PTV, which I would not have been able to get as good coverage with
a low energy beam.
 What is the final weighting of your plan?
- After discussion with my preceptor, she suggested we try to do field in field as there
were anterior and posterior spots on the plan that were not getting the appropriate
coverage. I have attached the chart below to show the different weight factors for all
the fields and field in field used.

 Did you use wedges? Why or why not?

 - I decided not to use wedges as we opted to use field in field instead. We tried using
wedges but we were still not getting the desired coverage on the anterior and posterior
aspects of the PTV. After using field in field we were able to obtain better coverage.
 Where is the region of maximum dose (“hot spot”) and what is it?
- The region of maximum dose was around my calculation point specifically on the left
lateral portion of the patient. The hot spot is 48.260 Gy.

 What is the purpose of normalizing plans?

- The purpose of normalizing plans is to make sure that the PTV is getting the
appropriate coverage. In the case of my plan we were getting more than what was
needed so normalizing the plan allowed me to bring the dose down a bit to achieve
95%.
 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.
- After I normalized my plan so that 100% of the prescribed dose was going to 95% of
the PTV my coverage came down a bit from 98% to 94.9%. My plan before
normalizing was little hotter, my hot spot before normalizing was 104.4% and after
normalizing it came down to 103.7% on my axial views.
This is the plan before normalizing.
This is the plan after normalizing.
 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 rational
for the objectives chosen.

Source Organ at Risk Planning Objective Objective Outcome Objective Met? (Y/N)
RTOG Bladder Dose to 35% of
0724 contour vol ≤ 45 Gy
RTOG Rectum Vol receiving 45 Gy 81.21% N
0724 ≤ 60% contour vol
RTOG Lt Femur Dose to 25% of 27 Gy Y
0529 contour vol ≤ 30 Gy
RTOG Rt Femur Dose to 25% of
0529 contour vol ≤ 30 Gy
RTOG Lt Femur Volume receiving 44 3.29% Y
0529 Gy ≤ 5% contour vol
RTOG Rt Femur Volume receiving 44 2.44% Y
0529 Gy ≤ 5% contour vol
RTOG Bowel Space Dose to 0.03 cc ≤ 54
0724 Gy
 RTOG Bowel Space Volume receiving 40 36.7% N
0724 Gy ≤ 30 % contour
vol
RTOG Bowel Space Volume receiving 45
0724 Gy ≤ 195 cc

References: