Pelvis Clinical Lab Assignment

Use the Pelvis CT data set provided in Canvas to complete the following assignment:
*MY ANSWERS ARE IN BOLD*
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 1 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. Each plan will build in complexity off of the previous one. After adjusting each plan, answer the
provided questions. Include a screen shot for each plan to show the isodose distribution along with a
DVH clearly displaying your PTV coverage. Note: Make sure that your plan shows the absolute dose
levels and that each view is large enough to clearly read the needed details. You may want to
screenshot each view separately. Describe and/or show how you read the PTV dose on the DVH. Only
provide the PTV when asked for PTV coverage. When asked for field weighting, show the field
weighting for that plan. Embed the question and then your answers with any associated visuals
within your completed assignment. A good visual image and a thorough description of the isodose
distribution in each plan are critical components. The reader should be able to follow your planning
process/outcome using your visuals and explanations.
• Important: Please do not normalize your plan when making these adjustments until instructed
to do so in the final plan.
• 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 field.

A single PA field using 6X energy is shown below. Transverse (top left), frontal (bottom left), and
sagittal (bottom right) views. The GREEN line is the 100% isodose line/4500cGy.
 • Describe the isodose distribution (be specific in your description of depth, location, etc).
The isodose distribution in the single PA field at 6X is accumulating on the posterior area of
the patient. This is due to the Dmax of a 6MV beam being approximately 1.5cm. The depth of
100% isodose line/4500cGy (green) is 12 cm deep from the patient’s external posterior
surface. The dose is falling off rapidly by the 90% isodose line/4050cGy (cyan blue), roughly 2
cm beyond the 100% isodose line. At the 50% isodose line/2250 (dark blue), the dose has not
even reached the anterior surface of the patient.
Below is a screen capture of the hot spot. My viewing planes are set to the location of the max dose.

• Where is the hot spot (max dose) and what is it?

The max dose is located posterior on the patient and is listed as 171.5%/7717.4cGy.
 • What do you think creates the hot spot in this location?
Since the singular, 6X beam is positioned posteriorly, the dose is concentrating posteriorly on
the patient. The maximum dose from the beam will deposit at a depth of Dmax, and for a 6X
beam this is about 1.5cm depth. This explains why the max dose is deposited roughly 1.5cm
from the patient’s posterior surface.
Below is a screen capture of the DVH for a single PA field at 6X. The Y axis is the “Ratio of Total
Structure Volume”, and the X axis is the “Relative Dose %” on the bottom axis and “Dose cGy” on the
top axis.
Y/Volume

X/Dose
• Using your DVH, what percent of the PTV is receiving 100% of the dose? Remember to describe
or show how you read this.
 The PTV is receiving 48.5% of the prescription dose. The PTV (red) line intersects the vertical
axis (Y/volume) at 48.5% of the total structure volume at the horizontal axis (X/dose) at 100%
of the dose (4500 cGy).

Plan 2: Change the PA field to a higher energy and calculate the dose.
A single PA field using 15X energy is shown below. Transverse (top left), frontal (bottom left), and
sagittal (bottom right) views. The GREEN line is the 100% isodose line/4500cGy of the Rx dose.

Below are two screen captures. Left showing the change in isodose distribution and right showing
the depth of the maximum dose.

• Describe how the isodose distribution changed and why?

The isodose distribution in the single PA field at 15X has not changed from accumulating on
the posterior area of the patient. This is due to the Dmax of a 15MV beam being approximately
2.5cm. The depth of 100% isodose line/4500cGy (green) is still 12 cm deep from the patient’s
external posterior surface. The dose is falling off less rapidly by the 90% isodose line/4050cGy
(cyan blue), roughly 2.5 cm beyond the 100% isodose line. At the 50% isodose line/2250cGy
(dark blue), the dose has reached further anteriorly to the surface of the patient. The hot spot
has reduced to 150.4%/6766.9cGy with the 15X beam. This demonstrates that the 15X beam
 is able to penetrate deeper within the patient while keeping the max dose to a lower
percentage.
Below is a screen capture of the DVH for a single PA field at 15X. The Y axis is the “Ratio of Total
Structure Volume” and the X axis is the “Relative Dose %” on the bottom axis and “Dose cGy” on the
top axis.
Y/Volume

X/Dose
• Using your DVH to confirm, what percent of the PTV is receiving 100% of the prescription dose?
The PTV is receiving 53.8% of the prescription dose. The PTV (red) line intersects the vertical
axis (Y/volume) at 53.8% of the total structure volume at the horizontal axis (X/dose) at 100%
of the dose (4500 cGy).

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.
A PA field, LT lateral and RT lateral using 6X energy is shown below. Transverse (top left), frontal
(bottom left), and sagittal (bottom right) views. The GREEN line is the 100% isodose line/4500cGy.
 • Describe the isodose distribution. What change did you notice?
After entering two lateral fields at 6X energy, the isodose is distributed both laterally and
posteriorly on the patient. Both lateral fields do not have enough weight to penetrate deep
enough to have the 100% isodose enter the PTV but the lower isodose lines are contributing
laterally to PA dose. This is seen by the horns on either side of the PA isodose lines in the
transversal plane.
Below is a screen capture of the hot spot. My viewing planes are set to the location of the max dose.
 • Where is the hot spot and what is it?
The hot spot is now deeper posteriorly and is right sided. The hot spot has decreased to
113.7%/5117.3cGy.
Below is a screen capture of the measurement from isocenter to the patient’s right and left side,
respectively. The level of measurement is at the hot spot location.

• What do you think creates the hot spot in this location?

Posteriorly on each lateral beam, the right beam has less tissue to attenuate the beam than
the left side does. The difference from isocenter to the patient’s skin surface posteriorly at
the level of the hot spot on the right side and left side is 21.2cm and 22.5cm respectively. This
is causing the hot spot to gather to the right of the patient.

Plan 4: Increase the energy of all 3 fields and calculate the dose.
A PA field, LT lateral and RT lateral using 15X energy is shown below. Transverse (top left), frontal
(bottom left), and sagittal (bottom right) views. The GREEN line is the 100% isodose line/4500cGy.
 • Describe how this change in energy impacted the isodose distribution.
Increasing the energy from 6X to 15X caused the isodose distribution from each beam to
penetrate deeper into the patient. This dose contribution causes the horns on the posterior
isodose distribution to become more even throughout the field. It also decreased the hot
spot 112.8%/5076.3cGy in this plan. The location of the max dose is approximately the same
due to the same reasoning in the previous plan.
• In your own words, summarize the benefits of using a multi-field planning approach? (Refer to
Khan Physics for benefits of multiple fields)
The goal of radiation treatment planning is to maximize dose to the tumor volume while
minimizing dose to surrounding tissue and organs at risk. If 2-field, parallel opposed beams
are used, we are placing 2 beams into the target volume and therefore the dose to the
surrounding tissue is halved. The more beams we use, the more dose is focused to the target
volume and the less dose each beam contributes to surrounding tissue. We are also able to
place beams intentionally to avoid certain organs at risk. By using a multi-field planning
approach, we can accumulate more dose to the target volume while sparing normal tissue
and organs at risk.
Below is a screen capture of the DVH for a 3 field (PA, RT lateral, LT lateral) plan at 15X. The Y axis is
the “Ratio of Total Structure Volume” and the X axis is the “Relative Dose %” on the bottom axis and
“Dose cGy” on the top axis.
Y/Volume

X/Dose
• 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.
In plan 2, PTV was receiving 53.7% of the prescription dose. In plan 4, the PTV is receiving
59.6% of the prescription dose. The PTV (red) line intersects the vertical axis (Y/volume) at
59.6% of the total structure volume at the horizontal axis (X/dose) at 100% of the dose (4500
cGy). The increase of volume receiving the prescription dose is due to the contribution of the
lateral beams.

Plan 5: Using your 3 high energy fields from plan 4, adjust the field weights until you are satisfied with
the isodose distribution.
A PA, LT lateral and RT lateral using 15X energy is shown below. Transverse (top left), frontal
(bottom left), and sagittal (bottom right) views. The GREEN line is the 100% isodose/4500cGy.
Field weighting for this plan is shown below.

• What was the final weighting choice for each field?

The final weighting of choice was PA: 39.8%, LT Lat: 30.1%, RT Lat: 30.1%.
• What was your rationale behind your final field weight? Be specific and give details.
My rationale for beam weighting was to find the weighting that most evenly spread dose
across the PTV while maintaining the 105%/4725cGy (red isodose line) posteriorly. The PA
beam needs to have enough weight to contribute dose when wedges are added laterally.
Keeping most of the 105% posteriorly (and not laterally) would set the plan up for success
when adding beam modifying devices. Having this rationale, I know these beam modifying
devices will be able to push more dose anteriorly. I kept the max dose low to not make the
plan too hot if normalization to a lower isodose line was needed. This max dose is 115.0%.

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.
A PA, LT lateral and RT lateral using 15X energy and 45° EDW is shown below. Transverse (top left),
frontal (bottom left), and sagittal (bottom right) views. The GREEN line is the 100% isodose
line/4500cGy.

Shown below is the field weighting for this plan 6.

 • 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..)
Final wedge orientation is 45° EDW (enhanced dynamic wedge). The orientation is HEEL
posterior of the patient. Upon the insertion of a wedge 45° EDW IN on the LT Lateral field and
45° EDW OUT on the RT Lateral field, the PA dose is pushed anteriorly.
• 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 isodose distribution before wedges is concentrated posteriorly. This is because the dose
between the PA and 2 lateral fields is greater where the three fields intersect. Using the
addition of 45° EDWs on both the lateral fields, heel posterior of the patient, the dose is
pushed anteriorly on the patient. Less dose can transmit through the heel of the wedge,
therefore positioning the heel posterior allows lateral dose to push anteriorly.
A PA field, LT lateral and RT lateral using 15X energy without wedges is shown below and same field
weighting. Transverse (top left), frontal (bottom left), and sagittal (bottom right) views. The GREEN
line is the 100% isodose line/4500cGy.
 • 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, the minimum distance required between any absorber (wedge) in the
beam and the skin’s surface is 15 cm to keep the skin dose below 50% of the Dmax.

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.
An AP, PA, LT lateral and RT lateral using 15X energy. Transverse (top left), frontal (bottom left), and
sagittal (bottom right) views. The GREEN line is the 100% isodose line/4500cGy.
 • What energy(ies) did you decide on and why?
15X energy was used for all four beams. A higher energy would help keep max dose low,
while also penetrating deep enough to cover the PTV. This higher energy allowed the dose
distribution across the PTV to be more evenly covered.
Below is a screen capture of this plan’s field weighting.

• What is the final weighting of your plan?

The final weighing on my plan is PA: 31.1%, LT: 19.4%, RT: 22.5%, AP: 27%.
• Did you use wedges? Why or why not?
I did not use wedges in my final plan. I was able to find a desirable coverage and low max
dose with field weighting only.
Below is a screen capture of the hot spot for my field weighted plan with no wedges. My viewing
planes are set to the location of the max dose. Transverse (top left), frontal (bottom left), and
sagittal (bottom right) views.
 • Where is the region of maximum dose (“hot spot”) and what is it?
The region of the maximum dose is anterior and left of the patient and it is
107.1%/4818.5cGy. When looking at the patient physically, the distance from the max dose to
the patient’s skin surface is less in this location than it would be in any of the other four
corners of our 4-field box.
• What is the purpose of normalizing plans?
Normalization can impact the plan by modifying the dose to achieve appropriate coverage to
the desired target. Normalization scales the plan to achieve the required prescription dose by
means of normalizing to a point, such as a reference point, a target volume, or a percentage
value. A plan can be normalized to a lower percentage (i.e., 95%), which would make the plan
hotter, or a higher percentage (i.e., 105%), which would make the plan cooler. A clinic can
define the standards of normalization. Regardless of the type of plan normalization, the
intent is always to achieve the prescribed dose to the target volume.
• 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.

Below is the plan WITHOUT normalization.

Below is the plan WITH normalization.
 Plan normalization made this plan .6% hotter to ensure that 100% of the prescription covers
95% of the target volume (PTV). This can be seen by the “plan normalization value” in the
bottom right corner of the screenshot. In the plan without normalization, it is set to 100%,
meaning the plan was not normalized. In the plan with normalization, it reads 99.4%,
meaning that the plan was normalized to the 99.4% isodose line in order to achieve 100% of
the prescription dose covering 95% of the target volume.
• Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and coronal
views. Show the PTV and any OAR.

Below is a screen capture of my final plan’s isodose distribution. OARs and PTV is labeled on the
screen capture

• 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 QUANTEC data for my original planning objectives for the bladder, bowel space, and
rectum. QUANTEC is a guide for physicians used for conventional fractionation only. I used
Embrace II data for the planning objective for the femurs. Upon consideration, my clinic uses
Embrace II and RTOG 1203 for gynecologic patients. As a clinical site, the goal is to keep dose
as low as reasonably achievable. These constraints were chosen by the clinic as they have
been proven achievable while also keeping dose to organs at risk low and dose to the PTV as
prescribed. I listed both planning objectives below.

QUANTEC
Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Bladder V65<50% V65=0 Y
Bowel V45<195cc V45=294cc N
Rectum V50<50% V50=0 Y
It is important to note that many of these objectives exceed our prescription dose. This
explains why some of these objectives are met while the others below are not. Although
QUANTEC is great data, the goal is to keep dose as low as reasonably achievable which can be
accomplished via tighter constraints.

Pictured to the left is a

screenshot of my clinic’s
planning objectives for
gynecologic patients.

EMBRACE II and RTOG 1203

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
PTV V100%>95% V100=95% Y
Rectum V40<80-100% V40=89.8% Y
Max<105% Max=105.5% N
Bladder V45<35-70% V45=92.2% N
Max<105% Max=105.3% N
Bowel V40<30-70% V40=37% Y
Max<105% Max=106.5% N
Femurs Max<50Gy Max=46.3Gy Y
Using the Embrace II and RTOG 1203 constraints, some objectives have not been met. This is
important to note because it would indicate improved planning was needed. This plan had
the parameters of using field weighting and/or wedges. Possibly using Field-in-Fields to block
dose to OARs and hot spots or using IMRT/VMAT would help meet these objectives for better
patient outcome.