Plan 1: Calculate the single PA field.

• Describe the isodose distribution (be specific in your description of depth, location, etc).
150%/6750.0cGy (thick blue isodose line) of the dose is being deposited within the
first 4.15 cm of tissue from the PA at isocenter. The 125%/5625.0 cGy isodose line
(thick green line) is at 7.5 cm, and the 100%/4500cGy (thick red line) is at isocenter.
Isocenter is located 11.7 cm from the posterior of the patient. There is a buildup of
dose posteriorly as the TPS is pumping 100% of the dose to isocenter, then the dose
falls off as the PDD decreases as we move more anteriorly from the isocenter. The
50%/2250.0 cGy isodose line (thick light blue) is at 25.5 cm from the PA at isocenter.
The isodose lines are relatively symmetrical when looking at the distribution from all
three views.
• Where is the hot spot (max dose) and what is it?
The hot spot is 171.8% of the dose which equals 7730.0 cGy. It is located posteriorly
and superiorly at a depth of ~1.1 cm. Below are the three views of the hot spot’s
location with isodose lines of 170%/7650.0 cGy (thick magenta line) and 168%/7560.0
cGy (thick brown line) shown.

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

The 6Mv beam has a dmax of ~1.5 cm. Most of the beam’s energy is deposited here.
As you can see, the 7650.0 cGy isodose line is between 0.9 and 1.5 cm deep on the
sagittal view with our hot spot at around 1.1 cm deep. When prescribing to a deeper
isocenter, the TPS is going to get 100% of the dose to isocenter, which means
increasing the MU until we meet that goal. Since we are only utilizing one treatment
beam, the dose cannot be spread out to spare normal tissue.
• Using your DVH, what percent of the PTV is receiving 100% of the dose? Remember to
describe or show how you read this.
According to the DVH, the 48.7% is receiving 100% of the dose. Below is the DVH
showing % dose on the horizontal axis with structure volume % on the vertical axis.
The purple cross hairs indicate the point on the PTV line that 48.7% of the PTV volume
is receiving 100% (or 4500 cGy) of the dose. There is an absolute dose DVH in the
initial screen shot of all three views.
Plan 2: Change the PA field to a higher energy and calculate the dose.
• Describe how the isodose distribution changed and why?
150%/6750.0 cGy (thick magenta line) isodose line is now being deposited within the
first 2.4 cm of tissue from the PA at isocenter. Our hot spot is also only 151.3% or
6809.0 cGy when compared to the 6Mv beam. This indicates that the dmax for a 15Mv
beam is around 2.4 cm. The 125%/5625.0 cGy isodose line (thick brown line) is at 6.4
cm, and the 100%/4500 cGy (thick red line) is at isocenter (11.7 cm from PA). The
50%/2250.0 cGy isodose line (thick light blue) is at 27 cm from the PA at isocenter. On
the coronal view, the divergence of the beam is not as pronounced with the higher
energy beam when compared to the 6Mv. The isodose distribution shows the
increased penetration power of the 15Mv and there is greater skin sparing, as our dmax
is deeper.
• Using your DVH to confirm, what percent of the PTV is receiving 100% of the
prescription dose?
According to the DVH below, 54.7% of the PTV is receiving 100% of the prescription
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?
The isodose lines coming in from the laterals are ‘curved’ (following the curvature of
the patient’s surface). There are horns (indicated with purple arrows) on either side of
the isodose distribution towards the anterior of the patient where the PA field and
lateral fields meet. The 3600.0 cGy isodose line (thick light green line) is nearly all
encompassing from each beam (that isodose line is connected throughout the field
*nearly). The 3150.0 cGy isodose (thick dark green line) IS connected throughout the
beams’ geometries. This is shown on the last screen shot of this series. The 4050.0
cGy and 4500.00 cGy (thin yellow and thick red respectively) isodose lines on the
laterals start building dose at the skin surface; however, the same iso lines for the PA
field are deeper in the tissue starting about 2.9 cm from the PA. The 4860.0 cGy
isodose lines are posterior and symmetrical at isocenter. The 4725.0 cGy line is
relatively symmetrical when looking left to right and post to ant through isocenter.
Breaking of the 3600.0 cGy (80%) isodose line (light green) vs the connected 70%
isodose line (dark green). This breaking is happening superiorly and inferiorly more
posterior within our beam geometry.
• Where is the hot spot and what is it?
The hot spot is 113.8% or 5121 cGy. It is located posteriorly at a depth of 5.5 cm from
PA and towards the right lateral beam about 13.6 cm from the patient’s right lateral
surface as indicated in the screen shots below. When compared to the previous plans,
the hotspot is smaller and much cooler.

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

When looking at the isodose distribution from Plan1, the buildup is greatest in the
posterior region within the first cm of tissue. We can assume that the beam will
behave the same when coming from the laterals. I have included screenshots of what
a single beam profile looks like coming in from all 3 fields below (100% of the dose
going through each beam). If we were to lay these 3 beams on top of one another and
see where the isodose lines overlap, this is where we would expect our hot spot.
Plan 4: Increase the energy of all 3 fields and calculate the dose.
• Describe how this change in energy impacted the isodose distribution.
There is better coverage with the tumor with 15Mv when compared to 6Mv along
with more skin sparing. The lateral fields don’t have as much of their energy
deposited as close to the skin surface (deeper dmax). The hot spot is in the same area
as the previous plan and just slightly cooler (0.5% lower) having a dose of 5100.0 cGy.
A lot of the dose (108%/4860.0 cGy isodose line – thick dark green), is just anterior to
the sacrum. Most of the PTV is covered by the 90%/4050.0 cGy isodose line (thick
yellow). There is no 4500.0 cGy isodose level starting on the skin with the laterals (like
in the previous plan), but there are still 4050.0 cGy isodose level pockets on each
lateral.
• In your own words, summarize the benefits of using a multi-field planning approach?
(Refer to Khan Physics for benefits of multiple fields)
Using multiple fields helps achieve the goal of maximizing the dose to the tumor while
minimizing the dose to normal tissues. Using multiple fields increases the ratio of
tumor dose to normal tissue dose. The more beams you add, the more homogeneous
coverage you get. This is why Vmat is so conformal.
• 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.
According to the DVH below, the PTV volume that is receiving 100% of the dose is now
61.6% with 3 field 15 Mv. In Plan2 (using single field 15 Mv), only 31.5% of the PTV
was receiving 100% of the dose.

(Above: Plan4 DVH////Below: Plan2 DVH)

Plan 5: Using your 3 high energy fields from plan 4, adjust the field weights un�l you are sa�sfied with
the isodose distribu�on.

• What was the final weighting choice for each field?

• What was your rationale behind your final field weight? Be specific and give details.
The line profile through isocenter was more uniform for this weighting as you can see
in the dose profile chart in the screen shots below. For those profiles, the PA to AP
dose profile at isocenter is relatively symmetrical as well as the dose from RT to LT
through isocenter. When looking at the DVH, the PTV coverage increased by ~6% to
67.3% for 100% prescription, and to 95.6% coverage by 95% of the prescription dose.
The hot spot is now at 110.2% or 4958.0 cGy, which is more reasonable than the
previous plans.
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..)
I chose the 30 Out wedge with the 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 hot spot in my plan was in the posterior of the patient so I wanted to push that
dose more anterior to get a better dose distribution throughout my PTV. As you can
see with the screen shots below, the 3600 cGy – 4275.0 cGy (orange line to light green
line) got pushed closer together near the anterior to the patient. This resulted in a
better PTV coverage when comparing the DVH before (57.2%) and after (69.4%) the
addition of wedges. (See screenshot of DVHes below).
(Above: Isodose distribution before wedge///Below: Iso distribution after wedge)
(Above: Isodose distribution before wedge///Below: Iso distribution after wedge)
(Above: Isodose distribution before wedge///Below: Iso distribution after wedge)
 (Above: DVH before wedge///Below: DVH after wedge)

• 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?
The minimum distance for a wedge or absorber from the patient’s surface to keep the
skin dose below 50% of the dmax is 15 cm, according to Khan.1
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 discre�on, adjust the weigh�ng 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 ra�onale with your preceptor and adjust it based on their
input.

• What energy(ies) did you decide on and why?

I ended up using 15Mv’s on all four beams. This made for a more uniform dose and
deeper penetration. The patient’s separation is relatively large, so the higher beam
energy is better for skin sparing as well.
• What is the final weighting of your plan?

• Did you use wedges? Why or why not?

I did not utilize wedges in this four-field plan. I found that with the addition of the AP
field, I could adjust the weighting of the beams to do what I needed for coverage,
symmetry of the isodose lines, and reducing the hot spot to an acceptable level.
• Where is the region of maximum dose (“hot spot”) and what is it?
The hot spot in this plan is 4861.0 cGy, which is 108% of the prescribed dose. It is a
very small region located anteriorly and towards the left lateral within the “box” of
our 4500.0 cGy isodose line.

• What is the purpose of normalizing plans?

The purpose of plan normalization is to scale our plan up or down depending on what
we need to achieve our clinical goals and objectives. In this case, our 95% was
covering the target well, so by normalizing to 95%, we are telling the TPS system that
the new 100% IDL is our original 95% IDL. When playing with different normalizations,
I am telling the TPS how we deliver MU from the machine to get the coverage we
want. We can make the plan hotter or colder, depending on our clinical goals and
objectives.
• 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.
As you can see in the screen shots below, the 4725.0 cGy IDL (white line) got bigger
and is more symmetrical when viewed on our axial and coronal planes. The 4500 cGy
IDL (red line), is now covering more tissue and the target. This change is shown the
best in our coronal and sagittal planes. The coverage of the 4500 cGy line has been
pushed slightly superior and anterior which results in better target coverage. The last
two screen shots show the 98.6% IDL before normalization and after normalization. I
chose 98.6% because when I normalized to 95% covering 100% of target structure, my
plan normalization value = 98.6%. The change is subtle between the last screen shots
table, but you can see that after normalizing, my 98.6% IDL (light pink line) from no
normalization is now my 100% IDL (red line) after normalization. (I did not put these
screen shots in absolute dose, because I am working off my percentage plan
normalization value.) The measurement tool was used as a verification that my IDL
changed from the 98.6% to the 100%. I did not have to move any of those
measurements when normalizing to 98.6%.
(Above: IDL w/ no normalization///Below: IDL w/ normalization)
No Normalization After Normalizing to 98.6%
• Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and
coronal views. Show the PTV and any OAR.
OARs included: Bladder (yellow), Bowel Space (purple), Lt Femur (orange), Rectum
(brown), and Rt Femur (light blue)
 • 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).
I did not include Bowel Space in the OAR table as this is contoured differently than
Bowel Bag (which my clinical site does check dose).

• 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 have used the tolerance table for pelvis receiving up to 50.4 Gy with the OARs that
were contoured used for my planning objectives. I did not use Bowel Space as Bowel
Bag as the Bowel Space is not contoured as a Bowel Bag.

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Bladder V45Gy(%) ≤ 70 89.5 N
Rectum V40Gy(%) ≤99 90.2 Y
Lt Femur V40Gy(%) ≤37 8.22 Y
Rt Femur V40Gy(%) ≤37 8.91 Y