Pelvis Clinical Lab Assignment

Use the Pelvis CT data set provided in Canvas to complete the following assignment:

Prescription: 45 Gee 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.

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Plan 1: Calculate the single PA field.
• Describe the isodose distribution (be specific in your description of depth, location,
etch).
o In my clinic, the lowest beam energy available is a 6 MV beam. I have chosen to
display the isodose levels at 450 cGy, 1350 cGy, 2250 cGy, 3150 cGy, 4050 cGy,
4500 cGy, 4950 cGy. On all the following plans with the prescription as 4500 cGy
in 25 fractions. In the single PA field, the 4500 cGy (100%) isodose line reaches
the isocenter as the planning calculation point is the isocenter. As we move more
anteriorly, we encounter the 90% (4050 cGy) level, which is roughly at the
midline of the patient. Next, we see the 70% (3150 cGy), followed by the 50%
(2250 cGy) isodose line, which encompasses the entire target. There are also
smaller incremental spaces between the 110% to 90% levels, and a more
significant distance between the 90%, 70%, and 50% isodose lines. Additionally,
in Figure 5, we see the 50% (2250 cGy) level follows the jaw, while 1350 cGy and
450 cGy are found beyond the jaws/field. Furthermore, at the isocenter, the
isodose lines are flat and exhibit less of a horn or jagged appearance compared
to the superior and inferior aspects of the field. Overall, the isodose distribution
is concentrated on the posterior aspect of the patient where the beam enters. It
is highest on the superficial posterior aspect and decreases significantly closer to
the target, with only the 70% (3150 cGy) isodose line fully encompassing the
target. This can be seen clearly using figures 1-5.

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Figure 1: PA 6 MV, Axial view, Z = 0.00 cm

Figure 2:PA 6 MV, Axial view, Z = 4.17 cm

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Figure 3: PA 6 MV, Coronal view, Y = 0.00 cm

Figure 4: PA 6 MV, Sagittal view, x = 0.00 cm

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Figure 5: PA 6 MV, 2250 cGy follows the field edge where 1350 cGy and 450 cGy are away beyond.

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

o Hot spot refers to an area within the patient where the delivered radiation dose
is the highest compared to the surrounding area in the plan. In my plan, the hot
spot is located at the very superficial posterior edge of the patient near the
sacrum. It is positioned 6.83cm superior to the isocenter and at a depth of
1.03cm posterior to the patient show in Figures 6, 7, and 8. My plan recorded a
hot spot of 171.2%, equivalent to 7705 cGy, due to the beam entering the
patient and depositing the maximum dose near the surface of the skin.

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Figure 6: PA 6 MV, HOT SPOT, Axial view, Z = 6.87 cm

Figure 7:PA 6 MV, HOT SPOT, Sagittal view, X = -0.88 cm

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Figure 8: PA 6 MV, HOT SPOT, Sagittal view, X= 0.88 cm

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

o The hot spot is situated where the dose maximum is deposited for a 6 MV beam
(1.5 cm) as the beam traverses through the patient. Lower energy beams tend to
deposit their energy more superficially due to the smaller buildup region,
resulting in less skin sparing effect. Additionally, this hot spot is located very
medially near the central axis where the dose is highest and then decreases as
we move more laterally. The hot spot at this spot can be attributed to the
variation of the patient's thickness.
• Using your DVH, what percent of the PTV is receiving 100% of the dose? Remember to
describe or show how you read this.
o In my plan, 48.2% of the structure is receiving 100% (4500 cGy) of the dose. By
utilizing the crosshair function in Eclipse, I zoomed into the DVH graph to read
the point of intersection. I made sure to only have the PTV structure on, so that
the DVH is not displaying the other structures in the plan. After clicking on the
DVH with the crosshair I used the arrow keys to be at exactly 4500 cGy. The
bottom X-axis displays the absolute dose, while the corresponding ratio of the
total structure volume is depicted on the y-axis of the graph.

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Figure 9: DVH PA 6 MV, PTV V4500cGy = 48.2131%

Plan 2: Change the PA field to a higher energy and calculate the dose.
• Describe how the isodose distribution changed and why?
o In my clinic, the highest available energy beam is 15 MV. Upon evaluating the
plan, I noticed that the 4500 cGy dose remains centered at the isocenter,
consistent with both plans utilizing this point for calculation. Similar to the 6 MV
plan, doses of 4950, 4500, and 4050 cGy exhibit a gradual decrease as we move
anteriorly in the patient. Notably, the larger spacing between isodose lines is
observed between 4050, 3150, and 2250 cGy and beyond. In the 15 MV plan,
both the 3150 cGy and 2250 cGy lines penetrate deeper into the patient, while
all the isodose lines have shifted more anteriorly. Overall, the isodose lines
appear to be flatter and smoother across the entire plan compared to the 6 MV
plan. Additionally, the 2250 cGy line is considerably more anterior, and the 3150
cGy line covers a larger portion of the PTV compared to the 6 MV plan. When
comparing the lower isodose lines between the 6 MV and 15 MV, we see the 15
MV isodose lines bulge out laterally, and higher isodose lines constrict, due to
the forward scatter for higher beams. Lastly, the maximum dose recorded in the
15 MV plan is 6797 cGy, a significant decrease from the 7704 cGy recorded
previously.
o This anterior shift of the isodose lines is attributed to the deeper dmax of the 15
MV energy compared to the initial 6 MV setting, resulting in a larger build-up

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 region, and achieving dmax at a greater depth, thereby providing a more
pronounced skin-sparing effect.

Figure 10: Plan Comparison: PA 15 MV vs. PA 6 MV

Figure 11: 15 MV PLAN ISODOSE LINE FLATTER vs. 6 MV ISODOSE LINE MORE JAGED AT CENTRAL AXIS

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 • Using the sagittal view, we can see the more anterior projection of the isodose lines
where the 2250 cGy reaches very superficially. Additionally, the flatness of the isodose
line can be seen when comparing the 4050/3150 cGy.

Figure 12:PA 15 MV, Sagittal view, X = 0.00 cm

Figure 13: PA 15 MV, Coronal view, Y = 0.00 cm

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 • Using your DVH to confirm, what percent of the PTV is receiving 100% of the
prescription dose?
o Using the steps mentioned in 6 MV plan, this plan recorded 53.8% of the PTV
receiving 4500 cGy (100% of the prescription dose).

Figure 14: DVH PA 15 MV, PTV V4500cGy = 53.8563%

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 the addition of the two lateral fields in the 3-field 6 MV plan, the isodose
lines exhibit a noticeable lateral bulge and a dip at the center, likely due to dose
contribution of the additional beams added. This results in a higher dose at the
surface near the beam entrance of each field compared to the single field plan
that utilized 15 MV. This is proven as 4500 cGy and 4050 cGy are found very
superficially on the lateral fields. Moreover, the isodose lines 4950, 4500, and
4050 cGy are disconnected compared to those at 3150 cGy and below.
Specifically, the 110% (4950 cGy) isodose line is found only along the lateral edge
of the PA field, where all three fields intersect and appear to be larger on the
right due to missing tissue. In contrast, the 90% (4050 cGy) isodose line has
shifted anteriorly, covering more of the target area than in the single field plan.
o Additionally, the isodose lines have shifted even more anteriorly in this plan.
Only the 450 cGy line is found at the anterior aspects, contrasting with the
concentration of other isodose lines where the fields overlap.

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Figure 15 Plan comparison: 3-FIELD 6 MV vs PA 15 MV

Figure 16: 3-FIELD 6 MV, 4950 cGy , Z=0.00 cm

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Figure 17: 3-FIELD 6 MV, 4500 cGy, 4050 cGy, Z=0.00 cm

Figure 18: 3-FIELD6 MV 3150 cGy – 450 cGy, Z=0.00 cm

• Where is the hot spot and what is it?

o This plan has a recorded maximum dose of 5104 cGy which is drastically lower
than single field 15 MV that recorded 6797 cGy. It is 0.92 cm inferior of the
isocenter and 5.69 cm from the posterior. It is found on the right posterior edge
of the patient.

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Figure 19: 3-FIELD 6 MV HOT SPOT, Sagittal view, X = - 7.13 cm

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

o The hot spot is located where the maximum dose is deposited as the beam
travels through the patient. Lower energy beams tend to deposit their energy
more superficially due to the lower buildup region, resulting in less skin-sparing
effect. The hot spot at this location is caused by the accumulation of dose from
all three fields, as well as the isocenter, which is the calculation point positioned
more posteriorly in the patient. It can also be attributed to the patient's anatomy
and position.

Plan 4: Increase the energy of all 3 fields and calculate the dose.
• Describe how this change in energy impacted the isodose distribution.
o With changing the energy from 6 MV to 15 MV, a drastic forward shift of the
isodose lines can be observed. The 4050 cGy isodose line is now reaching deeper
midline in the patient as seen in figure 21. The 4950 cGy isodose line has
decreased in size when compared to plan 3. The increase in energy has removed
4500 cGy from the lateral edge of the patient, and no break is seen in 4500 cGy
isodose line. However, the 4050 remains at the patient's lateral sides but has
significantly decreased in size. This is due to higher beam energies having lower
entrance dose, so less dose is accumulated from entrance and exit dose from
right and left lateral fields. The 2250 cGy has also shifted away from the patient’s
posterior surface and is now 0.87cm deeper compared to plan 3 (Figure 22). The
2250 cGy still follows the field, where 1350 cGy and 450 cGy are found beyond
the field. Again, the 4500 cGy seems to dip at the center and have a lateral
anterior bulge that is significantly larger than plan 3. The 4050 cGy and below
isodose lines also seem to have become more symmetric and flatter.

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 o Using the DVH, for the 15 MV plan we can see that 6.8% of the external receives
4100 cGy compared to 10.5% in 6 MV plan. This helps us see that the 15 MV plan
recorded less entrance dose as explained earlier.
Figure 20: Plan comparison: 3-FIELD 15 MV vs 3-FIELD 6 MV 4950 cGy

Figure 21: Plan comparison: 3-FIELD 15 MV vs. 3-FIELD 6 MV 4050 cGy, 4500 cGy

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Figure 22: Plan Comparison: 3-FIELD 15 MV vs 3-FIELD 6 MV depth is 2250cGy

Figure 23: Plan Comparison: 3-FIELD 15 MV vs 3-FIELD 6 MV

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Figure 24:3-FIELD 15 MV, Z= 0.00cm

Figure 25: 3-FIELD 15 MV, Z=0.00 cm

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Figure 26: 3-FIELD 15 MV, Z= 0.00 cm

Figure 27: DVH 3-FIELD 6 MV, EXTERNAL

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Figure 28: DVH 3-FIELD 15 MV, EXTERNAL

• In your own words, summarize the benefits of using a multi-field planning approach?
(Refer to Khan Physics for benefits of multiple fields)
o The multiple field approach can use a combination of different energies, beam
angles, beam entrance points, and even additional beam modifiers such as
wedges, to allow the planner to maximize the dose given to the target while
eliminating the excessive entrance dose and limiting dose to the normal organs
surrounding the target volume.

• 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 When comparing the two plans, the single field plan only delivers 4500 cGy
prescribed dose to only 53.8% of the PTV volume. This is drastically different as
the 3-field plan covers around 59.8% of the PTV to 4500 cGy prescribed dose.

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Figure 29: DVH PA 15 MV, PTV

Figure 30 3-FIELD 15 MV, PTV

Plan 5: Using your 3 high energy fields from plan 4, adjust the field weights until you are
satisfied with the isodose distribution. (When asked for field weighting, show the field
weighting for that plan.)

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 • What was the final weighting choice for each field?
o The final field weighting I have chosen is PA 35.6%, RL 31.5%, and LL 32.9%
Figure 31: 3-FIELD 15 MV WEIGHT

• What was your rationale behind your final field weight? Be specific and give details.
o With this plan, I aimed to maintain the maximum recorded dose close to 4950
cGy (110%), similar to the equally weighted plan. My objective was to minimize
the 4050 cGY to the lateral edge of the patient as much as possible. I began by
examining the 4050 cGy and 3150 cGy isodose lines, which I considered very high
at the lateral edges of the patient. By decreasing the weighting to the stated
levels, I was able to easily remove the 4050 cGy (90%) isodose from the lateral
edges. I attempted to further reduce the lateral weighting to approximately RL
24.5%, and LL 25.5%, and PA 50%. Although the 70% isodose was removed from
the lateral edges of the patient, the recorded plan max dose was 5351 cGy
(118%), and only 56.3% of the PTV received 4500 cGy. To address this, I gradually
reduced the PA field weighting and returned to the previously mentioned
weighting. With this weighting, I allocated more dose to the LL beam because
the patient is slightly thicker on the left side, which also resulted in equalizing
the 4950 cGy isodose lines.
Furthermore, while reviewing the equally weighted plan, I observed that 4950
cGY were primarily located on the right side of the patient. After adjusting the
weighting of the fields, I noticed that 4950 cGy isodose line were distributed
more evenly between the right and left sides of the patient, indicating a more
balanced dose distribution. Lastly, the DVH demonstrated that 59.2% of the PTV
received 4500 cGy.

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Figure 32:3-FIELD 15 MV FINAL WEIGHT

Figure 33: 3-FIELD 15 MV FINAL WEIGHT

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Figure 34: 3-FIELD 15 MV FINAL WEIGHT

Figure 35: Plan Comparison: 3-FIELD 15 MV FINAL WEIGHT vs 3-FIELD 15 MV EQUAL WEIGHT

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Figure 36: Plan Comparison: 3-FIELD 15 MV FINAL WEIGHT vs. 3-FIELD 15 MV INCREASED WEIGHT

Figure 37: Plan Comparison: 3-FIELD 15 MV FINAL WEIGHT vs. 3-FIELD 15 MV INCREASED WEIGHT

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Figure 38: 3-FIELD 15 MV FINAL WEIGHT 3-FIELD 15 MV INCREASED WEIGHT

Figure 39: 3-FIELD 15 MV FINAL WEIGHT

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Figure 40: DVH ,3-FIELD 15MV FINAL WEIGHT PTV

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 The final wedge orientation I have chosen is with the heel towards the posterior
of the patient. I selected a 45-degree wedge and weighed the field as follows: PA
52.5%, LL 23.6%, and RL 23.9%.
Figure 41: 3-FIELD 15 MV, WEDGE AND WEIGHT

• 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 plan without a wedge revealed that the 4950-4050 cGy isodose lines were
concentrated on the posterior aspect of the patient. Upon adding a wedge, the dose
distribution shifted anteriorly to cover more of the anterior aspect of the target. The
4500 and 4050 isodose lines now extend more anteriorly over the PTV without
displaying a dip at the midline of the patient. Furthermore, the 3150 cGy and 2250
cGY isodose line has shifted more medially, reducing the excess dose to the lateral

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 aspect. However, the doses of 1350 cGy and 450 cGy remain unchanged even with
the inclusion of the wedge. Additionally, along with the wedges, I implemented field
weighting to minimize the 4500 and 4050 cGy doses to the lateral aspects of the
patient. This weighting scheme also ensures closure of the 4500 cGy isodose line,
minimizing the central hole.
Figure 42: Plan Comparison: 3-FIELD 15 MV WEDGE vs. 3-FIELD 15 MV NO WEDGE

Figure 43: 3-FIELD 15 MV WEDGE 3-FIELD 15 MV NO WEDGE

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Figure 44: Plan Comparison: 3-FIELD 15 MV WEDGE vs 3-FIELD 15 MV NO WEDGE

Figure 45: 3-FIELD 15 MV BEFORE

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Figure 46: 3-FIELD 15 MV BEFORE

Figure 47: 3-FIELD 15 MV AFTER

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Figure 48: 3-FIELD 15 MV AFTER

• 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 To conserve the skin sparing effect, the compensator should be placed at least 15
cm from the patient.
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 For this plan, I have selected 15 MV for all the fields. When comparing plan 1 and
2, we observe that the higher beam energy can penetrate deeper since our
target is located deeper within the patient and is midline. Moreover, the higher
energy also results in less dose to the superficial skin.
• What is the final weighting of your plan?
o The final field weighing I have chosen is below.

Figure 49: 4-FIELD 15 MV FINAL WEIGHT

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 • Did you use wedges? Why or why not?
o I did not use a wedge for the plan as 4500-3150 cGy were already conformal to
the treatment field and were not at any of the superficial surface of the patient.
With the field weighting we already see the global max dose of the plan is only
4779 cGy. The isodose lines were also intact and did not have any dips or holes
as seen in pervious plans.
• Where is the region of maximum dose (“hot spot”) and what is it?
o The global maximum dose for this plan is 4779 cGy, situated at the anterior edge
where all four fields intersect. It is 1.22 cm inferior to the isocenter and 8.39 cm
from the anterior.

Figure 50: 4-FIELD 15 MV HOT SPOT, Axial view, X = - 1.23 cm

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Figure 51: 4-FIELD 15 MV HOT SPOT, Sagittal view, X = 6.12 cm

• What is the purpose of normalizing plans?

o Normalization enables the scaling of the plan to reach the prescription dose,
which can be applied either to a point or a specified volume. When a plan
undergoes normalization, the entire dose distribution can be adjusted to
improve dose coverage to the treatment target.
• 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 normalizing my plan, I did not observe a significant change in the isodose
lines within the two plans. The 450 cGy to 4050 cGy isodose lines remained
unchanged between the two plans. However, following normalization, the 4500
cGy isodose line now encompasses and follows the 4050 cGy line, covering a
majority of the PTV. Additionally, the maximum dose recorded in the plan
slightly increased from 4779 cGy to 4844 cGy.

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Figure 52: 4 FIELD 15 MV BEFORE NORMALIZATION

Figure 53: 4 FIELD 15 MV BEFORE NORMALIZATION

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Figure 54: 4 FIELD 15 MV BEFORE NORMALIZATION

Figure 55: 4 FIELD 15 MV AFTER NORMALIZATION

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Figure 56: 4 FIELD 15 MV AFTER NORMALIZATION

Figure 57: 4 FIELD 15 MV AFTER NORMALIZATION

• 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.
o I have chosen to follow my clinic's internal beam criteria. The GYN dose evaluation
criteria align closely with the fractionation schedule, prescribed dose, and

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 anatomical area for the specific site being planned. Since we are using a four-field
box, there are limited ways we can reduce the dose to the normal organs. However,
since the field is designed to fit the PTV with a 1cm margin, any organ or structure
within the intersection of the fields will receive a significant dose as the beam must
travel through the area of interest before it reaches the treatment target.
Additionally, since we normalized the plan so that 95% of the target receives 100%
(4500cGy) of the prescribed dose, the planned dose becomes higher to achieve this
goal. Overall, when evaluating the planning objectives for a four-field box plan is
able to meet the bladder, femurs, bowel space constraints. However, this plan is not
able to meet the D05%≤4500 cGy of the bowel space unfortunately. To reduce this
dose, we can introduce a subfield on the lateral fields that block the bowel space to
meet this constraint. As this plan is already well balanced, and the beam energy is
needed due to the treatment target's depth.

Figure 58: DVH 4-FIELD PLAN

Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
BLADDER Not Hot Spots ( max 4748 cGy Y
dose point)
FEMURS D05%≤4500 cGy D05%=4450 cGy Y
BOWEL SPACE D05%≤4500 cGy D05%=4703 cGy N
RECTUM NOT PTV D05%≤5040 cGy D05%=4674 cGy Y
BLADDER NOT PTV D05%≤5040 cGy D05%=4655 cGy Y

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BOWEL SPACE NO HOT SPOT ( max 4809 cGy Y
dose)
FEMURS max point dose 4673 cGy Y

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