Matthew Taylor

Clinical Lab 1 Pelvis

February 5th 2015
Use a CT dataset of the pelvis. Create a CTV by contouring the rectum
(start at the anus and stop at the turn where it meets the sigmoid
colon). Expand this structure by 1 cm and label it PTV.
Create a PA field with the top border at the bottom of L5 and the
bottom border 2 cm below the PTV. The lateral borders of the PA field
should extend 1-2 cm beyond the pelvic inlet to include primary
surrounding lymph nodes. Place the beam isocenter in the center of the
PTV and use the lowest beam energy available (note: calculation point
will be at isocenter).
Contour all critical structures (organs at risk) in the treatment area.
List all organs at risk (OR) and desired objectives/dose limitations, in
the table below:
Organs at Risk
Bowel
Cauda Equina
Femoral Heads
Bladder

Desired Objective
58 Gy max,
V45Gy<195cc
54 Gy
44 Gy
~60 Gy w/urine ~28
Gy w/o urine

Achieved Objective
1.10 Gy
3.08 Gy
2.97 Gy
15.34 Gy

Enter the prescription: 45 Gy at 1.8 /fx (95% of the prescribed dose to

cover the PTV). Calculate the single PA beam. Evaluate the isodose
distribution as it relates to CTV and PTV coverage. Also where is/are
the hot spot(s)? Describe the isodose distribution, if a screen shot is
helpful to show this, you may include it.
100% isodose line is at isocenter and the dose drops off anteriorly. The hot spot
is near the posterior side of the patient due to the fact that the beam is a PA
beam is entering in the posterior side. Below I have the sagittal and axial views
of what the isodose lines look like.

Change to a higher energy and calculate the beam. How did your isodose
distribution change?
100% isodose line is at isocenter and the dose drops off less rapidly due to the
higher energy of the beam. The isodose lines also buldge out more on the left and
right sides from the midline.

Insert a left lateral beam with a 1 cm margin around the ant and post wall
of the PTV. Keep the superior and inferior borders of the lateral field the
same as the PA beam. Copy and oppose the left lateral beam 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 beams. Describe this
dose distribution.
80% and 95% isodose lines on the lateral sides of the body due to the lateral beams
and not enough coverage of dose for the PTV.

Change the 2 lateral fields to a higher energy and calculate. How did this
change the dose distribution?
Higher energies resulted in higher penetration from the lateral beams resulting in
better coverage of dose for the PTV and reduction of higher isodose laterally.

Increase the energy of the PA beam and calculate. What change do you
see?

The isodose lines are going further into the patient towards the anterior side and
the 50 percent isodose line (black) has been pulled into the more posterior side of
the 3 field box.

Add the lowest angle wedge to the two lateral beams. What direction did
you place the wedge and why? How did it affect your isodose distribution?
(To describe the wedge orientation you may draw a picture, provide a
screen shot, or describe it in relation to the patient. (e.g., Heel towards
anterior of patient, heel towards head of patient..)
When adding in the wedges to both the lateral beams I oriented the heel posteriorly.
The PA beam is adding a lot of dose to the posterior side of the body due to the fact
that its entering through the posterior side. Dmax for 15x energy is about 2.7cm.
With that being said, the lateral beams will also be adding to the dose on the
posterior side of the body. Having the heels of the wedges oriented to the posterior
side will attenuate the lateral beams and move dose anteriorly. This will help reduce
the hot spots that are on the posterior side of the body and help drive the dose

gradient towards the anterior part of the PTV.

Continue to add thicker wedges on both lateral beams and calculate for
each wedge angle you try (when you replace a wedge on the left , replace
it with the same wedge angle on the right) . What wedge angles did you
use and how did it affect the isodose distribution?
As I increased the angles of the wedges I noticed the difference in the isodose lines
on the lateral sides of the body. As the angle increased the angle at which the
isodose lines also changed. For example, below you can see the difference in a 10
degree wedge and a 45 degree wedge.

Knowing how wedges work will help in initially deciding what wedge would be
beneficial to use depending on your dose distribution. As you can see the lateral
isodose lines change at which the degree of the slant is going from medial to lateral.
The coverage of the dose to the PTV has also moved more to the anterior side.
Looking at the two examples with the wedges above, its evident that the
appropriate wedge would be somewhere in between the two. Looking at the 45
degree wedge, you can see that the coverage isnt very good on the posterior side
of the PTV. Since the wedges are driving the dose anteriorly, there isnt much that
can be changed in order to get coverage posteriorly besides lessening the angle of
the wedges. As far as the 10 degree wedge goes, the angle isnt sufficient enough
at driving the dose anteriorly and would need to have a bigger angle in order to get
coverage.
Now that you have seen the effect of the different components, begin to
adjust the weighting of the fields. At this point determine which energy
you want to use for each of the fields. If wedges will be used, determine
which wedge angle you like and the final weighting for each of the 3 fields.
Dont forget to evaluate this in every slice throughout your planning
volume. Discuss your plan with your preceptor and adjust it based on their
input. Explain how you arrived at your final plan.
In addition to the answers to each of the questions in this assignment,
turn in a copy of your final plan with the isodose distributions in the axial,
sagittal and coronal views. Include a final DVH.
Below are the axial, sagittal and coronal images of my final plan as well as the DVH
report. The weighting was .4 for the PA beam and .3 for each of the lateral beams.
Altering the weighting for the lateral beams by .1 changed the plan noticeably and
would move much more dose to the right lateral side. The wedges that were used
were 30 degree wedges. Higher degree wedges left 80% isodose spots in the lateral
sides near the hips and lower degree wedges left the PTV getting less coverage of
dose. I used 15x energy for all three beams due to how deep the PTV was from each
side and knowing that 15x penetrates the deepest. I had tried putting 10X as my
energy for the PA beam since the distance from the SSD to the PTV is smaller than
that of the lateral beams. This resulted in less coverage of the PTV on the PTVs
anterior side.

4 field pelvis
Using the final 3 field rectum plan, copy and oppose the PA field to create
an AP field. Keep the lateral field arrangement. Remove any wedges that
may have been used. Calculate the four fields and weight them equally.
How does this change the isodose distribution? What do you see as
possible advantages or potential disadvantages of adding the fourth field?
After putting in the AP beam, taking off the wedges and weighting all the beams the
same, the isodose distribution changed noticeably. The biggest set back to doing
this would be the dose being dispersed in the bowel. The AP beam gave better
coverage in some slices for the anterior side of the PTV, but also gave worse
coverage in other slices. Adding in the AP beam also lessened the amount of dose
that was going into the lateral sides. As far as the hotspot coverage is concerned,
the 4 field pelvis plan was 1.1% less hot compared to the three field pelvis plan.
This particular patients PTV was closer to the posterior side of the body. Therefore I
think that it would make more sense to leave this treatment plan as a 3 field plan.
Had the PTV been more anterior, the 4 field plan may have worked better coverage

wise as well as protecting other areas of the body from getting as much dose.