Planning Assignment (3 field rectum)

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:
Organ at risk
Bladder

Desired objective(s)
<50% to receive 45Gy

Achieved objective(s)
50% receiving 35.8Gy

Small Bowel

<5% to receive 50Gy

5% receiving 21.7Gy

Large Bowel

<5% to receive 60Gy

5% receiving 51Gy

Femoral Heads

<5% to receive 50Gy

Lt- 5% receiving 60Gy

Rt-5% receiving 74Gy

a. 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% of the CTV and PTV is
receiving at least 95% of the prescribed dose. The isodose
distribution is higher/hotter posteriorly. The hotspot is
posterior, near midline, close to the surface of the patient, at
dmax.
b. Change to a higher energy and calculate the beam. How did your
isodose distribution change? The dose distribution of 6MV is more
posterior and the dose distribution of 23MV is more anterior.
PTV and CTV coverage is about the same, but the 6MV plan is
much hotter.
c. 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. The CTV and PTV are
getting the coverage that is needed but there is a lot of dose
distributed lateral to the treatment volume. The hotspot is
117.6% and it is outside of the PTV (posterior and right of the
PTV). The dose distribution does not look conformal.
d. Change the 2 lateral fields to a higher energy and calculate. How did
this change the dose distribution? The CTV and PTV are getting the
coverage that is needed. The higher doses are around the
treatment volume. The dose distribution lateral to the PTV is
lower with the energy of 23MV than 6MV. The hotspot is 113.2
in ~ the same spot as the hotspot was with the 6MV.
e. Increase the energy of the PA beam and calculate. What change do you
see? The coverage actually looks very similar for both plans.
The CTV and PTV is covered with both plans. The hotspot is
reduced with 23MV, however the exit dose from the PA beam
is slightly more anterior than the plan with the 6MV PA beam.

f. 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..) I
added the physical wedge of 15. The toe of the wedge is
anterior to the patient and the heel of the wedge is posterior. I

used this orientation because the hotspot is posterior in the

patient. The dose distribution is slightly more conformal and
the hotspot is decreased.
g. 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? 30The dose distribution is more anterior and slightly more
conformal. The hotspot was decreased. The hotspot is more
anterior than it was with the 15 wedge.
45- The dose
distribution is more anterior and less conformal. The hotspot
increased. 60- The dose distribution is more anterior, much
less conformal, and the hotspot greatly increased.
h. 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. I decided to use 6MV for the PA field to reduce the dose
distribution anterior to the PTV and 23MV on the laterals for
improved dose conformity. The dose distribution was most
conformal with the 30 wedge and the maximum dose was also
reduced, therefore I decided to use the 30 wedge. There was a
little dose distributed lateral to the treatment volume so I
weighted the PA field a little more. The PA field was weighted
37.7, The left and right lateral fields were weighted 31.1 each.
i. 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.

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? The dose
distribution is more anterior in the patient. This could be a
disadvantage because the bowel, femoral head, and bladder dose
could increase. The hotspot is decreased. If you had a plan that was
really hot, a fourth field might be an option to reduce the maximum
dose.