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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:
*Patient was simulated prone in the belly board for immobilization. The patients head was
resting on a prone Duncan cushion with their arms hugging the cushion.
1. 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.
Plan 1 has a single PA field that is calculated with 6MV energy. The dose distribution for
plan 1 seems to follow the anatomy of the data set. For example, the isodose line falls
anteriorly when passing through the rectum due to the large amount of air. 95% of the
PTV is being covered by 100% of the dose. The CTV has much better coverage because
it lives within the PTV. The hotspot lies posteriorly in the inferior portion of the sacrum.
The problem with using one beam to treat a deep PTV is that it results in a very hot plan
(151.6%) and poor dose conformity.

Figure 1: Plan 1 dose distribution. This plan is very hot and does not conform well to the target.

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2. Change to a higher energy and calculate the beam. How did your isodose distribution
change?
Plan 2 is calculated using a 23MV beam which is more penetrating than a 6 MV beam.
The dose distribution is still not conformal around the PTV, but the hotspot has been
reduced to 129.5% and is still located posteriorly in the sacrum. The reason the hotspot is
lower is because a plan using higher energy beams does not need as many monitor units
to deliver the prescription dose to the target.

Figure 2: Plan 2 uses a 23 MV beam instead of a 6 MV beam resulting in a lower hotspot for the plan.

3. 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 dose distribution for this plan does not fall as far anteriorly as plans 1 and 2, instead
it has started to create a box shape around the PTV. The addition of the two lateral beams
stops the dose from falling as anteriorly which spares the bladder and femoral heads to a
greater degree. The dose delivery is now shared between three beams as opposed to one
resulting in a more conformal dose distribution and less entrance dose around the
periphery of the patients body. However, the 98% isodose(red) line still falls in the
periphery of the body which is still too high (50-60% is more acceptable). The hotspot
has now moved to the overlap of the PA and left lateral beam entrances and did not cool
down at all.

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Figure 3: The addition of the lateral beams improved the conformity of the plan.

4. Change the 2 lateral fields to a higher energy and calculate. How did this change the dose
distribution?
Changing the beam energy for the lateral beams from 6 MV to 23 MV is more
appropriate for a 3 field rectum due to the depth of the target. Using a 23 MV beam
reduces the amount of MU required to deliver the prescription dose and thus reduces the
hotspot. The hotspot is still located at the overlap of the PA and left lateral beam
entrances, but has been reduced to 120.1%. The dose around the hips has decreased to the
80% isodose line (baby blue).

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Figure 4: Plan 4 uses a 23 MV beam energy on the lateral fields and improves the hotspot and conformity.

5. Increase the energy of the PA beam and calculate. What change do you see?
After changing the beam energy of the PA beam to 23 MV, the coverage of the PTV
increased and the amount of dose around the hips decreased. The hotspot stayed in the
same location as plan 4, but reduced to 115.6%. Most of the hotspots are located
posteriorly due to the entrance of the PA beam.

Figure 5: Plan 5 dose distribution.

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6. 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..)
My clinical site no longer uses physical wedges, as a result I rotated the collimators so
dynamic wedges could be used. For plan 6, I added 10 degree dynamic wedges with the
heel pointed posteriorly. The heel is pointed posteriorly to compensate for the slope of the
buttocks and to push dose from the PA beam more anteriorly. The hotspot is also located
under the heel of the wedge which reduced to the hotspot to 111.7%. The dose
distribution now falls more anteriorly because the beam is attenuated less at the toe of the
wedge and more at the heel. The amount of 80% isodose lines towards the periphery of
the patient was also decreased.

Figure 6: Plan 6 added small wedges to reduce the hotspot and push dose more anteriorly.

7. 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?
After testing all of the wedges, I determined the 30 degree dynamic wedge improved the
plan the most. This wedge decreased the hotspot to 105.2% and moved it closer to the
PTV. Overall, the plan cooled down because the heel of the wedge attenuated the higher
dose area located posteriorly.

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Figure 7: The 30 degree wedges improved the hotspot and dose distribution the most.

8. 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.
For the final plan I chose to use 23 MV beams on all of the fields due to the depth of the
target in relation to all of the fields. I also adjusted the weighting of each beam to find a
balance between an acceptable hotspot, PTV coverage, and dose around the periphery of
the patient. I weighted the PA beam at 40% and the two lateral beams at 30% each. After
adjusting the weighting I tested the wedges again to make sure another wedges would not
be better than the 30 degree dynamic wedge. This final plan gave me a hotspot of
106.4%, 95% of the PTV being covered by 100% of the prescription dose with a PTV
minimum of 96.4%, and only a small amount of the 70% isodose line around the
periphery of the patient.

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9. 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.
Field
Name
PA
RLAT
LLAT

Energy
23X
23X
23X

Gantry
Angle
0
90
270

Collimator
Angle
0
270
90

Table
Angle
0
0
0

MU

Accessory

Weighting

73 MU
81 MU
80 MU

None
EDW30IN
EDW30IN

40%
30%
30%

Table 1: The plan parameters of the final 3 field rectum plan.

Figure 8: Final plan dose distribution.

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Figure 9: Final plan DVH.

Organ at risk
Bladder

Iliac Crest (RTOG 0529)

Right Femoral Head

(RTOG 0529)
Left Femoral Head
(RTOG 0529)

Desired objective(s)
Max<65Gy1
V35<50% (RTOG 0529)
V40<35% (RTOG 0529)
V50<5% (RTOG 0529)
V30<50%
V40<35%
V50<5%
Max<48Gy
V30<50%
V44<5%
Max<48Gy
V30<50%
V44<5%

Achieved objective(s)
Max = 4630 cGy
V35 = 19.3%
V40 = 14.6%
V50 = 0%
V30 = 51.5%
V40 = 14.5%
V50 = 0%
Max = 4250 cGy
V30 = 50.6%
V44 <1%
Max = 4145 cGy
V30 = 39.4%
V44 = <1%

Table 2 shows the final organ at risk dose objectives for the final 3 field rectum plan.

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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?
Adding an AP beam creates a more conformal box around the PTV. The hotspot decreased to
106.1% and is now located in the CTV of the plan. The dose around the periphery of the patient
has been decreased so that only the 50% isodose line is outside the pelvis. The advantages of this
plan are better hotspot percentage and location, improved PTV coverage, and increased sparing
of normal tissue. The disadvantages include a slightly increased bladder dose due to the entrance
of the AP beam and increased treatment time for the therapists and patient.

Field
Name
PA
RLAT
LLAT
AP

Energy
23X
23X
23X
23X

Gantry
Angle
0
90
270
180

Collimator
Angle
0
270
90
0

Table
Angle
0
0
0
0

MU

Accessory

Weighting

46 MU
57 MU
57 MU
52 MU

None
None
None
None

25%
25%
25%
25%

Table 3 shows the plan parameters for a 4 field rectum.

Figure 10: Dose distribution for 4 field rectum.

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Figure 11: 4 Field rectum DVH.

Organ at risk
Bladder

Iliac Crest
(RTOG 0529)
Right Femoral Head
(RTOG 0529)
Left Femoral Head
(RTOG 0529)

Desired objective(s)
Max<65Gy1
V35<50% (RTOG 0529)
V40<35% (RTOG 0529)
V50<5% (RTOG 0529)
V30<50%
V40<35%
V50<5%
Max<48Gy
V30<50%
V44<5%
Max<48Gy
V30<50%
V44<5%

Achieved objective(s)
Max = 4648 cGy
V35 = 25.7%
V40 = 19.5%
V50 = 0%
V30 = 18.2%
V40 = 12.5%
V50 = 0%
Max = 3382 cGy
V30 <1%
V44 = 0%
Max = 3202 cGy
V30 <1%
V44 = 0%

Table 4 shows the dose objectives for the 4 field rectum.

References

1. Marks, LB, Yorke ED, Jackson A, et al. Use of normal tissue complication probability
models in the clinic. Int J of Radiat Oncol Biol Phys. 2010; 76 (3 supplement): S10-S19.