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).
Setup notes: Prone on belly board with arms above head clasping hand grips. Reversed knee sponge under
ankles.
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 TD 5/51 Desired objective(s)2 Achieved objective(s)
Small Bowel 50 Gy (1/3) No more than 150cc to exceed 35 Gy 150cc = 10.9 Gy
40 Gy (3/3)
No more than 70cc is to exceed 40 Gy 70cc = 11.9 Gy
No more than 35cc is to exceed 45 Gy 35cc = 12.4 Gy
No point doses above 50 Gy Max dose = 14.8 Gy
Femoral Heads Left Right
52 (3/3)
No more than 70cc is to exceed 40 Gy 70cc = 16.3 Gy 12.1 Gy
No more than 35cc is to exceed 45 Gy 35cc = 31.5 Gy 30.6 Gy
No point doses above 50 Gy Max dose = 45.4 Gy 45.4 Gy
Bladder 80 (2/3) Mean dose < 40 Gy Mean dose = 17.5 Gy
65 Gy (3/3)

1. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. International journal of radiation
oncology, biology, physics. May 15 1991;21(1):109-122.
2. Arthur G James Cancer Hospital Radiation Oncology: 3D Rectal Planning Objectives.
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.
The 95% line (green) fully covers the CTV and PTV volumes. The 100% isodose line (yellow)
however, covers only the CTV but cuts into some parts of the PTV. This makes sense since I
am normalized to 95% of the dose to cover the PTV. The isodose lines sort of mimic the
patients surface anatomy.
The hot spot is 158.9% and is located close to the patients posterior surface in the left
gluteal region at the level of d-max for a 6 MV beam (1.5 cm)
6X isocenter sagittal view
 6X hotspot axial & sagittal view

b. Change to a higher energy and calculate the beam. How did your isodose distribution change?
Using 10 MV, my CTV is still covered completely by the 95 and 100% line while my PTV is
covered by the 95% but not completely by the 100%. Isodose lines are penetrating slightly
deeper with the higher energy. My hot spot is now 147.6% which is lower than the 6 MV
plan and has moved superior slightly but is now a little deeper and corresponds to the
depth of d-max for a 10 MV photon beam (2.5 cm).
10X isocenter sagittal view

10X hotspot axial & sagittal view

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.
This beam arrangement creates a box shaped isodose distribution in the axial plane. With
equal weighting, lateral aspects of the patient are receiving high doses (>105%: black
isodose line). The bladder is now receiving less dose with only the 20% line (blue)
encompassing it compared to the previous PA only plans when the 60% isodose line was
encompassing the bladder. The hotspot is within the intersection of the RL and PA fields and
is 124.7%.
6x 3-Field isocenter axial view

6X 3-field hotspot axial & sagittal view

d. Change the 2 lateral fields to a higher energy and calculate. How did this change the dose
distribution?
PA: 6MV; RL & LL: 15 MV - The dose distribution looks similar except now the lateral aspects
of the patient are receiving a lower dose: before there were 105% isodose lines on the
lateral aspects of the patient and now there are no 95% isodose lines (green) and very little
90% (blue). There was a drop in MU for the PA beam even without changing the weighting
 which shows the greater efficiency of the higher energy lateral beams. The hot spot is still
within the intersection of the RL and PA fields and is now 120.7%
6 & 15X 3-Field isocenter axial & sagittal view

6 & 15X 3-Field hotspot axial view

e. Increase the energy of the PA beam and calculate. What change do you see?
PA: 10 MV; RL & LL: 15 MV - The 50% isodose line (red) now conforms more to the PTV so
the posterior aspect of the patient is getting less dose but the 20% isodose line (blue) now
extends more anteriorly. The hot spot is still within the intersection of the RL and PA fields
and is now 120.3%.
10 & 15X 3-Field isocenter axial & sagittal view
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 a 10 degree wedge to the left and right lateral beams with heels up in the axial
plane (wedge toe pointing anterior). I added the wedges in this direction since the dose is
hotter within the intersections of the lateral fields with the PA beam. This will cool off the
dose in this area and push it toward the anterior portion of the patient where dose is
cooler.
Adding the wedges decreased my hotspot to 118.1% and my PTV MIN increased slightly.
They did not change the isodose distribution much.

10 degree wedges isocenter axial & sagittal view

10 degree wedges hotspot axial & sagittal view

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?
20 degree wedges: Hot spot is now 115.0%. The 105% isodose distribution is smaller and is
starting to break up just a little bit. The PTV min is also a little higher.
20 degree wedges isocenter axial & sagittal view

20 degree wedges hotspot axial view

30 degree wedges: My hot spot is now 111.6%. My 105% isodose line has been pushed
slightly more anterior and is breaking up a lot more (see below).
30 degree wedges isocenter axial & sagittal view
 30 degree wedges hotspot axial view

45 degree wedges: My hot spot is now 107.6% and has now been pushed anteriorly (see
below). The 105% isodose lines have almost completely disappeared (black).
45 degree wedges isocenter axial & sagittal view

45 degree wedges hotspot axial view

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 on using 45 degree wedges since these seemed to improve my minimum coverage
and decrease my hotspot most. I stuck with the energies I had previously which were 15 MV
from the laterals and 10MV from the PA. I figured that increasing my PA beam energy
would probably decrease my hot spot but I decided against this since the bowel and bladder
would be receiving a higher dose if I did. Since my 100% isodose line was being pushed
slightly anterior, I knew I needed to add weight to my PA beam. Doing this reduced dose to
the lateral surface of the patient. I ended with a 45/27.5/27.5 (PA/LL/RL) weighting which
left my hot spot at 110.0% and gave me the best overall dose distribution.
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.
Attached in separate document

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?
Right and left lateral beams: 15 MV. AP and PA beams: 10 MV (copied from final 3-fld plan)
Isodose distribution: The isodose distribution is more square in shape in the axial plane
compared to the 3-field which showed some divergence from the PA beam. The hot spot is
lower with the 4 field plan at 107.8%.
Advantages:
o It gives an overall more conformal dose distribution (high dose is tighter).
o Lower hot spot
o Lower dose to lateral normal tissue
Disadvantages:
o Small bowel dose is a lot higher:
Max is 29 Gy compared to 14.8 Gy
150cc now getting 24 Gy compared to 10.9 Gy
o Bladder dose a lot higher: Mean 25.7 Gy compared to 17.5 Gy
o A beam entering through the belly board.
The purpose of the belly board is to get the small intestines out of the field for a
3 field plan. In this case, when treating with an additional AP beam, the belly
board would probably not be necessary anymore since we are choosing to treat
through the small bowel.
4-field plan isocenter axial view