Travis Kilmer

Pelvis Clinical Lab Assignment

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

Prescription: 45 Gy 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. After adjusting each plan, answer the provided questions. Tip: Copy
and paste each plan after making the requested changes so you can compare all of them as
needed.

Plan 1: Calculate the single PA field.

• Describe the isodose distribution.
o The isodose lines follow a path of highest dose (110%) to least dose (50%) from
posterior to anterior. The isodose lines have greater spacing as the strength of
the isodose lines decreases. The isodose lines go through the middle of the
femoral heads laterally, encompass all of the rectum, bladder, and PTV, and
infiltrates a decent portion of the bowel space.
• Where is the hot spot and what is it?
o The hot spot is located posteriorly near the external skin surface on the left side
of the body. The hot spot is recorded at 8022 cGy.
• What do you think creates the hot spot in this location?
o I think the hot spot is in this location because of multiple factors such as the
density of the table being in the way, the attenuation of tissues as the beam
moves through the body, and the beam energy being only 6 MV meaning it
doesn’t have as much penetration strength.
• Using your DVH, what percent of the PTV is receiving 100% of the dose?
o 47% of the PTV is receiving 45 Gy which is 100% of the prescription dose.

Plan 2: Change the PA field to a higher energy and calculate the dose.
• Describe how the isodose distribution changed and why?
o The isodose lines have been extended more anteriorly than with Plan 1. This
caused more of the normal tissue to be covered and more dose to reach the PTV
and critical structures. This can be attributed to the higher energy being used (18
MV). This causes the scatter outside the field to be minimized as a result in more
forward scattering.
• Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
o 52% of the PTV is receiving 45 Gy which is 100% of the prescription dose.
 Travis Kilmer

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 By adding right and left lateral beams, the treatment plan starts to become more
conformal. The 50% and 70% isodose lines form an oddly shaped “T” in the
pelvic area covering everything except the anterior 1/3 of the body and portions
of the right and left posterior pelvis. Patches of the 80%, 90%, 95%, and 98%
isodose lines, all successively smaller than the next, are found near the skin
surface on the left and right sides of the body, directly in the path of the lateral
beams. In the center of the pelvis, isodose line 80%-110% are found forming a
square with the anterior side of the square dipping posteriorly.
• Where is the hot spot and what is it?
o The hot spot is found in the gluteus maximus muscles on the right posterior side
of the body. It has a value of 5260 cGy.
• What do you think creates the hot spot in this location?
o I think the hot spot is in that location due to the overlapping of the right lateral
beam and PA beam. This causes a buildup of dose and causes the hot spot to be
placed there. I think that it was also placed on the right side compared to the left
because of the tissue differences of each side. Since the tissue is thicker on the
left side, it’s easier for dose to buildup on the right side of the patient’s body
where there is less tissue.

Plan 4: Increase the energy of all 3 fields and calculate the dose.
• Describe how this change in energy impacted the isodose distribution.
o By increasing the energy of all beams, more dose was dumped into the center of
the pelvis meaning less dose went to normal tissue structures on the periphery
of the body. The shape of the 50% and 70% isodose lines still formed an oddly
shaped “T” in the pelvic area but the lateral patches only included the 80%
isodose line. The anteriorly-dipping square in the center of the pelvis remained
except the 110% isodose line is now a circle that surrounds the former hot spot
found in Plan 3. There was a slight difference in distance between the isodose
lines in the center of the pelvis. By having the higher energies the isodose lines
were further apart from each other.
• What are the benefits of using a multiple-field planning approach? (Refer to Kahn, 5th
ed, Ch 11.5B)
o Khan states that by using a multiple-field planning approach, the amount of dose
to the peripheral tissues outside of the PTV can be reduced so more of the dose
can be placed within the PTV. This helps with meeting the constraints for organs
at risk and reduces the side effects of radiation that patients can experience.
• Compared to your single field in plan 2, what percent of the PTV is now receiving 100%
of the prescription dose?
 Travis Kilmer

o 55% of the PTV is receiving 45 Gy compared to Plan 2 only having the PTV
receive 52%.

Plan 5: Using your 3 high energy fields from plan 4, adjust the field weights until you are
satisfied with the isodose distribution.
• What was the final weighting choice for each field?
PA Field 26.82%
Right Lateral Field 36.58%
Left Lateral Field 36.60%

• What was your rationale behind your final field weight?

o The reason I chose this weighting is because I am still able to able to maintain a
decent amount of coverage while not exceeding 110% of the prescription dose.
One of the top priorities when planning is to meet the dose requirements for the
PTV. I believe the weighting I chose maximizes the coverage to the PTV while
reducing the amount hot spots to other tissues.

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.
• 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 orientation of both wedges are characterized by the heel being placed more
posteriorly and the toe facing anteriorly. The angle of the wedges are 30
degrees.
• How did the addition of wedges change the isodose distribution?
o The wedges caused the dose to shift more anteriorly due to the placement of the
heel. Since the heel of the wedge is thicker, it causes less dose to be dumped
into the corresponding area within the pelvis. This also caused the hot spot to
move more anteriorly and closer to the PTV. Also, with the wedges in place, dose
to the rectum decreased which is important so symptoms from radiation are less
severe. Dose, consequently, was added outside of the PTV and caused the
periphery areas to heat up. No more than 109% of the prescription dose was
found in the periphery.
• According to Kahn, 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?
(Refer to Kahn, 5th ed, Ch. 11.4)
o Khan states that a minimum distance of 15 cm between the absorber in the
beam and the surface is required.
 Travis Kilmer

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 I decided to use 18 MV because the next lowest energy available is 6 MV which is
not sufficient for reaching the PTV and providing optimal coverage. 18 MV
provides enough energy to deliver adequate dose to the target area and spares
more tissue than 6MV.
• What is the final weighting of your plan?
PA Field 25.33%
Right Lateral Field 25.33%
Left Lateral Field 24.00%
AP Field 25.33%

• Did you use wedges? Why or why not?

o I did not use wedges because, for this case, they were not necessary for a four-
field treatment. I tried to insert wedges to improve the plan but they created
changes that shifted dose to areas in the body that made the plan worse. By
keeping the “box-shaped” plan, dose conformality was much better and
improved the plan overall by sparing tissue and providing adequate coverage.
• Where is the region of maximum dose (“hot spot”) and what is it?
o The hot spot has a value of 4991 cGy and is located in the anterior, left lateral
portion of the body within the CTV3 contour.
• What is the purpose of normalizing plans?
o Normalizing a plan allows more dose to cover a greater area. By normalizing this
plan to 95% of the PTV receiving 100% of the dose, the 100% isodose line was
able to expand to cover a greater area of the PTV. This serves a great purpose for
plans where delivering enough dose to the PTV becomes difficult. By normalizing
the plan at a different isodose line, dosimetrists are able to manipulate the
coverage of dose and create the plan accordingly.
• What impact did you see after normalization? Why?
o After normalizing Plan 7 I saw how much better coverage I was able to get from
my isodose lines. I also saw the plan had developed more hot spots because of
the increase in dose due to the normalization. While the PTV had gotten better
coverage, this also meant that other critical structures such as the rectum,
bowel, femurs, and bladder had increased the amount of dose they were
receiving. All these impacts were due to normalizing the plan to 95%, which
essentially moved the isodose lines back causing the plan to heat up and deliver
more dose to a given area.
 Travis Kilmer

• Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal
and coronal views. Show the PTV and any OAR.

By looking at the isodose lines in the image above, each plane shows the conformality of
dose delivered to the PTV. By including organs at risk and the PTV, a further
understanding develops as to why I decided on this plan. Dose is being sufficiently
delivered to the PTV and the organs at risk, along with other normal tissues, are
receiving as little dose as possible without sacrificing coverage.
 Travis Kilmer

• Include a final DVH. Be sure to include clear labels on each image (refer to the Canvas
Clinical Lab module for clear expectations of how to format your DVH).

From looking at the dose volume histogram, Plan 7 can now be visualized graphically.
This is a great way to put a plan with many characteristics into numerical form and see
how it graphically presents itself. By changing the look of a plan, from CT slices to
graphs, a better understanding of how different criteria can be met develop. This allows
users to see where the plan is excelling and where there needs to be improvement.

• If you were treating this patient to 45 Gy, use the table below to list typical organs at
risk, critical planning objectives, and the achieved outcome. Please provide a reference
for your planning objectives.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Small Bowel Max Dose = 52 Gy Max Dose = 49.452 Gy
Bladder V40<60% V40<99%
V50<50% V60<0%
V70<20% V65<0%
 Travis Kilmer

V40<60% V70<0%
V50<50% V75<0%
V70<20% V80<0%
Rectum V50<50% V60<0%
V70<20% V65<0%
V50<50% V70<0%
V70<20% V75<0%
Left Femur V50<5% V50<0%
Right Femur V50<5% V50<0%
*These planning objectives are from the Minneapolis VA “hard constraints” for an IMRT pelvic
treatment plan which are based off of RTOG 0924.

These planning objectives were all met because of the low dose that was delivered. The only
constraint not achieved was the V40<60%. This is due to the PTV covering most of the bladder,
in turn, causing more dose to be delivered to that organ.