Planning Assignment (Brain)

Target organ(s) or tissue being treated: Prescription:_300cGy/fx x 10fx = 3000cGy_____________________________________________ Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below): Organ at risk Brain Stem LT Eye Rt Eye Lt Optic Nerve Rt Optic Nerve Lt Lens Rt Lens Optic Chiasm Spinal Cord Desired objective(s) <5000cGy Max dose <4500cGy Max dose <4500cGy Max dose <5400cGy Max dose <5400cGy Max dose <700cGy Max dose <700cGy Max dose <5400cGy Max dose <5000cGy Max dose Achieved objective(s) 3011cGy 2795cGy 2747cGy 2896cGy 2905cGy 300cGy 311cGy 2921cGy 438cGy

Contour all critical structures on the dataset. Place the isocenter in the center of the skull. Create a single Rt. lateral plan using the lowest photon energy in your clinic. Refer to Bentel pp. 336-340 to add a block to the Rt. Lateral field. From there, apply the following changes (one at a time) to see how the changes affect the plan (copy and paste plans or create separate trials for each change so you can evaluate all of them): Plan 1: Create a beam directly opposed to the original beam (Lt. lateral) (assign 50/50 weighting to each beam) a. What does the dose distribution look like? My coverage is good as the 100% surrounds the entire skull, however it does start to break up at the inferior portion. Even there though, the 98% continues to cover the entire brain. We also see some breaking up of the 100% near the chiasm at the slice of the eyes. b. Where is the region of maximum dose (hot spot)? What is it? The main issue that I am having is how hot it is. The 105% covers the posterior portion for the entire brain, and as we move superiorly, it starts to cover the entire brain. While the hot spot jumps around a little, it is mostly on the right anterior and superior portion as well as

the left inferior and posterior region. My global maximum hot spot is on the right anterior and superior portion of the skull and is reaching 111.3%. Plan 2: Adjust the weighting of the beams to try and decrease your hot spot. a. Did it help the hot spot? While I was able to slightly decrease my hot spot, it didnt do a whole lot. By adding a slightly higher weighting to the right lateral I was able to drop my global maximum to 110.7% and move that point to the left anterior superior portion of the brain. c. Did your isodose coverage of the brain change? While my isodose coverage of the brain did indeed change, it didnt get much better. The 98% line still covers the entire brain and the 100% covers all but the inferior portion. However, this still hasnt solved the issue of the heat. My 105% still covers most of the brain on the superior portion. Plan 3: Does your facility ever use wedging or segmented fields to decrease the hot spot? If so, try one of those techniques (wedging is easier at this point). a. Evaluate the isodose lines. Which direction does the wedge need to go? By using two thin 10 degree wedges, I was able to knock the hot spot down another two percent down to 108.3%. The wedges are oriented with the heel superiorly pushing the isodose lines more inferiorly and eliminating the 105% isodose lines. While there is some hot spots on the posterior skull, the 100% coverage is excellent and the rest of the brain has cooled down a bit. b. Which wedge provides the most even dose distribution? Once I made the jump from the 10 degree wedges up to the 15 degree wedges, the dose on the inferior and posterior portion became a little too hot. The global max jumped back up to 110% and the 105% isodose lines started to come back into the picture. My best coverage and plan thus far was from using the 10 degree wedges. Plan 4: Does your facility use other techniques to treat whole brains? Discuss this with your clinical instructors and work on creating different whole brain plans. Several of these other techniques include slight anterior obliques, collimator rotations, half-beam blocking with an off-axis prescription point. a. What are the advantages to these other techniques? Using different techniques can help to get better coverage throughout the brain while bringing our hot spot down. With the blocking for whole brain fields usually being pretty good, there arent a lot of critical structures we need to worry about. This brings our main focus to the coverage and heat of our plans.

b. When designing and evaluating different techniques, which one produces the most ideal plan? After running through a few different techniques, I have found that using electronic compensation has worked out the best.

Which treatment plan covers the target the best? What is the hot spot for that plan? With the target being the whole brain, using the electronic compensation method to paint in the dose was very beneficial. I was able to cover the entire brain with the 100% isodose line while leaving very little as a hot spot. After some work I was able to reach a global maximum hot spot of 104.4% which was located on the inferior and anterior portion of the skull. Most of the hot spots that I had to paint out was located around the ear, which clearly we needed to avoid.

Did you achieve the OR constraints as listed in the table on page 1? List them in the table. Yes What did you learn from this planning assignment? After seeing the progression of the plans and the different methods out there, I came away with a couple of important messages. First is that if you have the time, keep trying to make a plan better. Many times there are ways to increase coverage or block out structures that you hadnt thought of before. Our job is to create the best plan, and not settle for the quickest solution. Second, is that there are a lot of different methods out there to treat certain cases. This doesnt mean that one way is right and another is wrong, but there are numerous ways to achieve the same outcome. What will you do differently next time?
Now that I have a good idea on how isodose lines move when playing with some of the different factors, I will probably avoid treating simply two laterals. I will most likely go straight to a field in field or electronic compensation method and save myself the time. If I can make my first plan have decent results, it will leave me with more time to make it even better.