Lisa Stevenson

Fieldwork Lab 2
GYN Pelvis RTOG 0418
This patient has a stage IIIc2 endometrial carcinoma. The physician requested this plan
to be done via a VMAT technique and for the patient to have daily IGRT. Therefore, the tumor
margins were created in compliance with the protocol parameters. The physician contoured the
CTV based on a PET/CT fusion as well as to encompass the nodal regionals. The PTV was then
constructed by expanding the CTV by .7cm sup/inf and .7cm axially.
I proceeded to contour the small bowel, bladder, rectum, and femoral heads. (Figure 1.)
Three rings were created that were 3 mm, 10 mm, 15 mm, and 20 mm respectively with a normal
tissue contour outside of the third ring that extended to the external contour to assist in faster
dose fall off. (Figure 2) I chose a VMAT plan with 4 arcs that started at 188 and stop at 172. I
alternated the beams clockwise/counterclockwise in an effort to reduce treatment time and limit
patient motion during treatment. I split the beams and used collimator rotations of 10, 350, 85,
and 95 degrees to allow for the best PTV coverage while giving the optimizer the most MLC
configuration options since this is an irregularly shaped volume. (Figure 3.) A beam energy of
6MV was used. This is required for all VMAT plans at GHCI due to the neutron contamination
that occurs at higher energies. My objectives included a minimum of 100% of the prescription
dose to be delivered to the PTV since the prescribed dose needs to encompass 97% of the PTV in
order to be in compliance with the protocol objectives. I also added objectives to the rings in an
effort to obtain greater dose fall off. Upper dose limits were also applied to the bladder, rectum,
small bowel, and femoral heads. ) During treatment planning, the isodose lines werent curving
to spare the small bowel as much as necessary so I created an avoidance contour that was also
added to my objectives and given a moderate weighting. This seemed to create the desired result
and brought the small bowel dose into tolerance. (Figure 3)
I was able to meet all planning objectives very well with the VMAT technique. The plan
did not exceed 105.6% of the prescription dose. The VMAT plan provided 100% of the
prescription dose to slightly more than 97% of the PTV volume and 100% of the CTV received
98% of the prescription dose. The plan was well under the maximum allowable dose levels for

all ORs and I had adequate coverage of the PTV. (Figure 4 -5) Planning objectives reached for a
prescribed dose 5040cGy delivered in 28 factions of 200cGy per day include:

OR

Desired Objective

Achieved Objective

Small Bowel

<30% volume 40Gy

<30% volume 29.2Gy

Rectum

<60% volume 30Gy

<60% volume 24.6Gy

Bladder

<35% volume 45Gy

<35% volume 24.8Gy

Femoral Head

<15% volume 30Gy

<15% volume 22.6Gy

PTV

97% volume 50.4Gy

97.5% volume 50.4Gy

CTV

98% volume 50.4Gy

98% volume 50.4Gy

Figure 1 : Target Volumes and Organs at Risk

SMALL

PTV

CTV

BLADD
RECTUM

Figure 2: Beam Eye View to display Split Field and Collimator Parameters.

Figure 3: Rings and Avoid structures used to promote dose fall off.

Figure 4: DVH

CTV
PTV
SMALL
BOWEL

BLADD

L FEMORAL
HEAD
R FEMORAL
HEAD

RECTU

FEMORAL

Figure 5: Isodose Distribution