Ashley Pyfferoen 1

Planning Assignment (Brain)

Target organ(s) or tissue begin treated: Brain (Pinnacle) Prescription: PTV: 3750cGy, 250cGy/15Fx Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below): Organ at Risk Desired Objective(s) Eyes Lens Upper Cord 3750 3750 3750 Achieved Objectives Maximum (cGy) Mean (cGy) 3659 3623 256 249 3732 3712

Contour all critical structures on the dataset. Place the isocenter in the center of the skull. Create a single right lateral plan using the lowest photon energy in your clinic. Refer to Bentel pp. 336-340 to add a block to the right 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? A: I observed the dose conforming nicely to the skull and encompassing most of brain excluding the sinus cavity and posteriorly nearing the brain stem. Most of the 100% isodose line was covering the skull with the exception of some areas midline in the brain only getting 98% of the dose. These areas were located just superior of the isocenter. There were 10% hot spots anteriorly and posteriorly along the skull. There were also some 110% and 115% hot spots located inferiorly and posteriorly in the skull as well. b. Where is the region of maximum dose? A: The region of maximum dose is located posteriorly and inferiorly in the skull. This dose was measured at 4303cGy (115%) hot Plan 2: Adjust the weighting of the beams to try and decrease your hot spot. a. Did it help with the hot spot?

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A: Hot spots did not improve when changing beam weighing. Because the regions of overdose are located anteriorly and posteriorly, the adjustment of lateral beams wouldnt assist much. b. Did your isodose coverage of the brain change? A: There was some improvement in the area of the brain only receiving 98% of the dose. I was able to add more weight to the right lateral beam and improve dose to that region. While the hole did not completely disappear, it was significantly minimized. Plan 3: Dose your facility ever use wedging or segmented fields to decrease the hot spot? If so, try one of those techniques. a. Evaluate the isodose lines. Which direction dose the wedge need to go? A: I achieved the best dose distribution with the wedge heel superiorly on both fields to minimize the 105% hot spots in the superior portion of the skill. However, this increased dose inferiorly near the brain stem and superior spinal cord. One physician in our clinic is particularly mindful of the dose to the superior spinal cord; therefore, I didnt find the wedge to be useful. Instead, Gundersen Lutheran uses segmented fields to minimize hot spots in the skull and remove hot spots from around the eyes and superior spinal cord. b. Which wedge provides the most even dose distribution? A: I used the 15 wedge in this example; however, I mentioned that the use of wedges in our clinical setting is rare for whole brain treatments. 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 these other techniques include slight anterior obliques, collimator rotations, half-beam blocking with an offaxis prescription point. a. What are the advantages to these other techniques? A: My clinic always uses anterior oblique fields to treat whole brain patients. The anterior oblique fields allow for us to account for beam divergence in the eye. While our physicians still draw blocks to obstruct dose from reaching the eye, accounting for divergence decreases the amount of leakage through the MLC leaves. Our

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physicians have also used couch kicks on occasion to account for divergence to another critical structure. I have not had the opportunity to plan a whole brain with a couch kick as of yet. I also have utilized off-axis prescription points in whole brain treatments. The advantage to this technique is that dose can be delivered to an area that is colder in the brain. b. When designing and evaluating different technique, which one produces the most ideal plan? A: I have found that anterior oblique fields produce the most ideal plan for the patient. As mentioned above, anterior oblique fields account for beam divergence to decrease dose to the eyes and lens. They also provide a nice uniform dose distribution along the skull to ensure that the brain is receiving adequate dose. With the addition of segmented fields, we can decrease hot spots and decrease the dose as necessary around the critical structures. My facility relies heavily on this technique and produces positive results. Which treatment plan covers the target the best? What is the hot spot for that plan? o I think that both the lateral fields and anterior oblique fields cover the brain adequately (100% of the dose covering 97% and 98% of the brain, respectively). Both plans contain a 115% hot spot located posteriorly and inferiorly in the skull. However, after the use of segments on the anterior oblique fields plan, the hot spot was minimized to 104%. Did you achieve the OR constraints as listed above. o I was able to reach the constraints listed on the table my segmenting out hot spots posterior to the eyes and around the spinal cord and brain stem. What did you gain from this planning assignment? o This planning assignment truly helped me to understand the reasoning behind anterior oblique fields. Their use really aids in our ability to limit dose to the eyes. I also gained a better understanding of the variety of ways to treat whole brain patients such as wedges and half beam blocking. What will you do different next time? o Next time, I will try adding a different calculation point to see if the dose improves to areas that are cold. In addition, I might try working with a couch kick to see how divergence plays apart in the treatment of whole brains.