B.K.

Rectum 3D treatment planning Summary

Pt has stage IIIB rectum cancer. The prescription order is 1.8 Gy/fraction, 25
fractions, total dose 45 Gy; boost daily dose was 1.8Gy/fraction for 3 fractions, total
dose was 5.4Gy. Use department standards normal tissue volume constrains. A 3D
conformal treatment plan was decided per physician.
1. First of all, I made sure the dose for the plan. I will create two treatment plans
with sequential phase 1 1.8 Gy/fraction for 25 fraction and phase 2 1.8
Gy/fraction for 3 fraction which contributed the total dose to the target region
as 45Gy+5.4Gy=50.4Gy.
2. I started with the phase 1 1.8 Gy/fraction, 25 fractions, total dose 45 Gy.
3. Based on the volumes drawn by physician, a set of structures including OARs:
bladder, prostate, bilateral femurs, bowels, and the whole rectum was
created and contoured.
4. User origin was set to at isocenter. Preference points were created with the
calculation point at isocenter as a normalization point and a tracking point
without location as primary reference point.
5. I planned to add 4 beams from bilateral anterior oblique and posterior oblique
directions to avoid the beam entrance through critical structures: prostate
and bladders.
6. I added the first beam RAO at 315 degree with new DRR and MLC fitted PTV
4500 cGy with 1.0 cm margin. The same way to create the beams of RPO at
225 degree, LAO at 45 degree, and LPO at 135 degree.
7. I selected AAA as the calculation algorithm at 100% prescribed percentages.
8. After calculation, the dose max was 110.7%. I turned on the field weights and
adjusted each beams weight while watching the shift of the isodose lines. I
was able to cool down the plan to 106.1% with the hot spot at the posterior of
the body and the best isodose line distribution I could make.
9. From the DVH, it was obvious that the dose received in bladder and prostate
were very high. 95% volume was covered by 94.7% prescription dose.
Overall, I was not satisfied with this plan.
10.I then created another plan with 4-field box arrangement which was AP, PA,
and bilateral beams. MLC fitted the PTV 4500 cGy with margin of 1.0cm
bilateral sides and 1.5 cm superior and inferior. Manually blocked MLC to
spare more prostate and bladder.
11.After calculation and beam weighting adjustment, the dose max was 104.8%
with 95% volume covered by nearly 98% prescription dose. The maximum
prostate dose was 43.56Gy, and the maximum bladder dose was 46.35 Gy.
12.From the dose distribution and PTV coverage, I like this plan better than
previous one. So I compared both plan under plan evaluation. From DVH, the
plan with beam entered from oblique direction is hotter, and had higher dose
in bladder and rectum, but lower dose in bilateral femurs than the plan with 4
box fields. The PTV coverage was comparable.
13.I then worked on phase 2 the boost plan.

14.With the same energy but total dose of 540 cGy in 3 fractions, I had 4 beams:
AP, PA, Rt Lat, and Lt Lat. DRR and MLC were added and MLC were fitted to
PTV 5040 cGy with the margin of 1.0cm in general but 0.5 cm to the
directions close to the bladder and prostate.
15.Plan was calculated by AAA algorithm. All four field weights were adjusted to
achieve good target coverage and minimum plan dose.
16.A plan sum with phase 1 and phase 2 were inserted and evaluated by
checking the dose constrains in the bladder, prostate, and bilateral femurs,
the distribution of the isodose lines from transversal, coronal, and sagittal
views, and low dose spread.
17.Mary reviewed the plan and agreed with the dose coverage and constrains in
OARs.