Charity Rogstad

4/3/2017

Planning Assignment (3 field rectum)

Use a CT dataset of the pelvis. Create a CTV by contouring the rectum (start at the anus and stop
at the turn where it meets the sigmoid colon). Expand this structure by 1 cm and label it PTV.

Create a PA field with the top border at the bottom of L5 and the bottom border 2 cm below the
PTV. The lateral borders of the PA field should extend 1-2 cm beyond the pelvic inlet to include
primary surrounding lymph nodes. Place the beam isocenter in the center of the PTV and use the
lowest beam energy available (note: calculation point will be at isocenter).

Contour all critical structures (organs at risk) in the treatment area. List all organs at risk (OR)
and desired objectives/dose limitations, in the table below:

Organ at risk Desired Achieved objective(s) Reference

objective(s)
V35Gy<50% V35Gy 15% RTOG 0529
Bladder V40Gy<40% V40Gy 10% RTOG 0822
V50Gy<5% V50Gy 0% Bismarck Cancer Center

V30Gy<50% V30Gy 0% Bismarck Cancer Center

Small Bowel V40Gy<35% V40Gy 0%
V50Gy<5% V50Gy 0%
Max small bowel dose
was 1608 cGy
Femoral Head <50Gy RTOG 0822
Right Max 48.7 Gy
Left Max 47.8 Gy
Iliac Crest V30Gy<50% V30Gy 37% RTOG 0529
V40Gy<35% V40Gy 27%
Right V50Gy<5% V50Gy 0%

Left V30Gy 47%

V40Gy 26%
V50Gy 0%
 Enter the prescription: 45 Gy at 1.8 /fx (95% of the prescribed dose to cover the
PTV). Calculate the single PA beam. Evaluate the isodose distribution as it relates to
CTV and PTV coverage. Also where is/are the hot spot(s)? Describe the isodose
distribution, if a screen shot is helpful to show this, you may include it.
o Dose distribution for a single PA field is hot on through the posterior 75% of the
PTV. To cover 100% of the PTV with the 95% isodose line I decreased my
prescription to 85%. The Monitor Units (MUs) needed to deliver this dose are
237.9 MUs. The hotspot is 8200 cGy for the 6x PA field and is located at the
superior part of the field close to the skin surface measuring 1.4cm from the skin
surface. Dmax for 6x is 1.5 cm so this is a rationale position for my hotspot.

Figure 1: Hotspot for single posterior 6x beam.

 Figure 2: Axial image of isodose lines for posterior 6x beam.

Figure 3: Sagittal and Coronal images of isodose lines for posterior 6x beam.

Change to a higher energy and calculate the beam. How did your isodose
distribution change?
o For my 15x PA only plan I changed my prescription to 89% to get 100 % PTV
coverage by the 95% isodose line. This is a higher prescription line then in my 6x
 PA only plan due to 15x energy penetrating deeper than the 6x beam. The MUs
needed to deliver this plan are 207.5 MU which again is lower than the 6x plan
due both from the change in energy and the higher prescription isodose line that
was used. My hot spot is 7113 cGy and is located more towards the middle of my
treatment field but still very posterior measuring 2.2 cm from the skin surface.
Dmax for 15x is 2.7 cm so again this is a rational spot for my hotspot to be.

Figure 4: Hotspot for single posterior 15x beam.

Figure 5: Axial image of isodose lines for posterior 15x beam.

Figure 6: Sagittal and Coronal images of isodose lines for posterior 15x beam.

Insert a left lateral beam with a 1 cm margin around the ant and post wall of the
PTV. Keep the superior and inferior borders of the lateral field the same as the PA
beam. Copy and oppose the left lateral beam 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 beams. Describe this dose distribution.
 o There is better dose coverage with the 3 field plan in comparison to the Single PA
plan. The isodose line that I am prescribed to is 92% to achieve 100% PTV
coverage by 95% of the prescribed dose. The dose breaks up into 3 separate
sections, left, middle and right with hotspots on both lateral edges and along the
posterior of the PTV. The hotspot is now 6472 cGy its located at the patients left
lateral skin area. When I measured the distance from the skin surface it was 1.5
cm which is the dmax for a 6x energy.

Figure 7: Hotspot for 6x 3 field (Post, Rlat, Llat) plan.

Figure 8: Axial image of isodose lines for 6x 3 field (Post, Rlat, Llat) plan.

Figure 9: Sagittal and Coronal images of isodose lines for 6x 3 field (Post, Rlat, Llat) plan.

Change the 2 lateral fields to a higher energy and calculate. How did this change the
dose distribution?
o Overall PTV coverage is very similar to the above plan with the exception of less
dose in the lateral portions of the patient. The isodose line that was used is 93%
for 100% PTV coverage by 95% of the prescription. The hotspot which measures
 5266cGy is located close to the PTV just lateral and posterior measuring 8 cm
from the posterior skin edge.

Figure 10: Hotspot for 6x posterior and 15x Right and Left lateral plan.
Figure 11: Axial image of isodose lines for 6x posterior and 15x Right and Left lateral plan.

Figure 12: Sagittal and Coronal images of isodose lines for 6x posterior and 15x Right and Left
lateral plan.
 Increase the energy of the PA beam and calculate. What change do you see?
o Overall PTV coverage is very similar to the previous plan with hot spot of
5197cGy in the exact location of the previous hotspot. The isodose line that was
used is 94% for 100% PTV coverage by 95% of the prescription.

Figure 13: Hotspot for 15x 3 field plan.

Figure 14: Axial image of isodose lines for 15x 3 field plan.

Figure 15: Sagittal and Coronal images of isodose lines for 15x 3 field plan.
 Add the lowest angle wedge to the two lateral beams. What direction did you place
the wedge and why? How did it affect your isodose distribution? (To describe the
wedge orientation you may draw a picture, provide a screen shot, or describe it in
relation to the patient. (e.g., Heel towards anterior of patient, heel towards head of
patient)
o I placed both my 15 degree wedges heel to the patients posterior, I chose this
position because I needed dose anteriorly due to having a posterior beam but not
having an anterior beam. The coverage and hot spots are much better than the
plan without a wedge. My hotspot is now 5009 cGy. The isodose line that was
used is 96% for 100% PTV coverage by 95% of the prescription. Another
observation is that my lateral MUs increased by about 30cGy on each field in
comparison to the plan with lateral fields that didnt have a wedge.

Figure 16: Wedge position for 15x 3 field plan with 15 degree wedge on the laterals.
Figure 17: Hotspot for 15x 3 field plan with 15 degree wedge on the laterals.
Figure 18: Axial image of isodose lines for 15x 3 field plan with 15 degree wedge on the
laterals.

Figure 19: Sagittal and Coronal images of isodose lines for for 15x 3 field plan with 15 degree
wedge on the laterals.
 Continue to add thicker wedges on both lateral beams and calculate for each wedge
angle you try (when you replace a wedge on the left, replace it with the same wedge
angle on the right). What wedge angles did you use and how did it affect the isodose
distribution?
o Instead of 15 degree wedges I added 30 degree wedges and altered my
prescription line to 97%. My hotspot is now located about 2.7 cm from the left
lateral skin edge it measures 5179cGy. At the superior and inferior edges of my
PTV the 95and 100% isodose lines are bowing in compared to the 15 degree
wedge plan.

Figure 20: Hotspot for 15x 3 field plan with 30 degree wedge on the laterals.
Figure 21: Axial image of isodose lines for 15x 3 field plan with 30 degree wedge on the
laterals.

Figure 22: Sagittal and Coronal images of isodose lines for 15x 3 field plan with 30 degree
wedge on the laterals.
 o The use of a 45 degree wedge increased my hotspots throughout my plan with a
hotspot of 5546 cGy at the left lateral skin edge similar position to the 30 degree
wedge plan. The isodose line that was used is 97% for 100% PTV coverage by
95% of the prescription. In comparison to my plan with no wedge the MUs need
for this plan have more than doubled due to the use of the 45 degree wedge. As
seen in the 30 Degree wedge plan the isodose lines are bowing in at the Sperior
and Inferior areas of the PTV. Also the posterior edge of the PTV doesnt have as
good of coverage as the 15 degree wedge plan.

Figure 23: Hotspot for 15x 3 field plan with 45 degree wedge on the laterals.
Figure 24: Axial image of isodose lines for 15x 3 field plan with 45 degree wedge on the
laterals.

Figure 25: Sagittal and Coronal images of isodose lines for for 15x 3 field plan with 45 degree
wedge on the laterals.
 o The use of a 60 degree wedge increased my hotspots at the anterior and lateral
aspects of my plan with a hotspot of 6678 cGy at the left lateral skin edge similar
position to the previous wedge plan. The isodose line that was used is 90% for
100% PTV coverage by 95% of the prescription. In comparison to my plan with
no wedge the MUs need for this plan have more than tripled due to the use of the
60 degree wedge and 90% line instead of 94% line that was used for the no wedge
plan.

Figure 26: Hotspot for 15x 3 field plan with 60 degree wedge on the laterals.
Figure 27: Axial image of isodose lines for 15x 3 field plan with 60 degree wedge on the
laterals.

Figure 28: Sagittal and Coronal images of isodose lines for for 15x 3 field plan with 60 degree
wedge on the laterals.
 Now that you have seen the effect of the different components, begin to adjust the
weighting of the fields. At this point determine which energy you want to use for
each of the fields. If wedges will be used, determine which wedge angle you like and
the final weighting for each of the 3 fields. Dont forget to evaluate this in every slice
throughout your planning volume. Discuss your plan with your preceptor and
adjust it based on their input. Explain how you arrived at your final plan.
o I used 15x on all three fields, I put 45 degree wedges on both lateral fields with
the heel towards the patients posterior. My weighting is 40% from the post and
30 % from each lateral. My hotspot is 4904 cGy and is located near the anterior
portion of the PTV on the right side. The isodose line that was used is 98% for
100% PTV coverage by 95% of the prescription.

Figure 29: Hotspot for 15x 3 field plan with 45 degree wedge on the laterals. Posterior beam is
weighted 40% and lateral beams are each weighted 30%.
Figure 30: Axial image of isodose lines for 15x 3 field plan with 45 degree wedge on the
laterals. Posterior beam is weighted 40% and lateral beams are each weighted 30%.

Figure 31: Sagittal and Coronal images of isodose lines for 15x 3 field plan with 45 degree
wedge on the laterals. Posterior beam is weighted 40% and lateral beams are each weighted 30%.
 Lt Femoral head
PTV
Rt Femoral head

Bladder

Small Bowel

Figure 32: DVH for 15x 3 field plan with 45 degree wedge on the laterals. Posterior beam is
weighted 40% and lateral beams are each weighted 30%.

Lt Iliac crest

PTV

Rt Iliac crest

Figure 33: DVH for 15x 3 field plan with 45 degree wedge on the laterals. Posterior beam is
weighted 40% and lateral beams are each weighted 30%.
4 field pelvis

Using the final 3 field rectum plan, copy and oppose the PA field to create an AP field.
Keep the lateral field arrangement. Remove any wedges that may have been used.
Calculate the four fields and weight them equally. How does this change the isodose
distribution? What do you see as possible advantages or potential disadvantages of adding
the fourth field?

The isodose lines are more conformal to the PTV creating a four field box look. The isodose line
that was used is 98% for 100% PTV coverage by 95% of the prescription.There is no streaking
of the 80% line on the lateral aspect of the patient but there is streaking noticed with the 75%
line. The coverage is more uniform throughout the PTV but the bladder and small bowel also
have increased dose with this plan. All the organs at risk are within acceptable ranges so even
though I think this looks like a better plan I would present both options to the physician for his
final review.

Figure 34: Hotspot for 4 field plan (Anterior, Posterior, Left Lateral, and Right Lateral).
Figure 35: Axial image of isodose lines for 4 field plan (Anterior, Posterior, Left Lateral, and
Right Lateral).

Figure 36: Sagittal and Coronal images of isodose lines for 4 field plan (Anterior, Posterior, Left
Lateral, and Right Lateral).