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Pelvis Clinical Lab

Plan 1:
• Describe the isodose distribution.
The distribution is forward-directional (posterior to anterior) from where the beam enters the
patient.

• Where is the hot spot and what is it?


The hotspot, defined by ICRU as an area of dose outside of the PTV receiving greater than 100%
of the dose,1 lies posteriorly. The maximum point dose is 165.9%.

• What do you think creates the hot spot in this location?


The hotspot location is 1.4cm from the posterior patient surface - at approximately dmax depth
for 6MV (the beam energy used) – where there is electronic equilibrium. As the dose is
normalized to the center of the PTV, the maximum dose deposition occurs at dmax depth.

• Using your DVH, what percent of the PTV is receiving 100% of the dose?
44.3% PTV volume is receiving 100% of the dose.

Plan 2:
• Describe how the isodose distribution changed and why?
The lower dose isodose lines penetrate further within the patient, and the interval between them
is larger, due to the higher energy used (10MV). The hotspot dose has decreased.

• Using your DVH, what percent of the PTV is receiving 100% of the prescription dose?
48.8% PTV volume is receiving 100% of the dose.

Plan 3:
• Describe the isodose distribution. What change did you notice?
The isodose lines now spread out laterally, incident with the lateral beams. There is less dose
anteriorly, but areas of high dose where the beams enter laterally, at approximately dmax depth.
Areas with the highest dose occur at the overlap between the posterior and lateral beams,
posteriorly.

• Where is the hot spot and what is it?


113.4%, posteriorly at the overlap between posterior and right lateral beams.

• What do you think creates the hot spot in this location?


The contribution of entry dose from both the right lateral and posterior field, along with exit dose
from the opposing left lateral field, creates an area of high dose. Along the central axes of the
lateral beams, the patient separation is slightly larger on the right side of the patient than the left.
This means that there is more tissue to penetrate before reaching the normalization point
(isocenter), and so the dose deposition within the RLAT beam is higher. The hotspot is located
on this side of the isocenter, and there are areas of 107% laterally near the right side of the
patient surface, that are not present on the left side of the patient at dmax depth.
Plan 4:
• Describe how this change in energy impacted the isodose distribution.
The higher isodose lines are now concentrated more centrally within the patient, around the PTV,
at the intersection of all 3 beams. The hotspot is further reduced, but located in the same place as
Plan 3, as the beam arrangement or weighting hasn’t changed.

• What are the benefits of using a multiple-field planning approach? (Refer to Kahn, 5th ed, Ch
11.5B)
With the exception of some palliative treatment intents and the treatment of superficial tumors
such as skin cancers, multiple beams provide superior tumor/PTV coverage. Using parallel-
opposed fields can help with achieving dose at significant depth – i.e. at mid-plane depth - within
a patient, but the beam entry dose and the overlapping beam exit dose creates areas of high dose
within normal tissue along the beam path. Using more than 2 fields will help achieve better
conformity of dose distribution and avoid these areas of high dose outside of the treated volume.2

• Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the
prescription dose?
54.8% PTV volume is receiving 100% of the dose, compared to 48.8% in Plan 2.

Plan 5:
• What was the final weighting choice for each field?

Table showing the relative weighting of the three fields.

• What was your rationale behind your final field weight?


The LLAT is weighted a little more than the RLAT to compensate for the difference in patient
separation along the central axis of these beams. This helps to make the dose more
‘homogenous’ in that the doses laterally are more balanced. The weighting of the POST beam
was a balance between PTV coverage and hotspots posteriorly. At this weighting, the 95%
isodose line doesn’t cover the PTV anteriorly. However, weighting the laterals more heavily in
order to increase dose anteriorly also increases the integral dose laterally to over 95% -
irradiating large areas of normal tissue to the same dose as the PTV volume. The hotspot with
this weighting is 115.2%, with large areas of 110% throughout the rectum, but the 70% isodose
line is largely confined to the intersection of the three beams.
Axial slice, showing the global maximum dose. The 70% isodose line is cyan. The 95% isodose line is yellow.

Plan 6:
• What final wedge angle and orientation did you choose? To define the wedge orientation, describe
it in relation to the patient. (e.g., Heel towards anterior of patient, heel towards head of patient..)
I chose 30 degree virtual wedges – both thick-end posterior. This attenuates the dose posteriorly,
reducing the area that was previously 110% without wedges, and allows more of the beam to
pass through unattenuated anteriorly, which increases the 95% coverage in the anterior aspect of
the PTV. This also increases lateral integral dose anteriorly, but not above 80%. The patient
separation and contour make it difficult to achieve adequate coverage, and dose conformality and
homogeneity under these conditions. The hotspot is now reduced to 109%, although there are
still significant (>15mm, as per ICRU)1 areas greater than 107% of the prescribed dose. Using
wedges with a greater wedge angle would reduce this dose further, however it would be at the
cost of increasing lateral integral dose.

Axial slice, showing the global maximum dose. The 70% isodose line is cyan. The 95% isodose line is yellow.

• How did the addition of wedges change the isodose distribution?


The patient contour suggests that lateral wedges could be used thick-end anterior to compensate
for the slope of the contour, where the patient separation is greater posteriorly than anteriorly.
This would attenuate the beam anteriorly, providing better dose homogeneity ant-post.
However, the presence of the posterior beam negates the effect of the patient contour on the
lateral beams, and instead concentrates the higher doses posteriorly, due to beam overlap. The
addition of wedges, thick-end posterior helps to attenuate the beam posteriorly, reducing the dose
in this area. The beam is attenuated less through the thin-end, which is located anteriorly. This
has the effect of moving the dose distribution anteriorly, effectively evening out the dose, or
making it more homogenous across the PTV.

• According to Kahn, what is the minimum distance a wedge or absorber should be placed from the
patient’s skin surface in order to keep the skin dose below 50% of the dmax? (Refer to Kahn, 5th
ed, Ch. 11.4)
15cm. In most linacs, a physical wedge is placed at least 50cm from the isocenter, however the
treatment SSD may mean that the patient is much closer to the head of the machine than that.2

Plan 7:
• What energy(ies) did you decide on and why?
The ANT, RLAT, LLAT and POST beams are all 18MV. I decided on 18MV for the beams
because of the patient separation. Laterally, the separation is 39cm, and higher energy beams
penetrate further in tissue. I considered using 6MV posteriorly, since the PTV is located more
posteriorly within the patient, however this would increase the likelihood of needing to increase
the weight of the ANT beam or to use lateral wedges to ensure adequate anterior coverage of the
PTV.

• What is the final weighting of your plan?


Since the PTV is located relatively posteriorly, I weighted the ANT beam enough to ensure
adequate coverage of the anterior aspect of the PTV, without depositing a lot of dose anteriorly
in adipose tissue or bowel. It is therefore weighted a little more lightly than the POST beam. The
lateral beams are weighted almost evenly – there is a small difference to compensate for the
difference in patient separation on each lateral side.

• Did you use wedges? Why or why not?


There are no wedges in this plan. Weighting the beams as they are ensures adequate coverage
and homogeneity of dose, so I felt wedges were not required. Not using wedges reduces the
complexity of the plan – especially for calculation purposes, but also reduces the burden on the
therapists if they are using manual wedges.

• Where is the region of maximum dose (“hot spot”) and what is it?
The global maximum dose is 106.4% of the prescribed dose but is located within the PTV. This
is a small area, however, not considered clinically significant as it doesn’t exceed 2cm2.2 The
maximum target dose, and hotspot that are considered clinically relevant are 106%. One of these
areas is located within the PTV, on the anterior, left part of the PTV (see diagram) – the
maximum target dose. The hotspot that is outside the target is located at the posterior, right side
of the field, just outside of the PTV. The locations of these areas of 106% is deliberate – it is the
most homogenous dose distribution. The area of higher dose is spread out as much as possible
throughout the treatment field, instead of being concentrated in one area.
Axial slice of patient demonstrating dose distribution and location of areas of 106% of the prescription dose.

• What is the purpose of normalizing plans?


Normalization is the process in which the dose distribution is scaled so that it can be presented in
a consistent manner - as a percentage of the prescription dose. Normalization is the
determination of where 100% of the prescribed dose should be, and the resulting distribution of
absorbed dose is calculated relative to that. Normalization can be achieved in several different
ways – setting 100% of prescribed dose at body/target maximum or minimum dose; requiring
that a particular dose percentage covers a particular target volume percentage; setting 100% of
the prescribed dose at a particular point; or entering an overall percentage value.3

• What impact did you see after normalization? Why?


After normalizing the plan so that 100% of the dose was covering 95% of the volume, the overall
dose increased. Whichever isodose line encased 95% of the PTV (say, 97%) was instead set to
100% of the prescribed dose. Therefore, all the doses were adjusted accordingly (by 3% for
example). The dose distribution didn’t change, as nothing affecting the dose was changed. The
only thing that changed was how the absorbed dose was displayed.
• Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and coronal
views. Show the PTV and any OAR.
• Include a final DVH. Be sure to include clear labels on each image (refer to the Canvas Clinical
Lab module for clear expectations of how to format your DVH).
• If you were treating this patient to 45 Gy, use the table below to list typical organs at risk, critical
planning objectives, and the achieved outcome. Please provide a reference for your planning
objectives.

Organ at Risk (OAR) Desired Planning Objective Planning Objective


Outcome
Bladder V45<35% RTOG04184 V45 = 86%
V65<50% QUANTEC5 V65 = 0
Rectum V30<60% RTOG0418 V30 = 94%
V50<50% QUANTEC V50 = 0
Lt. Femoral head V30<15% RTOG0418 V30 = 15%
V50<5% RTOG Prostate Group6 V50 = 0
Rt. Femoral head V30<15% RTOG0418 V30 = 16%
V50<5% RTOG Prostate Group V50 = 0
Bowel V40<30% RTOG0418 V40 = 36%
V45<195cc QUANTEC V45 = 391cc

References:

1. Jones D. ICRU Report 50 - Prescribing, Recording and Reporting Photon Beam Therapy. Med Phys.
1994;21(6):833-834. doi:10.1118/1.597396

2. Khan F, Gibbons J. Khan's The Physics Of Radiation Therapy. 5th ed. Philadelphia: Wolters Kluwer; 2016.

3. Eclipse Photon And Electron Instructions For Use. Varian Medical Systems; 2017.

4. Jhingran A., et al. A Phase II Study of Intensity Modulated Radiation Therapy (IMRT) to the Pelvis +/
Chemotherapy for Postoperative Patients with either Endometrial or Cervical Carcinoma. Radiation
Therapy Oncology Group (RTOG) | Clinical Trials | Study Number 0418.
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0418. Published 2019.
Accessed February 26, 2019.

5. Bentzen SM, Constine LS, Deasy JO, et al. Quantitative Analyses of Normal Tissue Effects in the Clinic
(QUANTEC): an introduction to the scientific issues. International Journal of Radiation Oncology Biology
Physics. 2010;76; 3-9.

6. Lawton C, Michalski J, El-Naqa I et al. RTOG GU Radiation Oncology Specialists Reach Consensus on
Pelvic Lymph Node Volumes for High-Risk Prostate Cancer. International Journal of Radiation
Oncology*Biology*Physics. 2009;74(2):383-387. doi:10.1016/j.ijrobp.2008.08.002