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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 objective(s) Achieved objective(s)

Bladder 15% 45 Gy 15% = 38 Gy
Max 50 Gy Max = 44 Gy
Bowel 180cc 35 Gy 180cc = 3.4 Gy
Max 50 Gy Max = 43 Gy
Femoral Head 40% 40 Gy Rt: 40% = 30 Gy, max = 38 Gy
Max 50 Gy Lt: 40% 28 Gy, max = 37 Gy

a. 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.
6x was used. Since the plan was normalized to 95% of the dose covering the PTV, the
PTV was completely covered by the 95% isodose line; 97% of the PTV was covered by
the 100% isodose line. CTV was completely covered by 100% isodose line. To achieve
such coverage there was an extensive hot spot of 152.5% on the sacrum and an overall
large area of dose over 100%.
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Figure 1. PA field borders and isodose lines, 3 views single PA field, 6x

b. Change to a higher energy and calculate the beam. How did your isodose distribution
change?
Energy was changed to 10x. The coverage remained very similar, but the hot spot was
reduced to 139.4%.

Figu
re 2. Comparison of isodose lines. On the left 10x, on the right 6x
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c. 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.
Excellent target coverage, but a very large area of dose above 100%; global hot spot was
reduced to 132%. The bladder dose decreased significantly; dose to femoral heads
increased, and there was a lot of dose deposited on the lateral sides of the patient.

Figure 3. Lat filed borders and isodose lines, 3 views, using 6x, PA and lateral fields

d. Change the 2 lateral fields to a higher energy and calculate. How did this change the dose
distribution?
Dose outside the PTV on the lateral aspects of the patient reduced. Hot spot reduced to
125.2%. Coverage remains at 95% of dose covering the PTV.
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Figure 4. Comparison of isodose lines. On the left lateral fields using 6x, on the right lateral fields using 10x

e. Increase the energy of the PA beam and calculate. What change do you see?
Energy used for all three fields was changed to 10x. No significant changes were noticed.

f. 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.)
To insert wedges on the lateral fields, the collimator was rotated to 90. Wedges were
placed with toes facing the anterior of the patient to even out the isodose lines and avoid
hot spots at the common angles between the lateral fields and the posterior field.
The overall shape of the isodose lines remained unchanged; the hot spot went down to
117.9% and the dose on the lateral sides of the patient was further minimized.
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Figu
re 5. 10 wedges on lateral beams, toes facing anterior of the patient

g. 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?
Wedge angles used were 10, 20, 30, 45, and 60. As the wedge angle increased, the
hot spot decreased. Dose on the lateral aspects was decreased and shifted closer to the
wedge toes. When using the largest, 60 wedge, the isodose lines were shifted anteriorly
and more dose was pushed to the sides towards the wedge toes.

h. 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.

For the final plan, I used 6x for the PA field and 10x for the lateral fields with weighting
of 0.535:0.231:0.234 PA: Lt Lat: Rt Lat. 60 wedges were used for the lateral beams
with toes facing the anterior of the patient. MLCs were added to the PA field to block the
femoral heads.
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i. In addition to the answers to each of the questions in this assignment, turn in a copy of
your final plan with the isodose distributions in the axial, sagittal and coronal views.
Include a final DVH.

Figure 6. MLCs blocking femoral heads from the PA field; isodose distributions for the final plan, 3 views
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Figure 7. Final DVH

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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?
Using a four-field box technique has advantages and disadvantages when compared to a three-
field dose distribution. The coverage and the hot spot are comparable. The distribution is slightly
more conformal when using four fields, and the dose to the femoral heads is decreased. A
potential disadvantage is the increased dose to the bladder.
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Figure 8. Comparison DVH four-field box vs three fields