Nick Piotrowski Planning Assignment (Prostate)

Target organ(s) or tissue being treated: Prostate Prescription:___180cGy/Fx x 25 Fx = 4500cGy_________________

Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below): Organ at risk Bladder Rectum Lt Femoral Head Rt Femoral Head Desired objective(s) 50% < 60Gy 45% < 40Gy 40% < 40Gy 25% < 45Gy 40% < 40Gy 25% < 45Gy Achieved objective(s) 50% < 35.0Gy 29.1% < 40Gy Max Dose 45.0Gy Max Dose 20.9Gy Max Dose 20.7Gy

Contour all critical structures on the dataset. Expand the prostate structure by 1cm in all directions and call it PTV. Place the isocenter in the center of the PTV. Create a single AP plan using the lowest photon energy in your clinic and 1.5cm margin around the PTV for blocking. 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 look at all of them): Plan 1: Create a beam directly opposed to the original beam (PA) (assign 50/50 weighting to each beam) a. Where is the region of maximum dose (hot spot)? What is it? With a hot spot of 114.4%, the region of maximum dose is primarily in the posterior portion of the patient. b. What are the doses to the rectum, bladder and femoral heads (evaluate the DVH)? Rectum is currently reaching a maximum dose of 47.0Gy, and almost 87% is getting 40Gy, which is much higher than our restrictions. The bladder is receiving a maximum dose of 46.1Gy, and 50% is only getting 42.1Gy, well below the given tolerance. The left and right femoral heads are almost identical, receiving a maximum dose of only 1.53Gy. Plan 2: Increase the energy of both beams to the highest photon energy available.

a. How did the isodose distribution change with the higher energy? The 18 megavoltage(MV) energy forced the isodose lines laterally, providing better coverage for the 100% isodose line. It also pushed the dose a little deeper into the patient, eliminating the hot spots near the posterior surface. The 114.4% global max was dropped down to 104.2%. b. Did the doses to the rectum and bladder change? The dose to the rectum was decreased slightly, with a maximum dose of 46.3Gy, and 85% of the organ receiving 40Gy. While it is better than before, it does not meet our restrictions. The bladder dose also decreased slightly with a 45.5 maximum dose, and 50% is now receiving 40.0Gy. c. If you change the weighting ratio, how does it affect the dose distribution? When increasing the beam weighting of the AP beam, the isodose lines are pulled marginally closer to the anterior portion of the body. In doing this, we are able to spare more of the rectum but add some to the bladder dose. Plan 3: Add a Rt lateral field. Create a tighter blocked margin posteriorly along the rectum (try using 0.7cm vs. 1.5cm). Now, create an opposed beam, or a Lt. lateral. Assign even weights to all the beams (which should now be 4 beams) a. What is the biggest change you noticed with the isodose lines? The dose along the superficial portions of the anterior and posterior regions has dramatically decreased. The dose distribution has spread out laterally creating more of a square shape in the center of the patient instead of the previous rectangle running anterior to posterior. Once again the hot spot has been decreased to 102.3% by taking dose off the posterior region. b. What happened to the rectal, bladder and femoral head doses? Which structure received the biggest dose change? Why? The dose to the rectum has severely decreased to a maximum dose of 44.9Gy, and only 26.6% of the organ now receiving 40Gy. The maximum dose to the bladder has stayed relatively constant with a maximum dose of 45.7Gy, and with 50% of the structure reaching 34Gy. Once again the left and right femoral head doses are relatively similar, getting maximum doses of 27.5Gy and 27.1Gy respectively. Fortunately, the doses are still within tolerance as only 25Gy is reaching 25% of the volume. The largest changes came from both the femoral heads as well as the rectum. By taking the dose from the posterior and adding it to the laterals, the increase in dose to the femoral heads and decreased dose to the rectum was expected. With two beams taking some of the weight off of the PA beam, the dose distributed to the posterior is dramatically less.

Plan 4: Adjust the weighting of the beams to try and achieve the best possible dose distribution. Which treatment plan covers the target the best? What is the hot spot for that plan? The final plan that I created the best dose distribution covering the target most efficiently. While I was missing some of the posterior portion of the PTV with the 100%, the 98% isodose line covered the entire PTV. The plan resulted in a 102.3% hot spot that was located on the PTV in the center of the patient. Did you achieve the OR constraints as listed in the table on page 1? List them in the table Yes What did you learn from this planning assignment? The only way to avoid overdosing some critical structures is by spreading the dose across numerous beams. If a beam shooting directly through an organ at risk is having harmful effects, there is always another angle that can be used to take some of the dose. Unfortunately that does not always mean it is going to work out perfectly. Without moving the reference point or using wedges there was no way I could cover the posterior portion of the PTV with 100% of the dose. Had I done so, I would have sacrificed the rectum in the process.

What will you do differently next time? If I were creating this plan from scratch I would start out with a minimum of 4 beams and potentially a 6 beam IMRT. It is nearly impossible to get the coverage you want while keeping the bladder and rectum below tolerance by using a simple AP/PA method. I may also look to add wedges on the lateral beams, or move the reference point posteriorly to bring the dose distribution deeper.

Still curious? Try adding 2 more beams, so youll have 6 total beams on the plan (PA, RPO, RAO, AP, LAO, LPO). Assign even weighting to all 6 beams. a. Now what does the isodose distribution look like? Is it more or less conformal than a 4 field plan? It is definitely more conformal than a 4 field plan as the isodose lines are shaped more like a circle around the PTV. The coverage is better and needs less work to achieve better results. b. What are the doses for the critical structures? The rectum is receiving a maximum dose of 45.3Gy but unfortunately 57% of the organ is reaching 40Gy. The bladder is also higher with a maximum dose of 45.9Gy and 50% of the dose getting 35.2Gy. Finally, the left and right femoral heads are reaching maximum doses of 27.6Gy and 28.3Gy respectively. c. What are the advantages to using this technique? Disadvantages? Using a 6 field plan will improve the coverage of the PTV with ease. It is a more conformal plan and can potentially produce better results. However, without using beam weighting and maybe collimator rotations, the critical structures are receiving more than the necessary dose. It also presents for a more difficult plan to treat, as the time the patient is on the table increases.