Kevin Kocos

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 V80 < 15% V80 = 0% Yes
V75 < 25% V75 = 0% Yes
V70 < 35% V70 = 0% Yes
V65 < 50% V65 = 0% Yes
Right and Left Femur Max Dose < 50 Gy L = 4738 cGy; R = 4694 Yes
V45 < 25% L = 3.48%; R = 2.76% Yes
V40 < 40% L = 8.59%; R = 8.37% Yes
Max Dose < 50 Gy Max Dose = 4091 cGy Yes
Small Intestine 100 cc < 40 Gy 100cc = 1373 cGy Yes
180cc < 35 Gy 180cc = 926 cGy Yes
65cc < 45 Gy 65 cc = 1217 cGy Yes
*Constraints used from RTOG protocols for conventional fractionation that are posted at the
Minneapolis Veterans Affair Radiation Oncology Clinic

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.

The hot spot is located directly posterior to the sacrum between S3-S4 and is 6444 cGy.
The isodose lines are distributed in a somewhat uniform arch shape. The higher dose
lines are conformed tightly toward the middle of the PTV while the low dose lines reach
farther toward the anterior surface of the patient.
 Figure 1: Single PA Beam

Change to a higher energy and calculate the beam. How did your isodose distribution change?

The isodose lines kept the same arch shape but each line has stretched farther anteriorly.
This has created slightly better coverage for the PTV and the 50% isodose line now
reaches the anterior surface of the patient.

b. 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.

The isodose lines form an almost perfect rectangular shape that encompasses the entire
posterior half of the patient. The anterior portion of the isodose rectangle sits anterior to
the to the PTV while the posterior portion of the rectangle lies posterior to the sacrum.
The isodose lines of 4050 cGy to 4410 cGy also break off laterally. There is also a
portion of 4500 cGy isodose lines that break off laterally however the concentration is
much greater on the patients left side.
 Figure 2: 3 field 6 MV; Equal beam weighting

c. Change the 2 lateral fields to a higher energy and calculate. How did this change the
dose distribution?

The hips were now significantly spared from the higher isodose lines. The hips now do
not have any dosing from the 4050 cGy, 4275 cGy, 4410 cGy and the 4500 cGy lines.

d. Increase the energy of the PA beam and calculate. What change do you see?

There was better overall coverage of the PTV from the 90% and greater isodose lines.
Also there slightly more sparing of the hips in regards to the 3150 cGy isodose line.

e. 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..)

I placed the 2 lateral 15 wedges with the heels facing the posterior of the patient in order
to cool off the areas where the beams intersect. The addition of the wedges offered better
overall coverage for the PTV while also having a hotspot that is 40 cGy cooler.

f. 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?
30 Lateral Beam Wedges: The higher isodose lines around the PTV have expanded to
offer better overall coverage. The hips have began to get hotter as a small portion of the
4050 cGy isodose line is reappearing laterally on the patient.

Figure 3: 30 lateral wedges

45 Lateral Beam Wedges: The plan has become significantly hotter as the 4500 and
4590 cGy isodose line expands and covers a greater area in bladder, prostate and hips.
The 4050 cGy isodose line has now expanded within the hips as well and the hotspot has
increased almost 200 cGy.
Figure 4: 45 lateral wedges

60 Lateral Beam Wedges: The plan has become substantially hotter at this point, with
all isodose lines spilling over into the hips. The hotspot has also increased approximately
1000 cGy with the 60 wedges.
 Figure 5: 60 Lateral beam wedges

g. 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.

In discussing with the lead dosimetrist, we have both come to agreement that the best
parameters for this plan use the 3 fields with an 18 MV energy and a 15 lateral wedge
pair. The beam weighting for this plan is 38% posterior and 31% for both of the lateral
fields. These parameters achieved the second best overall PTV coverage which was
97.67% while sparing the hips and surrounding tissue. This plan also gave us a very
reasonable hotspot that is about 9.4% over the prescription dose.

h. 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: 3 field w/ 15 lateral wedge pair; Posterior 38% and lateral fields 31%

Figure 7: DVH of 3 field w/ 15 lat wedge pair; Posterior 38%, lateral fields 31%
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 4 field plan offers the best overall PTV coverage out of all of the plans which is 99.23%
without any increase in the hotspot. The 4 field plan also offers better sparing of the hips having
only the 50% isodose line reaching out laterally. However there is also the 50% isodose lines
giving dose anteriorly to the patient, making it the biggest drawback. Due to the anterior dose
from the 4 field, I would still prefer the 3 field arrangement with 15 wedge pair.

Figure 8: 4 Field Pelvis

Figure 9: 4 Field Pelvis DVH