DOS Clincial Practicum I

Pelvis Lab
Ashley Coffey
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
Bladder

Desired objective(s)
>6500 cGy

Achieved objective(s)
2305 cGy

Small Bowel

>4000 cGy

1690 cGy

Femoral Heads

>5200 cGy

Rt 2808/Lt 3125 cGy

Colon

>4500 cGy

*4648 cGy
(Colon is covered by
entire tx field and blocks
were not used)

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.
With just a PA beam
at 6 MV, the isodose lines will not penetrate far into the

patient. They tend to bunch tightly near the entry point

of the beam. Since we are using a single angle, the hot
spot will be near the
posterior surface of
the patient. It
measures to be about
1.5cm deep on the
upper left corner of the
field.

b. Change to a higher energy and

calculate the beam. How did
your isodose distribution change?
While the isodose lines have penetrated slightly farther,
the dose does not cover much of the PTV. They still
remain uniform like 6MV. This hasnt changed because we
are still only incorporating one beam. The hot spot is in
the upper medial
portion of the field
and is about 2.3cm
from the surface of
the patient.

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.
With resorting back to 6MV, the isodose lines are shallower again.
However, the tumor is covered significantly better with the laterals
added versus the single posterior angle. Less normal tissue is
irradiated in the anterior portion with more normal tissue being
treated on the lateral sides. The hot spot now is in the most
posterior right corner of the fields; this is due to the less bone in
the region and where the PA and right lateral beam meet.

d. Change the 2 lateral fields to a higher energy and calculate. How did
this change the dose distribution?
When you increase the lateral
energy, the dose lines increase
to completely encompass the
PTV in the 80% line (hot pink).
The tumor is receiving better
coverage due to the thickness of
the lateral anatomy, such as
muscle and femoral heads. The
lateral fields are better able to
penetrate through the bone with
18MV.
e. Increase the energy of the PA beam and calculate. What change do you
see?
While the PTV is still completely covered by the 80% isodose line,
increasing the PA beam will push the other lines, such as those
between 88% and 95%, further to cover more of the tumor.
Therefore, this plan is increasingly better to provide higher dosage
to the tumor in its entirety. The PTV coverage is increased by about
14%. However, the bladder receives more dose due to higher
penetration with 18MV.

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..)

The heel, or thickest part of the wedge, is facing the posterior end
of the patient. We are trying to push the dose higher since we are
not delivering an AP field. This will help to cover the anterior
portion of the PTV. Therefore, the isodose lines will be pushed
deeper into the body with the heels facing in in this direction. Thus
far, this is still the best option as far as tumor coverage when
analyzed to the previous sections.

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?
As I continued to add wedges, the isodose lines continued to
penetrate farther. The available wedges are 15, 30, 45, and
60 . The 15 wedge did improve the isodose lines but not
enough to receive adequate coverage. While using the largest
wedge (60 degrees) provided nice coverage of the tumor in
some areas, the lines
were pulling and
streaking over the
PTV in other slices;
this is due to overwedging the field.
Also, some of the
normal tissues and
structures increased
in dose by at least
200cGy while the PTV
was not receiving
enough coverage.
Therefore, after analyzing each slice, the 45 wedge provided
the most coverage while sparing some of the other tissues.
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.

After decided that 45 wedges are the best option to increase

coverage without over-wedging, I started adjusting the beam
weighting until I received acceptable PTV coverage. I ended
with 25% beam at the PA and 37.5% at each lateral field. This
provides 83.05% intended dose coverage to the PTV. However,
the PTV should be receiving 90% and higher. Although not
discussed in this lab, if the prescription is changed to 93%, the
coverage becomes 99.82% which is better. The consequences
of this are having a 7% hot spot versus a 5% hot spot (AT VCU,
they plan to the max dose). The hot spot is also in the
posterior and superior part of the right iliac crest, which
wouldnt pose any additional problems if it were 7% hot.
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.

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?

With prescribing to 95% and maintaining equal weighting, the

PTV receives much better coverage with a four field. The 6MV four
field PTV receives almost 50% coverage while the 18MV receives
85.3% coverage. Also, if adjusting the prescription for max dose to
cover the 93% line instead of 95%, the coverage for 6MV and 18MV
increases to 78.3% and 99.4% respectively. The only difference is
that the hot spot jumps from 4753 cGy and 4757 cGy (5%) to 4833
cGy and 4854 cGy (7%). The hot spot is not in any structures so the
increase should be acceptable; ultimately, it is physicians decision
on which is more important.
Advantages of 4 Field: Less dose to the femoral heads
Better isodose line conformity
Disadvantages of 4 Field: More dose to the bladder
More dose to the small bowel
Everything still meets dose constraints regardless of more
normal tissue being irradiated. With the ability to change weighting

and add wedges, the PTV can be nearly 100% so a four field box
with such modifiers would be the most viable option overall.