Professional Documents
Culture Documents
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:
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 patient is positioned in a prone set-up for the treatment of the rectal region for
displacement of the small bowel away from the treatment field so that it receives
less dose. A single PA beam was applied to the treatment plan resulting in a
drastic increase in radiation dose to the very posterior aspect of the patient. The
hot spot was listed as 187%, which is extremely high. The anterior portion of the
PTV is decreasing in coverage as you scroll through the CT slices. The minimum
coverage for the PTV is 87.2%. Due to only one posterior beam being applied,
the anterior portion of the patient is cooler. The isodose lines are relatively
uniform and are somewhat rectangular in shape. The yellow 95% isodose line is
encompassing the entirety of the PTV. Since there is thicker adipose tissue
located in the entrance of the PA beam, a higher photon energy should be applied
to transverse the patient more anteriorly and to obtain optimal PTV coverage.
Figure 1. Comparison of CTV versus PTV coverage.
Figure 2. Isodose distribution and evaluation of the hot spot of a single PA beam using 6 MV.
b. Change to a higher energy and calculate the beam. How did your isodose
distribution change?
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.
A 3-field beam arrangement using a PA field and two opposing laterals using 6
MV, decreases the maximum dose to 131.1%. The isodose distribution appears to
be divided into three sections, as the 6 MV energy used for the lateral beams isnt
penetrating deep enough to reach the target. This is part of the reason why the
skin dose on both laterals is high and the 120% isodose line is visualized. Equal
weighting for all fields is also making the lateral beams hotter, as the lateral fields
should be weighted less than the PA.
Figure 4. 1 cm margin used for the anterior and posterior wall of the PTV.
As both lateral fields have been increased to a 10 MV energy and the PA has
remained at 6 MV, the isodose distribution is similar, except the lateral skin dose
is not as hot. The higher energy photon beam is traversing the patient even
deeper. The green 90% isodose line is seen converging with the square box
isodose distribution surrounding the target. Since this patient is thicker, a more
appropriate beam arrangement would be to increase to 15 MV for both lateral
fields and alter the weighting so that the posterior beam is pumping out more
dose.
Figure 6. Isodose distribution of a 3-field beam using 6 MV for the PA beam and 10 MV for
both laterals.
d. Increase the energy of the PA beam and calculate. What change do you see?
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..)
For the two opposed lateral fields, a 10 enhanced dynamic wedge was applied.
The collimator had to be rotated to 90 in order for the enhanced dynamic wedge
to be positioned in the correct direction. The left lateral field had incorporated an
EDW10IN, with the heel pointing posteriorly and the toe of the wedge anterior to
the patient. The right lateral field incorporated an EDW10OUT, with the heel and
toe arrangement the same as previously mentioned.
Figure 8. Orientation of a 10 EDW and the effect on the dose distribution.
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?
At Maury Regional Medical Center, we use enhanced dynamic wedges instead of the
traditional hard wedges. Below are the wedges that I used to alter the dose distribution.
10EDW This wedge increased the hot spot to 123.5%. A higher wedge needs to
be applied as the dose did not change much.
25 EDW - The hot spot decreased to 119.9% and pushed the 100% and 95%
isodose lines anteriorly in the patient.
45EDW The hot spot is now at 117.1%, however, until different field weighting
can be used, the lateral dose is not optimal.
60EDW The maximum dose is 137.9% and the isodose lines visually resemble a
wedge shape.
Figure 9. Orientation of various EDW and the effect on the dose distribution.
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.
For my final 3-field rectal treatment plan, I altered the field weighting to allow the
majority of the radiation dose to come from the posterior beam. Since the patient
is in a prone position, an anterior beam usually wouldnt be applied because the
belly board would attenuate a portion of the dose. Both lateral fields are equally
weighted and the PA beam is weighted at 44.2%. I used a 15 MV energy for all
of the beams. This allows the lateral beams to penetrate deeper into the adipose
tissue and reach the tumor volume. The PA beam required a 15 MV energy to
increase the anterior PTV coverage. As you scrolled through the CT slices, the
PTV was losing coverage anteriorly with lower energy photon beams. Also, the
left lateral field I inserted a EDW60IN and for the right lateral field I inserted a
EDW60OUT. This higher wedge also aided in pulling my isodose lines anteriorly
to provide adequate PTV coverage.
Figure 10. Final 3-field rectum plan with DVH, using 15 MV and unequally weighted beams.
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?
By weighting all four of the beams equally, my plan had a maximum dose of
114.8%. The hot spot fell within the PTV. The isodose distribution is conformal
to the tumor volume, however, this plan is still too hot. At my clinical facility,
rectal tumors are generally treated with the patient prone on a belly board. You
wouldnt want to use an AP beam in this case, because the couch and belly board
would attenuate a portion of the dose. The orange 80% isodose line can be seen
covering the bladder and small bowel.
Figure 11. Final 4-field rectum plan, using 15 MV and equally weighted beams.