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Planning Assignment (Brain)

Target organ(s) or tissue being treated: Whole Brain


Prescription: 250cgy x 15 fractions for a total dose of 3750 cgy
Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below):
Organ at risk Desired objective(s) Achieved objective(s)
Lens

Max dose < 25 Gy Max dose was 850cGy
Eyes Max dose < 50 Gy
Mean dose < 35 Gy
Max dose was 3798.4 cGy
Mean dose was 1681.3 cGy













Contour all critical structures on the dataset. Place the isocenter in the center of the skull. Create a single Rt.
lateral plan using the lowest photon energy in your clinic. Refer to Bentel pp. 336-340 to add a block to the Rt.
Lateral field. 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 evaluate all of them):
Plan 1: Create a beam directly opposed to the original beam (Lt. lateral) (assign 50/50 weighting to each
beam)
a. What does the dose distribution look like? 95 % line covers the entire brain.
b. Where is the region of maximum dose (hot spot)? What is it? The maximum dose is
superiorly and anteriorly. There is also a hot spot posteriorly in skin by the occipital bone. The
hot spot in this plan is 14%
Plan 2: Adjust the weighting of the beams to try and decrease your hot spot.
a. Did it help the hot spot? No, since this is treated midplane and the brain is quite symmetric
unless extreme weighting is used it doesnt change much when adjusting weights.
b. Did your isodose coverage of the brain change? When I did an extreme weighting for one side
compared to the other, a significant hot spot occurred > 25 %.
Plan 3: Does your facility ever use wedging or segmented fields to decrease the hot spot? If so, try one of
those techniques (wedging is easier at this point). The plan of choice includes field in fields.
Wedges can be used if needed. We try not to use hard wedges.
a. Evaluate the isodose lines. Which direction does the wedge need to go? The wedge heal needs
to be directed towards the superior aspect of the field (hot spot).
b. Which wedge provides the most even dose distribution? 10 degree wedge gave the best dose
distribution, the higher the wedge I tried, it increased the hot spot.
Plan 4: Does your facility use other techniques to treat whole brains? Discuss this with your clinical
instructors and work on creating different whole brain plans. Several of these other techniques include slight
anterior oblique, collimator rotations, half-beam blocking with an off-axis prescription point.
a. What are the advantages to these other techniques? Beam block technique would not overlap
fields and have no divergence, field in field is an easy way to decrease hot spots, anterior oblique help super
impose the lens and decrease scatter. We also use IMRT here at St Paul Cancer center to be able to spare the
hippocampus.
b. When designing and evaluating different techniques, which one produces the most ideal plan?
I am in favor of the field in field technique with the gantry rotated. It is an easy way to decrease the hot spots.
IMRT also does an excellent job sparing the hippocampus region but for palliative whole brain treatment, the
complex treatment plan using IMRT is not warranted.

Which treatment plan covers the target the best? What is the hot spot for that plan?
When I compared the use of wedges vs field in field technique, I found the field in field decreased the hot spot
the best compared to using the wedge. The hot spot for this plan was 105 %.


Did you achieve the OR constraints as listed in the table on page 1? List them in the table. Yes I did. I
listed them above.

What did you learn from this planning assignment? Years ago we clinically set up whole brains on the
treatment machine and used a hand block for blocking the eyes. I am so glad that we are now planning
whole brains and seeing the great benefit in using field in fields or wedges. This decreases the dose to
the skin causing less side effects. I did not realize how much dose the posterior eye received. By
palpating the bony orbit years ago, I assumed we were blocking the eye adequately. I assumed wrong.
Also check the physician blocking to make sure the lens is blocked out of the field.

What will you do differently next time? Set adequate flash, remember to change field size on field in
field technique. Also remember that field in field techniques work great and the weighting to the sub
fields is about 5 %.

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