Kristine Phillips

Planning Assignment (3 field rectum)

4/8/2016
A 3 field treatment planning course was created for a rectal mass with the patient
positioned prone on the table. The CTV (clinical target volume) was created by
contouring the entire rectum from the start of the anus to where the rectum turns to meet
the sigmoid colon. A PTV (planning target volume) was created from this CTV volume
by adding a 1cm margin to account for daily setup variations and motion. A single PA
beam was placed with the following field borders: bottom border 2cm below the PTV,
top border at L5, and lateral borders 1-2cm beyond the pelvic inlet to include primary
nodal areas. Isocenter was placed centrally within the PTV and 6MV energy was used
initially for this plan. Organs at risk that were contoured as dose limiting structures
included the femurs, small bowel, and bladder. I took the following dose objectives for
such organs at risk from approved plans to the pelvis delivered at my clinical site, when
giving 45Gy. Mean dose for the bladder was to be under 29Gy, 40Gy going to less than
35%, and 35Gy going to less than 50% of the bladder. 5% of the femurs can get 44Gy,
35% can get 40Gy, and 50% can get 30Gy. The entire peritoneal cavity containing the
small bowel can take 45Gy to less than 195cc volume. The prescription dose for this plan
is 45Gy at 1.8Gy per fraction for 25 fractions.
Figure 1 displays the isodose distribution after calculating the dose from the
single PA beam with aforementioned beam parameters. With one single PA beam, the hot
spot will always be posterior at the beams entrance. If we were to prescribe to the 100%
isodose line, prescription dose of 45Gy is delivered to only 62% of the PTV and 61% to
the CTV. When we prescribe to the 95% isodose line, 83 % of the CTV is receiving the
prescription dose of 45Gy and 80% of the PTV is receiving the prescription dose.
Although prescribing to the 95% isodose line appears superior with better coverage of the
PTV and CTV, it just means that our max dose is now 5% hotter. The maximum dose for
this plan is 131.4% when prescribing to 100% isodose line meaning that the posterior
surface is receiving 31.4% more dose than the prescribed 45Gy (45Gy x .3 = 13.5 + 45Gy
= 58.5 Gy when prescribed to 100%); its easy to see that this plan can not afford to get
5% hotter as that posterior surface/anatomy would then receive 61.5 Gy (58.5Gy x .05 =
61.5Gy).
Figure 1. Isodose distribution for a single PA beam, 6MV beam energy prescribed to
100% isodose line.

When we change the beam energy from 6MV to 10MV, the isodose distribution
does not change significantly; the biggest change between energies is the decrease in
maximum dose. The 6MV plan with a single PA beam delivered a maximum dose of
131.4% and when I recalculated dose with 10MV, the maximum dose decreased to
124.5%. 10MV beams have higher penetrating capabilities, thus can deliver a decreased
dose maximum value. When prescribing to 100% isodose line, the prescription dose of
45Gy is delivered to only 63% of the PTV and the CTV. When prescribing to the 95%
isodose line, the prescription dose of 45Gy is delivered to 82.2% of the PTV and 86.5%
of the CTV. If I prescribe to the 100% isodose plan, 6MV and 10MV have almost
identical coverage of the PTV and CTV and neither plan meets the requirement of 95%
of the prescribed dose is to cover the PTV.
Figure 2. Isodose distribution for a single PA beam, 10MV beam energy prescribed to
100% isodose line.

Adding two lateral beams on the initial plan with a single PA beam, changes the
isodose distribution completely. By distributing the prescription dose over 3 beams
evenly as opposed to 1 beam, we can decrease the maximum dose and create better dose
distribution within the PTV. Figure 3 displays the isodose distribution with 3 beams (PA,
right lateral, and left lateral), all of which are 6MV and equally weighted. The maximum
dose dropped to 110% with three beams but the prescription dose of 45Gy is delivered to
62% of the PTV and CTV when prescribed to 100% isodose line; the PTV and CTV
coverage appear to be very similar to what was witnessed with the previous two plans. If
we run this same plan with 10MV energy on the lateral fields (keeping 6MV on the PA
beams) and equal beam weighting, we will see yet another change in the dose
distribution; Figure 4 displays the dose distribution with such parameters. The maximum
dose again decreased with the use of 10MV energy from 110% to 108.4% and it is
evident in figure 4 how much the dose distribution changed from 6MV versus 10MV, as
well as the decrease in visual hot spot volumes between the two plans. 45Gy is delivered
to 64% of the PTV and 62.8% of the CTV. Now if we prescribed to the 95% isodose line,
45Gy is delivered to 97.6% of the CTV and 91.5% of the PTV which is a huge difference
then what was witnessed with previous plans; since the maximum dose from this plan is
lower then the rest at 108.4%, the physician might be okay planning to the 95% isodose

level, knowing that the max dose is really only around 113% now. Figure 5 displays the
dose distribution when prescribing to the 95% isodose line. Changing nothing but the
energy of the PA beam to 10MV from 6MV is displayed in Figure 6; the maximum dose
dropped from 108.4% to 108% and dose is equally distributed throughout the field. You
can visually see that the 95% isodose line provides greater coverage of the PTV and CTV
volumes than if we were to prescribe to the 100% isodose line.
Figure 3. Isodose distribution of 3 field plan (PA, left lateral, and right lateral), 6MV
beam energy prescribed to 100% isodose line.

Figure 4. Isodose distribution with 6MV PA beam and 10MV right and left lateral fields,
prescribed to the 100% isodose line.

Figure 5. Isodose distribution with 6MV PA beam and 10MV right and left lateral fields
prescribed to the 95% isodose line.

Figure 6. Isodose distribution with all 3 beams (PA, left lateral, and right lateral) at
10MV beam energy, prescribed to the 100% isodose line.

With each new change in the previous plans, the dose distribution continues to get
better and maximum dose decreases. To further help the dose coverage of the PTV and
CTV, dynamic wedges can be placed in the path of the beam to help move dose around.
Figure 7 displays the isodose distribution when a 10 degree wedge is utilized on both
lateral fields; one can see in the upper, left corner box, both wedges are placed with the
heels posterior and toes anterior. The PA beam adds equal dose to the PTV and CTV like
the laterals, but areas where the lateral fields overlap the PA field cause visual hot spots
in the posterior surface; having the heels posterior will block dose to the overlap area and
push dose anterior where we are missing the target volumes. Maximum dose continues to
drop with each new plan revision and the use of wedges decreased maximum dose from
8.4% to 7.2%. When I change the thickness of my wedges, one can see drastic changes in
the isodose distribution. Figure 8 displays the isodose plan with a 30 degree on the lateral
fields, positioned the same as the 10 degree wedges. The maximum dose is now 106.2%
and one can see that the 95% isodose line provided full PTV and CTV coverage.

Prescribing to 95% is depicted in figure 8 and the PTV has full coverage. Figure 8 also
shows how the 100% isodose line breaks up within the PTV and it appears to cover less
of the PTV than what was witnessed in previous plans. The reasoning for this could be
contributed from the use of thicker wedges in the fact that it is pushing too much of the
dose from the posterior surface to the anterior surface, away from the posterior PTV
volume. Figure 9 displays the same plan with the use of two 45 degree wedges utilized on
the lateral fields, toe and heel positions remain the same with all three plans; one can see
how 45 degree wedges adjust the isodose distribution anterior and now the posterior PTV
and CTV coverage is cold.
Figure 7. Isodose distribution with the use of 10 degree wedges on the lateral fields only.

Figure 8. Isodose distribution with 30 degree wedges (both toes anterior) on the lateral
fields to push dose away from hot spot regions such as the posterior overlap between the
fields.

Figure 9. Isodose distribution when 45 degree wedges (both toes anterior) are used on
the lateral fields to push dose away from overlap between the fields. Beams are with
10MV energy and this image is depicted with the prescription planned to the 95% isodose
line.

45 degree wedges have been proven to push the dose too far forward. I could plan
with 30 degree wedges in this instance to bring dose back posterior or I can adjust beam
weighting to change the dose distribution; if I assign more dose to the PA beam by taking
dose away from the lateral beams, my dose distribution changes without having to change
wedge thickness. Figure 10 displays the PA beam with half of the dose and the lateral
fields split the remaining half of the dose (PA=.5, Rt=.25, Lt=.25). Maximum dose
decreased to 104.6% and 100% isodose line came back behind the PTV; the posterior
surface is no longer cold in regards to prescription dose.
Figure 10. Isodose distribution display with 45 degree wedges on the lateral fields (heels
posterior) and varying beam weighting; PA giving 50% of the prescription dose and
laterals split the remaining 50%.

After practicing with beam modifying devices and moving the dose distribution
within the target volume through the use of wedges, different beam energies, and
different dose weighting between each field, I can create an optimal treatment field that
best covers the PTV and CTV with the prescription dose. The Plan I choose to use as my
final plan included all three of the above beam modifiers. I changed the PA beam to 6MV
as the PTV is close to the superior surface and we do not need a large, penetrating beam
from that angle. The lateral beams remained at 10MV as the beam has a lot of soft tissue
to go through before reaching the PTV from the lateral side body. With the use of the
6MV beam covering the posterior portion of the PTV, I was able to keep 45 degree
wedges on the laterals (heels posterior) to push dose anterior. I tried using the 30 degree
wedges on the laterals but the maximum dose only increased compared with 45 degree
wedges and the 98% isodose line (as well as the 100%) did not fully cover the PTV like it
did with 45 degree wedges. I also added a small 10 degree wedge to the posterior beam to
push dose inferiorly as the shape of the PTV is bigger inferior. I went back and forth
between two plans, with and without this wedge on the PA beam, and both plans gave
100% of the prescription dose to the PTV when prescribing to the 98% isodose line. The
reason I choose the plan with the 10 degree wedge is because the maximum dose was
104.4% compared with 105.1% without the use of the wedge. Prescribing to the 98%
isodose line means that the hot spot regions are actually 2% hotter than 104.4%; however,
106.6% maximum dose is within standard. I also adjusted the beam weights to assign
more dose from the PA beam and the two lateral beams continued to split the remaining
prescription dose; because I am using wedges to push dose anterior, I need to deliver
more dose from the PA to keep the posterior portion of target volume covered. Figure 11
displays this plans isodose distribution and figure 12 displays the same plans dose
volume histogram.
Figure 11. DVH of final treatment plan, prescribing to the 98% isodose line; prescription
dose is delivered to 99.5% of the PTV volume.

Figure 12. Isodose distribution of the final treatment plan, prescribing to the 98% isodose
line. Although 100% isodose line breaks up, 98% isodose provides almost full coverage
of PTV. See pink isodose line below with viewing planes at reference point.

When analyzing my final plan, I determine if it meets my desired objectives to the

surrounding organs at risk. 195cc volume of the small bowel is receiving 24.28 Gy and
that meets the objective of less than 45Gy. The volumes of the bladder are as follows:
V40Gy= 40%, V35gy=43.2%, and the mean dose = 29 Gy; according to the
aforementioned desired dose objectives to the bladder, V40Gy does not achieve our
objective but mean dose level and V35Gy does meet the desired objective. The volumes
of the small bowel include: V44Gy=2.9%, V40Gy=4%, and V30Gy=53%; V30Gy is the
only one that does not meet desired objectives as it is 3% higher than desired. In order to
further spare these organs at risk, the PTV and CTV coverage can be sacrificed.
A four field pelvis treatment plan was further created from my desired 3 field
treatment plan by adding an opposed AP beam from the PA parameters. All of the
wedges utilized in my 3 field plan were deleted and all 4 beams were equally weighted
with dose. Figure 13 displays this 4 field beam arrangement and its affect on dose
distribution.
Figure 13. 4 field treatment plan with equal beam weighting, no wedges, and mix of
6MV and 10MV energies.

Possible advantages with the use of this fourth beam includes better coverage of
the PTV in the anterior surface as well as a decrease in maximum dose; the more beams
used in any treatment plan equates to a lower maximum dose as the prescription dose is
spread out more. However, these advantages are not superior to the major disadvantage
created with this 4th beam and that is additional toxicity to anterior, abdominal organs.
One can see in the DVH of figure 13, the small bowel is receiving more than desired dose
as well as the bladder. This is exactly why a straight anterior beam is rarely used to target
a volume within the pelvis; we give more than desired dose to the bladder and small
bowel and the patient has adverse side effects because of it while the possibility of
permanent damage is increased.