Plan 1 6x

 Describe the isodose distribution. The plan becomes colder after 12cm into the patient and loses more than half the dose after 14cm
missing half of the PTV.
 Where is the hot spot and what is it? The hot spot is inferior of the patient and beam, near the field edge. It is about 1cm posterior of the
patient at a dose of 77Gy.
 What do you think creates the hot spot in this location? Most of the dose is being deposited on entry because of the 6x beam. The Dmax
or 100% of the dose is deposited around 1.5 cm in the patient.
 Using your DVH, what percent of the PTV is receiving 100% of the dose? 47.7% of the PTV is receiving 100% of the dose.
Plan 2 10x
 Describe how the isodose distribution changed and why? There is less of a cold spot and less of a hot spot. There is more dose covering the
entrance and exit of the beam slightly as seen with the isodose lines ant and post.
 Using your DVH, what percent of the PTV is receiving 100% of the prescription dose? 48.8%
Plan 3 6x
 Describe the isodose distribution. What change did you notice? The dose is high at entry of the lateral fields and becomes cold about 6cm
into the patient, this does not meet or cover the PTV. There is more dose covering the PTV from the PA field.
 Where is the hot spot and what is it? The hot spot is 50.94Gy as seen above. It is at the entrance of the PA field about 3.5cm in depth. Hot
spots can be seen on the right and left side of the inferior portion of the PA field entrance with the hottest being the right side.
 What do you think creates the hot spot in this location? Because of the PA field depositing the dose max upon entering the patient (around
1.5cm) and the intersection of the lateral beams distributing extra dose creates the hot spot. The laterals are not contributing a high dose
but any dose added would increase the hot spot.
Plan 4 10x
 Describe how this change in energy impacted the isodose distribution. There is less dose being distributed at the entry of the lateral
beams where we do not want dose. Most of the dose is targeted around the PTV.
 In your own words, summarize the benefits of using a multi-field planning approach? (Refer to Khan, 5 th ed, Ch. 11.5B) The benefit of
using a multi-field approach is so that the dose is not targeted to one area. The dose can be distributed better around the target avoiding
hot spots or an increased isodose line to just one area. These helps minimize dose to OAR also. The target can also be covered better when
the beam comes from multiple angles.
 Compared to your single field in plan 2, what percent of the PTV is now receiving 100% of the prescription dose? Plan 2 was at 48.8%. This
plan is at 49%. So there is an increase.
Plan 5 10x
 What was the final weighting choice for each field? As seen above. PA field: 0.363 (36%), LT LAT: 0.321 (32.1%), RT LAT: 0.316 (31.6%). The
PA field carries the most weight with the laterals being close to the same.
 What was your rationale behind your final field weight? My rationale was to clear the entry dose of the lateral fields and get the dose to
the PTV. But there is now an increase in hot spots.
Plan 6 Wedge 10x EDW45IN
 What final wedge angle and orientation did you choose? The final wedge orientation I chose was 45in. The heel is to the posterior of the
patient.
 How did the addition of wedges change the isodose distribution? Include a screen shot (including axial and coronal) of the isodose
distribution before and after the wedge placement using a plan evaluation/comparison view. Although it creates some dose around the
lateral fat folds, it distributed the dose to cover more of the PTV anteriorly and more evenly. The 105% and 107% isodose lines are
minimum. The hot spot also decreased some. This wedge angle and orientation kept the hot spot down significantly compared to others
and allowed for better dose distribution. The PA field was given more weight.

 According to Khan, what is the minimum distance a wedge or absorber should be placed from the patient’s skin surface in order to keep
the skin dose below 50% of the dmax? (Refer to Khan, 5th ed, Ch. 11.4) 15cm is the rule of thumb.

Plan Eval: Plan 5 vs. Plan 6

Plan 6 EDW 45IN

 What energy(ies) did you decide on and why? I chose 10x for the PA field, and 18x for the rest of the fields. I did this because the patient is
thick, especially in the abdomen/pelvis region. This allows be to get the dose through the patient to the PTV. The higher the energy the
more skin sparing occurs as the dmax increases. I did compare a 6x AP beam with less weighting after this and the results were essentially
the same. I wanted to see if I could spare the bowel anymore.
 What is the final weighting of your plan? The final beam weights were PA-28.5%, Lt Lat-18.9%, Rt Lat-23.1% AP-29.5%
 Did you use wedges? Why or why not? No wedges were used because I do not have unrealistic or concerning hot spots.
 Where is the region of maximum dose (“hot spot”) and what is it? My region of dose max is 106.5%.
 What is the purpose of normalizing plans? The purpose of normalizing is to cool the plan off or heat the plan up by adjusting the MUs.
 What impact did you see after normalization?  Why? Include a screen shot (including axial and coronal) of the isodose distribution before
and after applying normalization using a plan evaluation/comparison view. After normalization my coverage increased to the PTV and my
hot spot went up slightly. My 100% is not broken up anymore either. (Screenshot below)
 Embed a screen cap of your final plan’s isodose distributions in the axial, sagittal and coronal views. Show the PTV and any OAR.
 Include a final DVH. (Screenshot below).
 Use the table below to list typical organs at risk, critical planning objectives, and the achieved outcome. Provide a reference for your
planning objectives.
 Organ at Risk (OAR) Planning Objective Objective Outcome Objective Met? (Y/N)
Final Plan 7 Rectum Max<55Gy/V40Gy<60% Max 47.053Gy Yes to Max, No to
Volume
Bowel Max<46-47.5Gy/ Max 47.764Gy N
V40Gy<30%
Rt Femur Max<50Gy Max 46.1Gy Y
Bladder Max<60Gy/ V45Gy<50% Max 47.2 Yes for the Max, No for
Gy/V45Gy=93% Volume
Lt Femur Max<50Gy Max 46.046 Gy Y
Before Normalization vs. After Normalization