Dustin Melancon

Planning Assignment (Brain)

Target organ(s) or tissue being treated: whole brain Prescription: Whole brain irradiation treatment using external beam radiotherapy with right and left lateral fields. One fraction per day with a daily dose of 300 centigray (cGy) over 10 fractions. The target will receive a total dose of 3000 cGy with a source to axis distance (SAD) of 100 cm. Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below): Organ at risk Left eye lens Right eye lens Desired objective(s) Maximum dose of 1000 cGy Maximum dose of 1000 cGy Achieved objective(s) 370.3 cGy 271.6 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? The dose is evenly distributed throughout the brain. b. Where is the region of maximum dose (hot spot)? What is it? The maximum dose is located at the patients vertex. Plan 2: Adjust the weighting of the beams to try and decrease your hot spot. a. Did it help the hot spot? No, the hot spot moves towards the surface of the beam that had an increased weight. b. Did your isodose coverage of the brain change? Yes, the dose is no longer evenly distributed like the equally weighted plan. 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). My facility uses field in field techniques to decrease the hot spot. a. Evaluate the isodose lines. Which direction does the wedge need to go? The brain is well covered, but there is a region of high dose near the vertex. It begins at

Dustin Melancon the orbital ridge and follows the skull to the occipital protuberance. I used unequal weighting and various open and enhanced dynamic wedge (EDW) fields.

In attempt to reduce the vertex hot spot, I used left and right lateral fields with the collimator at 0 degrees and a 10 degree EDW. For the posterior hot spot, I used left and right lateral fields with the collimator at 90 degrees and a 10-degree EDW. b. Which wedge provides the most even dose distribution? The 10-degree wedge provided a better dose distribution than the other wedges. I achieved the best dose distribution with a field in field technique. 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 obliques, collimator rotations, half-beam blocking with an offaxis prescription point. a. What are the advantages to these other techniques? I didnt have issues with excessive dose to critical structures. If I did, slight anterior oblique fields with collimator rotations would have been useful. I tried 0 and 90 degree collimator rotations to achieve the desired wedge since the EDW are located on the Y field. This technique did not provide better results than a simple whole brain plan. Off-axis prescription points can help achieve the desired dose distribution for the target, but this technique created undesirable target coverage. b. When designing and evaluating different techniques, which one produces the most ideal plan? The ideal plan has two parallel-opposed laterals using a field in field technique. It has a 107.7% hot spot with the right eye lens receiving 267.0 centigray (cGy) and the left eye lens receiving 360.7 cGy.

Which treatment plan covers the target the best? What is the hot spot for that plan? The plan that covers the target best is also the right and left lateral with a field in field technique. The hot spot for this plan is 107.7%. The conventional whole brain plan also provided similar target coverage, but the hot spot was 113%. The right lens received 271.6 cGy and the left lens received 370.3 cGy in the conventional plan. One opinion could be that the conventional plan is better because less port films are needed; however, I dont see this being an issue for most patients.

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

Dustin Melancon

What did you learn from this planning assignment? I learned that sometimes removing the hot spot from one region simply relocates this dose to another. I also learned that using a more complicated technique isnt always the best one. My treatment plan using conventional left and right lateral fields was better than my plan with EDW and unequal weighting. What will you do differently next time? I spent an excessive amount of time trying to reduce the hot spot with wedges. The basic plan that used left and right laterals still had better target coverage than the plan with wedges. Next time, I will use my best judgment based on this experience. Depending on the location of the hot spot, conventional left and right lateral fields or additionally using the field in field technique can help create desirable treatment plans.