Planning Assignment (Brain)

Target organ(s) or tissue being treated: brain Prescription:___300cGy x 10 fractions = 3000cGy_______________________________________________ ______________________________________________________________________ Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below): Organ at risk Rt Lens Lt Lens Cord 7 Gy 7 Gy 60Gy Desired objective(s) Achieved objective(s) Yes, max Rt lens dose = 314 cGy Yes, max Lt lens dose = 358 cGy Yes, <1% of cord receiving 60 Gy

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? Dose distribution looks like a rind on the skull, with the hottest areas close to the skin surface. b. Where is the region of maximum dose (hot spot)? What is it? The hottest region is along the scalp, where the temporal and frontal lobes join, with a global max = 113.2%. The cervical spine is also HOT, but it doesnt contain the hot spot. Plan 2: Adjust the weighting of the beams to try and decrease your hot spot. a. Did it help the hot spot? Slightly decreasing it to 113% b. Did your isodose coverage of the brain change? Yes, making it more balanced and homogenous. 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). We use segmented fields more commonly than wedging. Field in field is the predominate technique.

a. Evaluate the isodose lines. Which direction does the wedge need to go? b. Which wedge provides the most even dose distribution? 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 off-axis prescription point. a. What are the advantages to these other techniques? This clinic is open to the use of any technique that provides optimal treatment. If the patients head is rotated, causing misalignment with the lenses of the eyes, a gantry angle is used. Typically, if the head is angled more towards one shoulder than another, the technique of altering the couch angle is used. An off axis calculation point is not traditionally used here, unless using half-beam blocking. The reason to utilize half beam blocking would be if there was any chance of future treatment, or a potential for craniospinal irradiation (CSI). The half beam would provide a flat, non divergent, match line across the x-axis which could match against a future CSI field without contributing any dose. In this case, an off axis point would be needed because using the isocenter would provide an innacurate calculation, due to the close proximity to the field edge. b. When designing and evaluating different techniques, which one produces the most ideal plan? For my clinical purposes, a field in field beam arrangement with a collimator rotation provides the most ideal plan. By using this technique and not using blocks or hard wedges, there is less wear and tear on the therapist, and a decreased potential for human error. Theres also an increasingly conformal dose. Which treatment plan covers the target the best? What is the hot spot for that plan? The Field in Field plan covers the best with the hot spot at 105%. Did you achieve the OR constraints as listed in the table on page 1? List them in the table. Yes, please see table. What did you learn from this planning assignment? I learned the blocking procedure for a whole brain, where to locate constraints for a whole brain and what they are. I learned how to design a field in field (FiF) beam arrangement and how to accurately decrease the dose using the FiFs. I learned how to manipulate the hot spot and the acceptable value. And I was introduced to the other methods of treating a whole brain (ie. Wedges, blocked fields, half beam block, collimator rotations). I also didnt know much about the CSI field setup before this assignment.

What will you do differently next time? Next time I will start with open fields, then block ORs, turn on hot regions and continue to build blocked field in fields beams based off of those regions. While evaluating and building, it is important to save throughout.