File - Patty Sponseller, CMD
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Transcript File - Patty Sponseller, CMD
Hodgkin’s Lymphoma
T R E AT M E N T P L A N N I N G
ABOVE AND BELOW THE DIAPHRAGM
WHY IS IT SO COMPLEX?
PAT T Y S P O N S E L L E R , C M D
It’s just AP/PA right?
Mantle
Para-aortics
Although AP/PA a lot going on here!
Radiation Fields
Mantle covers chin and just
below diaphragm
Laterally “flash” skin to
include both axilla
Involved field radiation
Inverted Y covers paraaortic,
pelvic and inguinal lymph
nodes
Mantle RT
R A D I AT I O N T O A L A R G E A R E A O F T H E N E C K ,
CHEST AND AXILLA
C O V E R A L L T H E M A I N LY M P H N O D E A R E A S
ABOVE THE DIAPHR AGM
S H I E L D I N G T O PA R T O F T H E L U N G S , H E A R T
AND SHOULDERS
MANTLE IS DERIVED FROM THE NAME OF A
G A R M E N T M U C H L I K E A C L O A K I N M E D I E VA L
TIMES
Variation with the DD
throughout the fields
•
PAT I E N T T H I C K N E S S C H A N G E S
• PAT I E N T C O N T O U R I R R E G U L A R I T I E S
• DIFFERENT HETEROGENITIES
• MISSING TISSUE
• BEAM CHAR ACTERISTICS
• G E O M E T R I C M AT C H
Basic dose distribution data is
Why is this?
obtained under standard
conditions
Homogenous density in a water
phantom
Perpendicular beam incidence
Flat surface
During Treatment
• The beam may
be obliquely
incident with
respect to the
surface
• Surface may be
curved or
irregular in
shape
• Under these
conditions,
standard DD are
not applicable
without
corrections
Corrected in Pinnacle
Beam data includes profile scans across the beam,
depth doses and output factors (ratio of the dose
measured for a specific F S standard to a 10 cm2)
measured for every machine energy and many square
field sizes. This measured data is used to determine
the many, many free parameters in the Pinnacle
model for EACH linear accelerator.
In Pinnacle we are then modeling the energy that
comes from the head of the Tx unit including all the
scatter within the head that affects the energy
spectrum.
Modeling – Convolution Algorithm
An integral that calculates at every point within the
dose grid. That dose calculation includes the
attenuation of the beam as it travels through tissue
times the energy fluence of energy spectrum times
the energy kernel.
Convolution Algorithm
Want to know more?
Imaging
Conventional X rays
Ultrasound
CT scan
PET (FDG)
Ability to screen for distant Dz
Uptake in nodal areas that
look normal on CT
False positives
Not good at detecting
marrow involvelment
Simulation for Adjacent Fields
Maintain patient position when all fields are treated
Proper immobilization for entire torso
Clam shell used if pelvis RT for males
Consider oophoropexy for females
Supine position with arms akimbo
Immobilization indexed to treatment couch
Matching new fields with previously TX
Tattoo documentation cannot be overemphasized
Compare prior DRR’s and portal images
Examine the chart carefully for possible changes
during prior RT
Reproduce prior RT with new scan to ensure which
segment of spinal cord was irradiated
Goal is a
Homogenous
Dose
Distribution
Adjacent fields
have the same
divergence
Adjacent
Fields
Adjacent fields do not
match divergence
Dose discrepancies over
spinal cord
Inverted Y
May need to split up
inverted Y into 2 fields for
adult or tall adolescent
Otherwise-
Paraortics/Spleen
You have this problem
The larger inverted Y does
not match the divergence of
the mantle field
Hot and cold spots
Blocking
Spleen/Paraortic Fields
or Inverted Y usually
can accommodate MLC
Mantle Fields typically
are a combination of
MLC and Cerrobend
blocking
Lung Block shapes are
usually too complex for
MLC
May consider a larynx
block on AP field
Combination of MLC’s and custom blocks
Portal Imaging
See the
combination
here
Field Blocks
Blocks are shaped or tapered to match the
divergence of the beam
This minimizes block transmission pneumbra
(partial transmission of the beam at the edges of the
block)
Do we do this for all our photon blocking at UWMC?
Custom Blocking
Lipowitz Metal
Cerrobend (brand name)
Approx 83% of Pb density
Low melting point
Materials making up Cerrobend are
Bismuth
Lead
Tim
Cadmium
How thick are the blocks?
Half Value layer
The thickness of the material required to attenuate
the intensity of the beam to half its original value
How many HVL’s in MV photon blocking?
Original Value
100%
50%
25%
12.5%
6.25%
3.12%
1.56%
5 HVL’s
How thick are the blocks?
5 HVL’s of Cerrobend needed
What is the HVL thickness of Cerrobend?
1 HVL of Cerrobend is 1.5 cm thick
In the megavoltage range of photons the most
common used thickness is 7.5 cm
Which is equivalent to about 6 cm of pure lead
Mantle Fields
Dose Distribution is
calculated with
cerrobend blocking
Pinnacle will not
allow Step N Shoot
with custom blocking
Here we use a “Poor
Man” Technique
Treat more than one
field, close jaws and
adjust weighting
Other Techniques
Use wedge on
AP field if FS
allows
Compensators
Decimal
Para/Spleen or
Inverted Y
Usually MLC’s can be
used for blocking on all
fields
May require Step N
shoot for hot spots
Point under a block
17 cm
4.5 cm
6.25 cm
17 cm
Fields
17 X 17 cm = 17 cm 2
4.5 x 17 cm= 7 cm 2
6.25 x 17 cm= 9 cm 2
Calculate the dose under a block at 10 cm depth
Which blocks are bettter?