Kevin Kocos

Planning Assignment (Lung)

Target organ(s) or tissue being treated: Left Lung

Prescription: 60 Gy, 30 fractions, 2 Gy per session

Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below):

Organ at risk Desired objective(s) Achieved objective(s)

Spinal Cord Max Dose < 45 Gy 44.3 Gy

V20 < 37% V20 = 15.75%

Total Lung - CTV Mean Dose < 22 Gy Mean Dose = 10.66 Gy
Mean Dose < 35 Gy Mean Dose = 16.73 Gy
Esophagus
V60 < 33% V60 = 2.3%
Heart V45 < 66% V45 = 7.59%
V40 < 100% V40 = 12.71%

Contour all critical structures on the dataset. Place the isocenter in the center of the PTV (make
sure it isnt in air). Create a single AP field using the lowest photon energy in your clinic. Create
a block on the AP beam with a 1.5 cm margin around the PTV. 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 look at all of them).

Plan 1: Create a beam directly opposed to the original beam (PA) (assign 50/50 weighting to
each beam)
a. What does the dose distribution look like?
Dose distribution is very heavy on the surface of the patient. It then becomes
concave towards the isocenter and makes it look similar to an hourglass.
b. Is the PTV covered entirely by the 95% isodose line?
 No. the 95% isodose line covers 89.24% of the PTV.
c. Where is the region of maximum dose (hot spot)? What is it?
The hot spot is on the anterior surface of the patient near the left pectoralis
major. The hot spot is 8195 cGy.
Plan 2: Increase the beam energy for each field to the highest photon energy available.
a. What happened to the isodose lines when you increased the beam energy?
Increasing the energy of the beam cooled down the surface and brought the
isodose lines more the interior of the patient slightly more. The hour glass shape of
the isodose lines became tighter and moved toward the middle of the body as well.
b. Where is the region of maximum dose (hot spot)? Is it near the surface of the
patient? Why?
The hotspot still remains toward the anterior surface of the patient but has
moved slightly interior. The isocenter sits closer to the posterior of the patient
therefore there is a greater amount of MUs required produced for the anterior beam,
making it hotter on the anterior surface.
Plan 3: Adjust the weighting of the beams to try and decrease your hot spot.
a. What ratio of beam weighting decreases the hot spot the most?
53.9% posterior, 46.1% anterior weighting
b. How is the PTV coverage affected when you adjust the beam weights?
PTV did not change significantly with the adjustment of the beam weights. The
best PTV coverage that I could achieve was 72.8% coverage of the 95% isodose line
with a 42.1% anterior weighting and a 57.9% posterior.
Plan 4: Using the highest photon energy available, add in a 3rd beam to the plan (maybe a
lateral or oblique) and assign it a weight of 20%
a. When you add the third beam, try to avoid the cord (if it is being treated with the
other 2 beams). How can you do that?
I placed a left lateral beam with a .7 cm blocked margin around the spinal cord
i. Adjust the gantry angle?
ii. Tighter blocked margin along the cord
 iii. Decrease the jaw along side of the cord
b. Alter the weights of the fields and see how the isodose lines change in response to
the weighting.
c. Would wedges help even out the dose distribution? If you think so, try inserting
one for at least one beam and watch how the isodose lines change.
I placed an AP 30 degree wedge onto this plan. It cooled down the 50% and 70%
isodose lines significantly and also cooled down the spinal cord enough to make it a
passing dose. It also brought down the hotspot 100 cGy.

Which treatment plan covers the target the best? What is the hot spot for that plan?
Trial 4c (with a 30 degree anterior wedge) covers the PTV the best with the 95% isodose
line covering 91.23% of the PTV. The hot spot for this plan is 6566 cGy.

Did you achieve the OR constraints as listed above? List them in the table above.
Yes the organ constraints were met with this plan, however PTV coverage was still not
adequate.

What did you gain from this planning assignment?

I was able to use many different trial comparisons for the final version of this
assignment. I tried using anterior and posterior obliques as my third lines however
none of those plans offered a good balance between the hotspot, PTV coverage and
spinal cord dose. In the end the left lateral plan used with a wedge ended up being
the best. The anterior/posterior beams only, could not give me adequate PTV
coverage. I gained very valuable planning experience from this. I became more
proficient in critically looking at small changes to each plan to optimize the overall
treatment.
 What will you do differently next time?
At this point, I given the parameters of the assignment, I would not do anything
different. I did use 6 different trial comparisons for the final plan and none of them
worked better than the one that I chose. If anything I could choose a different
isocenter or PTV that would be able to change the calculations and isodose lines.