Pat Sheil

Planning Assignment (Lung)

Target organ(s) or tissue being treated: Right Lower Lung

Prescription: 200cGy x 30 fractions = 6,000cGy

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)

Lung V20Gy <30% Unsuccessful:
V30Gy <20% V20Gy=39%
Mean <12Gy V30Gy=35%
Mean= 24Gy
Heart Mean <26Gy Successful:
Mean=23.7Gy
Esophagus V50 <40% Unsuccessful:
Mean <34Gy V50Gy=45%
Mean=34.7Gy
Spinal Cord Max Dose <50Gy Unsuccessful:
Max=59Gy

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)
Figure 1. Isodose Distribution of an AP/PA Plan using 6X Beams.

a. What does the dose distribution look like?

Dose appears to be hot at the anterior and posterior
superficial surfaces due to the opposed fields
entrance/exit dose and low beam energy (6x). Dose
sputters out mid lung creating dose breakage of the
100% isodose line.
b. Is the PTV covered entirely by the 95% isodose line?
No, the PTV is not entirely covered by the 95% isodose
line. The 95% isodose line covers roughly 83.1% of the
PTV, while the 85% isodose line covers 100% of the PTV.
c. Where is the region of maximum dose (hot spot)? What is
it?
 The region of the dmax is at the anterior portion of the
body with a dose of 7486.4cGy (124.8% of the prescribed
dose) and is located 1.82cm from the anterior surface.
Plan 2: Increase the beam energy for each field to the highest photon
energy available.
Figure 2. Isodose Distribution of an AP/PA Plan using 18x Beams.

a. What happened to the isodose lines when you increased the

beam energy?
Superficial hot spots went away superiorly/inferiorly. Due
to the higher energy, the dose is able to penetrate
farther and transverse more deeply through tissue giving
a more uniform dose distribution. The 95% isodose line
covers approximately 90% of the PTV. The 90% isodose
line covers the entire PTV.
b. Where is the region of maximum dose (hot spot)? Is it near
the surface of the patient? Why?
The region of the dmax is still at the anterior portion of
the body and the global max has decreased to 6652.9cGy
(110.9% of the prescription dose). Hot spot is at the
 anterior portion of the patient due to the posterior
location of the tumor. The AP field has to traverse
through more tissue to reach the posteriorly situated
tumor volume than the PA field. The increase beam
energy of 18x also increases the skin sparing effect.
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?
Adjusting the beam weighting to AP (48.1%) and PA
(51.9%) decreased my hotspot the most down to 109.8%
(6590.7cGy). The global dmax shifted to the posterior
surface instead of anterior after adjusting the weighting
and is 3.49cm away from the surface.
Figure 3. Global Dmax Depth with Altered Beam Weighting.

b. How is the PTV coverage affected when you adjust the beam
weights?
PTV coverage is not affected very much by the change in
weighting of the beams. PTV is still receiving full
 coverage at the 90% isodose level. The 95% isodose line
still covers 90% of the PTV.
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%
Figure 4. Isodose Distribution of a 3-Field Plan using 18x Beams and
Wedges.

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. Adjust the gantry angle?
Adjusted gantry angle to 270 degrees (RLAT) in order
to spare the lung.
ii. Tighter blocked margin along the cord
Changed MLC margin around the PTV from 1.5cm to .
5cm to spare the spinal cord.
iii. Decrease the jaw along side of the cord
Decreased the jaw on X1 from 8cm to 7cm in order
spare the spinal cord.
b. Alter the weights of the fields and see how the isodose lines
change in response to the weighting.
 The optimum plan achieved with the 3rd field (RLAT)
was done with the following weighting: AP (37.5%), PA
(29.7%), and RPO (32.8%). Due to the addition of the
RLAT field, the isodose lines spare more of the lung
and are more conformal around the PTV.
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.
Due to the sloping areas of the patients anatomy,
wedges are ideal to even out dose distribution. I
added wedges to the AP/PA/RLAT fields, which helped
push the dose distribution around the spinal cord
while still covering 90% of the PTV. The global max
decreased to 108.4% with the hot spot falling inside of
the PTV rather than free space in the lung.
Figure 5. Display of Wedges Shaping the Dose Distribution and Hot
Spot.

Which treatment plan covers the target the best? What is the hot spot
for that plan?
Plan 4 covered my target the best with a global dmax of 108.4%.

Did you achieve the OR constraints as listed above? List them in the table
above.
Although this was the best plan of the four, it was still not ideal
and failed to meet the prescribed constraints. The large size of
the tumor (10.98cm) covered majority of the lung, which caused
the right lung to receive a large amount of dose. The tumor being
closely situated to the spinal cord and esophagus made the
structures unavoidable using AP/PA and 3-field technique. I
initially used an RPO field instead of RLAT to try to avoid more of
the spinal cord but it ended up treating more of the lung and not
salvaging the spinal cord at all.
Figure 6. CT Slice Showing Length of the Tumor.
Figure 7. CT Slice Showing Location of Tumor in Proximity to Spinal
Cord.

What did you gain from this planning assignment?

This was a very valuable assignment. The assignment allowed me
to become more knowledgeable of the planning system features
and boosted my confidence. While completing this assignment I
found that there were many instances that forced me to think
outside the box. It was really great to learn just how adding
different fields, wedges, collimator/gantry angles, and beam
energies can drastically change a plan. The other interesting
thing was I learned was how the location/size of the tumor can
alter the whole plan. For example, my PTV was very large and sat
next to the spinal cord making it a not so great fit for an AP/PA or
3-field plan. RapidArc or a hybrid plan could have been used to
bring dose off of the spinal cord and make it more conformal.
 What will you do differently next time?
Next time I will try to move the reference point and see how that
alters the dose distribution and I would also play with the
normalization value to see if I could improve my coverage. Next
time I have a plan with a large PTV situated so close to the spinal
cord I will try a hybrid plan with AP/PA and arcs in order to spare
that spinal cord and esophagus. I would also try to make a
complete RapidArc plan if permissible.