Ryan Clark

Planning Assignment (Lung)

Target organ(s) or tissue being treated: Right upper lung
Prescription: 60.00Gy @ 2.00 Gy X 30
Organs at risk (OR) in the treatment area (list organs and desired objectives in the
table below):
Organ at risk
Lung

Spinal Cord
Esophagus

Desired objective(s)
V20Gy <30%
V30Gy <20%
V5Gy <55%
Mean <12Gy
<50Gy

Achieved objective(s)
Yes (28%)
Yes (18%)
Yes (48%)
Yes (11.5Gy)
Yes (43.2Gy)

Heart

Mean <34Gy
V50 <40%
Mean <26Gy

Yes (25.6Gy)
Yes
Yes (6.6Gy)

Brachial Plexus

Dmax<67Gy

Yes (4.3Gy)

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). Refer to Bentel, pp. 370-376 for references:
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?
The dose distribution traverses the entire body and is similar at both the
anterior and posterior of the patient. There is a noticeable amount of
unwanted dose buildup toward both the anterior and posterior portions of the
body due to the sloping of the body contour. The spine attenuates the beam
of the PA field as it passes through. The portion of the spine that receives the
beam entrance has increased dose due to the extra scatter of bone. The
isodose lines also bend in toward the central axis as the beam traverses

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through the lung tissue. This is caused by the lack of secondary electron
scatter in the less dense lung tissue.
b. Is the PTV covered entirely by the 95% isodose line?
The PTV is almost covered by the 95% isodose line. The 95% isodose line
covers roughly 98.5% of the PTV. The coverage is lost laterally as the width of
the lung increases inferiorly. This is due to the dose bending inward toward
the mediastinum because of the lower density of lung tissue.
c. Where is the region of maximum dose (hot spot)? What is it?
The region of maximum dose lies roughly 2cm deep from the patients
anterior within the right breast tissue. The hotspot is 120.4% higher than that
of the prescribed dose (7242cGy).
Plan 2: Increase the beam energy for each field to the highest photon energy
available (18X).
a. What happened to the isodose lines when you increased the beam
energy?
Again, the overall 95% coverage of the PTV decreased as the lung widens
inferiorly. The amount of dose buildup toward the surface of the tissue for
each beam also decreased with the increase in beam energy. The amount of
dose in the lung greatly decreased as the higher beam energy has even less
scatter in the low density tissue. This caused the isodose lines bend inward
toward the central axis of the beams.
b. Where is the region of maximum dose (hot spot)? Is it near the surface
of the patient? Why?
The hotspot decreased to 107.8%. It is still anterior but is now 4cm deep from
the patients skin surface. The higher beam energy of 18X has caused a
better skin sparring effect, making the region of higher dose deeper in the
patients tissue.
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?

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Only a small amount of beam weighting could be done to decrease the
anterior hotspot until a higher hotspot shifted toward the posterior portion of
the patient. Beam weighting: AP 49%/PA 51%.
b. How is the PTV coverage affected when you adjust the beam weights?
There is only a very minor decrease in coverage toward the anterior portion
of the PTV due to the small change in beam weighting.
Plan 4: Using the highest photon energy available, add in a 3 rd 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?

An RPO field was added with a gantry angle of 240 degrees to avoid
the cord. The X1 bank of MLCs have a .5cm margin around the PTV to
provide tighter conformity and to also spare the spinal cord. The X1
jaw was decreased by .5cm to help reduce possible dose leakage
through the MLCs as well.

a. Alter the weights of the fields and see how the isodose lines change in
response to the weighting.
The optimum beam weighting when adding the third RPO field is
25.4% PA, 28.0% for the RPO, and 46.6% for the AP. The Hot spot
was reduced to 104.5% and the 95% isodose line covers 95% of
the PTV.
b. 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.
Wedges added to the PA and RPO helped reduce the hotspot where
the two fields overlapped and offered better coverage of the PTV
due to beam hardening. The collimator was turned to 90 degrees
for each field so that the wedges were oriented laterally across the
patient. The fields were then given tighter margins of .5cm around
the PTV to help spare the spinal cord. The area of tissue where the
fields overlapped saw a decrease in dose as the area of 100%
isodose line went down to 75-80% of the dose. The wedges are
dynamic and cause the isodose lines to tilt by 30 degrees. A wedge

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was not added to the AP field as the beam was attenuated too
much and caused a lack of coverage anteriorly for the PTV.

Which treatment plan covers the target the best? What is the hot spot for that
plan?

The three field plan using the 30 degree wedged pair in the PA and RPO fields offers
the best coverage of the PTV and has a small hotspot of 105.8% posteriorly. Having
the collimators rotated to 90 degrees allowed for the wedges to align with the
patients body contour laterally. The 95% isodose line covers 100% of the PTV. The
beam weighting was adjusted to 43% for the PA, 23.6% for the RPO, and 33.4% for
the AP field.

Did you achieve the OR constraints as listed above? List them in the table
above.
I was able to achieve all of the OR constraints. Being able to make tighter margins
around the PTV and going off cord helped reduce dose to the spinal cord. I was able
to achieve the lung constraint as the total lung volume was below 20Gy. The V50
<40% for the esophagus was also met despite the tumors close proximity. The
mean dose constraint for the heart and the maximum dose to the brachial plexus
were met as well.
What did you gain from this planning assignment?
This planning assignment really allowed me to experiment with the use of different
locations for my reference point to normalize the isodose lines for better coverage.
Learning how using lower energy beams provided better coverage in the lung tissue
was helpful as well. This plan really demonstrates the importance of adding extra
blocking and going off cord with gantry angles to help reduce the dose to the spinal
cord. Creating this plan also allowed me to use different combinations of EDWs to
help reduce hotspots and improve coverage near the RPO and PA fields.
What will you do differently next time?
I would begin planning by initially setting tighter margins around the PTV and
reducing the field size to help spare the spinal cord. The plan initially showed that
the cord was receiving well above the 50Gy threshold on the DVH. I will also add a
reference point to help normalize the dose distribution off the isocenter to help the
inferior/posterior portion of the PTV that was lacking some coverage. The
combination of using a .5cm margin around the PTV and placing a reference point to
normalize the plan to the100% isodose line yielded the best coverage and sparing
of the cord. The extra RPO field would also be better to add earlier on in the plan as
it greatly increased the posterior coverage and caused a minimal hotspot when an
enhanced dynamic wedge of the 30 degrees was added with the heel abutting the

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other wedge in the posterior field. I used 18MV for the beams at the beginning of
the assignment, but now know that using 6MV for each field may provide better
coverage but a greater hotspot towards the skin surface.