Heather Maurer

February 2014

Planning Assignment (Lung)
Target organ(s) or tissue being treated: Large right paratracheal lesion
Prescription: Total of 39 Gy in 3 Gy fractions
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 minus GTV
Mean < 15 Gy Mean = 12.4 Gy

Spinal cord
Total < 36 Gy Total = 41.4 Gy

Heart
Mean < 30 Gy
V30 < 50%
V40 < 35%
Mean = 13.7 Gy
V30 = 24.3%
V40 = 2.5%

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?
Rectangle, doesnt cover well, medial edge bows in creating poor coverage of PTV, large
Ant & Post hot spots
b. Is the PTV covered entirely by the 95% isodose line?
No the 95% IDL covered 93.8% of the PTV
c. Where is the region of maximum dose (hot spot)?
Hot spots were both Ant and post between the skin and lung and slightly more lateral
What is it?
122.9% or 47.9 Gy

Heather Maurer
February 2014

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?
The IDLs are no longer so condensed at the skin surface, they bow in slightly from each
side, large bow from medial side is now gone, still rectangular in shape.
b. Where is the region of maximum dose (hot spot)?
Similar to previous plan (Ant and post between the skin and lung) now the hot spot is
closer to chest wall than skin surface.
Is it near the surface of the patient?
It is near the surface, but not as close as in the previous plan
Why?
The higher energy has a deeper dmax therefore delivering less dose to skin 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?
AP .494 and PA .506
b. How is the PTV coverage affected when you adjust the beam weights?
In this particular case minimal. 95% IDL covers 97.9% PTV
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?
i. Adjust the gantry angle?
Due to the position of the tumor and the expansion of the GTV to a PTV
then is no way to completely avoid the spine with gantry rotation
ii. Tighter blocked margin along the cord
Even with a block margin of 0 part of the cord was still in the field.
iii. Decrease the jaw along side of the cord
Due to size and shape of PTV the cord was partially in the field even when
closing down jaw right to the PTV
Heather Maurer
February 2014

b. Alter the weights of the fields and see how the isodose lines change in response
to the weighting.
Now there is much more dose on the posterior side creating a hot spot between
the PA and RPO. AP need to be weighted more to pull IDLs up to cover ant portion
of PTV. Looks like wedges may be needed for hot spot, weighting to reduce hot
spot doesnt leave adequate coverage of 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.
Yes, a wedged pair between the PA and RPO works best.

Which treatment plan covers the target the best?
The 3-field plan with wedges
What is the hot spot for that plan?
109% or 42.5 Gy
Did you achieve the OR constraints as listed above? List them in the table above.
All accept the cord. See table
What did you gain from this planning assignment?
Seeing the effects that a wedged pair can have on a plan. Working with beam going
through both lung and tissue (inhomogeneous field). How to adjust blocking margins,
within reason, to help with coverage or restraints.
What will you do differently next time?
AP/PA really gets the cord so I would probably try doing parallel opposed fields slightly angled off
zero. Still keeping wedges and discussing margin near cord with doctor for restraints.