Peter Hirschi

Spring 2015
Planning Assignment (Lung)
Target organ(s) or tissue being treated: Lung Tumor
Prescription:_Daily dose of 1.8 Gy, 28 fractions, Total dose 50.4 Gy.
Ptv coverage:
99% of Ptv should receive 97% coverage.
95% of Ptv should receive 100% coverage.
1% of Ptv should not receive more then 110%
Organs at risk (OR) in the treatment area (list organs and desired objectives
in the table below):
Organ at risk

Desired objective(s)
V5 65%
V20 35%
Max dose of 50 Gy to 0.03cc

Achieved objective(s
V5 16%
V20 6%
47.74 Gy to 0.03cc

Heart

Volume
80%
60%
30%

Volume
Dose
Less then 1% 40 Gy
Less then 1% 45 Gy
Less then 1% 60 Gy

Esophagus

Volume
15%
Max dose

Total Lung
Cord Margin

Dose
40 Gy
45 Gy
60 Gy
Dose
45Gy
105%

Volume
15%
Max dose

Plan 1: Create a beam directly opposed to the original beam (PA) (assign
50/50 weighting to each beam)

Dose
34.5G
81.3%

Figure 1

a. What does the dose distribution look like?

The 100% line from the posterior aspect covers a large area because the
field weighting of
50/50 requires twice as many MUs from the PA field in order to contribute
dose to such an
anterior tumor. The entire cord margin falls within the 100% line so the plan
is not acceptable.
Anetrioroly the 100% line goes to a depth of around 4cm.
b. Is the PTV covered entirely by the 95% isodose line?
Not even half of the PTV is covered by the 95% line. In fact the 90% line
barely covers the PTV
c. Where is the region of maximum dose (hot spot)? What is it?
On the example slice shown in figure one, the hot spot is located 1.5cm from
the posterior aspect of the patient. It is 161.2% which correlates with an
absolute dose of 290.1 Cgy.

Plan 2: Increase the beam energy for each field to the highest photon
energy available.

Figure 2

a. What happened to the isodose lines when you increased the beam
energy?
The 95% line coverage of the PTV actually decreased. But the hot spot
decreased from 161.1%
to 137%. Also the 100% line from the PA beam became more even at
midplane with 16x
because the higher energy had less attenuation through the spine. The 90%
line coverage of
the PTV increased.
b. Where is the region of maximum dose (hot spot)? Is it near the surface
of the patient?
The hotspot is in the posterior portion of the patient just like the 6mv plan.
However, the hot

spot for the 16mv plan is 2.62 cm deep.

Why?
The depth of maximum dose (Dmax) for 6mv is 1.5cm below the patients
surface while the
Dmax for 16mv is 3cm below the patients surface.1 This is evident in these
two plans because
the hot spot correlates with were the most dose is being deposited, the
Dmax. Therefore the
hot spot should get farther from the surface of the patient as beam energy
increases.
Plan 3: Adjust the weighting of the beams to try and decrease your hot
spot.

Figure 3

a. What ratio of beam weighting decreases the hot spot the most?
The most effective beam weighting decrease the hot spot was AP 73.6 PA
26.4. The hot spot
moved anteriorly and was lowered to 101.4%

b. How is the PTV coverage affected when you adjust the beam weights?
Coverage of the posterior aspect of the PTV decreased because the AP beam
is so heavily weighted in order to get a lower hot spot. The 110% line on the
50/50 weighting plan that went almost midplane from the posterior part of
the patient was completed removed with the new weighting.
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

a. When you add the third beam, try to avoid the cord (if it is being treated
with the other 2
beams).
A third beam of 16Mv was added at 315 degrees in order to stay of the cord.
The Angle was
also chosen to help push dosed deeper to the left posterior aspect of the PTV
that was not
being covered. Lung volume being treated was also a concern because the
volume of irradiated

lung increases when oblique fields are used through the lungs compared to
using just AP/PA
fields.2 The 3rd beam was assigned a weighting of 20%
A. Alter the weights of the fields and see how the isodose lines change in
response to the weighting.
Weighting was adjusted until the greatest possible PTV coverage was found.
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.
Different wedges were tried but no noticeable increase of PTV coverage was
achieved.

Which treatment plan covers the target the best? What is the hot spot
for that plan?
The three field plan covers the PTV the best. The hot spot is 102%, located
just anteriorly to the PTV

Did you achieve the OR constraints as listed above? List them in the table
above.
AS the table above indicates all dose constraints were met except for the
dose coverage of the PTV. The dose to cord margin is close to its constraints
it is receiving 47.74 Gy to 0.03cc when the tolerance is only 50Gy. The dose
is high because the PTV is very anterior and a PA field is going straight
through the spine in order to get dose to the PTV. The PTV coverage is not
acceptable. Therefore this plan should be improved before actually treating a
patient. The DVH in figure 5 shows that the dose constraints were met.

Figure 5

What did you gain from this planning assignment?

I really enjoyed this assignment. It gave me some conceptual ideas to think
about as I changed different parameters. Ive learned a lot just by spending
time on the planning system on my own, but this assignment was great
because I had defined goals and task.
What will you do differently next time?
I would continue to work on this plan. The first thing I would do is use the
normalization tool to increase dose in order to improve the 95% coverage of
the PTV. I would make the plan hotter until I found a good balance between
PTV coverage and an acceptable hot spot.

References
1. Washington C, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed.
St. Louis, Missouri: Mosby Elsevier; 2010: 153.

2. Bentel GC. Dose Calculation for External Beams-Parts I-II. In: Bentel, GC.
Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996:370.