Jenny Kouri

Clinical Practicum I
April 3, 2015

Planning Assignment (Lung)

Target organ(s) or tissue being treated:
Prescription: 300cGy per fraction to 96% for 10 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)

Esophagus

Maximum dose < 47Gy

Max dose= 30.63Gy

Heart

V45 < 30%

V45= 0%

Total Lung

V20 < 20%

V20= 16.29%

Spinal Cord

Maximum dose < 36 Gy

Max dose= 28Gy

(*VA rule of thumb: sc max

dose < 110% of prescribed
dose)

*Spinal Cord was kept below

33Gy.

*for final wedge plan

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? This plan uses 6 MV beam energy. The
PTV (yellow colorwash) is fully covered by the 95% isodose line (green). The 100%
isodose line (red) clipped the PTV. The PTV coverage was 91.26%. The isodose lines
displayed more of an hour-glass shape. The 110% isodose line (blue) is dispersed
laterally in the field due to the low attenuated dose in the lung. Low-density tissue,
such as the lung, gave rise to higher dose within the lung.
b. Is the PTV covered entirely by the 95% isodose line? No
c. Where is the region of maximum dose (hot spot)? What is it? The hot spot was
located laterally from the spinal cord and posteriorly of the left lung. This spot was
located 0.71cm from the treatment couch. The hot spot was 3819 cGy, 127% hotter than
the prescription dose.
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
isodose lines filled-out, meaning the shape of the previous hour-glass widened to a
more rectangular shape. The posterior remained hot. The PTV was fully covered by the
95% isodose line. The PTV coverage was 99.53%.
b. Where is the region of maximum dose (hot spot)? Is it near the surface of the
patient? Why? The hot spot was located posteriorly at 2.57cm from the treatment couch.
This spot sits higher than the 6MV hot spot because dmax for 18 MV was at 3 cm. The
dose at the hot spot was 3473.2Gy.
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? The anterior and
posterior beams were weighted 55% and 45%, respectively. The max hot spot decreased
to 3379.7, 112% hotter than prescribed dose. The location of the hot spot remained
posteriorly.

b. How is the PTV coverage affected when you adjust the beam weights? The PTV
coverage was 99.09%.
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%. This patient was simulated with his arms
placed down by his sides; therefore, a lateral beam would not be a good clinical
approach. Dose would be attenuated in his arm and not in his lungs. This is shown in the
figure below.

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 went off cord 0.7 mm. Angling the beam helped to
avoid 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 added a 15-degree
wedge to compensate for the sloped chest.

Which treatment plan covers the target the best? What is the hot spot for that plan?
The plan with the AP/PA wedge had PTV coverage of 99.12%. The max dose point was
3598cGy, barely under 120% of the prescribed dosage. The hot spot was 1.1cm from the
posterior. The lung V20 was 16.29% and the heart V45 was 0%. To compare, in a plan
without a wedge the PTV coverage was 97.13% with a maximum dose point of 3617cGy in
approximately the same location as the maximum dose point in the plan without the wedge.
The lung V20 is 16.26% and the heart V45 is 0%.

Did you achieve the OR constraints as listed above? List them in the table above. Yes.
What did you gain from this planning assignment? This assignment allowed me to appreciate
the difference between 6 MV and 18 MV beam energies. 18 MV allows for better coverage
of the PTV, but due to the low attenuation of lung tissue, lower energy beams are

recommended for a more conformal treatment.

What will you do differently next time?
Even though the desired objectives for the critical structures were met, I would mix beam
energies, 6MV and 18MV, to get a more conformal coverage. Using lower beam energy is
protocol. However to achieve better coverage, 18MV can be used with the 6MV. 18MV is
not desirable alone in lungs as it increases lateral range of electrons. As energy increases, the
therapeutic depth increases. The dmax for 18MV is 3.2cm for Varian linear accelerators. In
a lung, there is not enough tissue to build dmax at 3.2cm and build up does not occur in air.
Therefore, the dose rebuilds on the tumor tissue. This does not provide even coverage; it will
leave part of the tumor cool where the build up is trying to occur. Also with mixed energies,
the max dose point can be lowered within limits of 120% of the prescribed dose. Another
option is adding a left anterior oblique (LAO) at approximately 40-degrees, off-cord. In
addition, I would add a right posterior oblique (RPO) parallel-opposed (POP) of the LAO
beam. This would lower the maximum dose point by spreading more dose. However, a
drawback is increasing the V20. It is critical not to exceed this constraint, if so; the patient
increases risk of pneumonitis and fibrosis.