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Lung Lab
Lung Lab
Shands James
4/29/2016
DOS 771 Clinical Practicum I
Planning Assignment (Lung)
Target organ(s) or tissue being treated: Lung tumor located near midline of right lung
Prescription: 200 cGy x 30 fractions = 6000 cGy
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:
*Organ at risk chart was developed for each plan variation and can be found in each plan section.
Patient was simulated supine with a headrest and knee cushion for patient comfort and
immobilization.
James 2
Plan 1: Create a beam directly opposed to the original beam (PA) (assign 50/50 weighting to
each beam)
Figure 1: Plan 1 isodose lines from all planes. 100% line is yellow.
Organ at risk
Desired objective(s)
Achieved objective(s)
Spinal Cord1
Heart2
V45<66%
V45 = 12.6%
V60<33%
Mean Dose = 3400 cGy2
V60 = 0%
Mean Dose = 1640.4 cGy
V35<50%
V35 = 26%
V50<40%
V5<65%
V50 = 10.4%
V5 = 92%
Left Lung(Contralateral)3
V5<60%
V5 = 0%
V20<37%
V20 = 39.7%
Esophagus
Right Lung(Ipsilateral)
James 3
Figure 2: Plan 2 isodose lines from all planes. 100% line is yellow. All beam energies
changed to 23 MV.
James 4
Organ at risk
Desired objective(s)
Achieved objective(s)
Spinal Cord1
Heart2
V45<66%
V45 = 12.5%
V60<33%
Mean Dose = 3400 cGy2
V60 = 0%
Mean Dose = 1676.7 cGy
V35<50%
V35 = 26.2%
Right Lung(Ipsilateral)3
V50<40%
V5<65%
V50 = 14.5%
V5 = 93.4%
Left Lung(Contralateral)3
V5<60%
V5 = 0%
V20<37%
V20 = 39.9%
Esophagus
Plan 3: Adjust the weighting of the beams to try and decrease your hot spot.
James 5
Figure 3: Plan 3 isodose lines from all planes. 100% line is yellow. Weighting of each beam
was changed to reduce hotspot.
Organ at risk
Desired objective(s)
Achieved objective(s)
Spinal Cord1
Heart2
V45<66%
V45 =5.8 %
V60<33%
Mean Dose = 3400 cGy2
V60 = 0%
Mean Dose = cGy
V35<50%
V35 = 6.7%
V50<40%
V5<65%
V50 = 0.9%
V5 = 91.5%
Left Lung(Contralateral)3
V5<60%
V5 =0 %
V20<37%
V20 = 38.3%
Esophagus
Right Lung(Ipsilateral)
James 6
The beam weighting that reduced the hotspot the most was 54.5% from the AP beam and
45.5% from the PA beam. The hotspot was reduced to 105.9% from 109% (Plan 2) as
result of changing the weights of the beams.
b. How is the PTV coverage affected when you adjust the beam weights?
The PTV coverage of Plan 3 was not as good as Plan 2. In this case, the changing the
beam weighting reduced the coverage, but reduced the hotspot. This change in PTV
coverage is not what I expected to see when changing the beam weights.
James 7
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 5: Plan 1 isodose lines from all planes. An RPO beam was added to see the change in hotspot and PTV
coverage.
Organ at risk
Spinal Cord1
Desired objective(s)
Max Dose = 5000 cGy
Achieved objective(s)
Max Dose= 4354.9
V45<66%
V45 =12.9%
V60<33%
Mean Dose = 3400 cGy2
V60 = 0%
Mean Dose = 1723.4 cGy
V35<50%
V35 = 26.3%
V50<40%
V5<65%
V50 = 13.4%
V5 = 93.7%
Left Lung(Contralateral)3
V5<60%
V5 =0.21%
V20<37%
V20 = 40.2%
Heart2
Esophagus
Right Lung(Ipsilateral)
James 8
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? I used an RPO beam at an angle of 210 degrees
which avoided an entrance and an exit on the cord. I also turned the
collimator so that the X jaw would better block the cord.
ii. Tighter blocked margin along the cord? On the side of the spinal cord
(X1), I changed the auto margin from 1.5 cm to a margin of 1 cm which
blocks the cord to a greater degree.
iii. Decrease the jaw alongside of the cord. After decreasing the margin
around the PTV, I adjusted the X1 jaw to fit snugly against the MLC to
further decrease the dose to the spinal cord by preventing leakage from the
MLC.
Figure 6: Beams eye view of RPO beam to improved blocking of the spinal cord.
James 9
b. Alter the weights of the fields and see how the isodose lines change in response
to the weighting. The lines conformed to the PTV better and the hotspot improved
as I adjusted the weight.
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. After
reviewing the locations of the hotspots, I dont think that a wedge would be helpful
in this case. Below is a picture of the AP beams eye view (BEV). The orange cloud
is the 105% location and does not fall to either side of the PTV.
Figure 7: BEV of AP beam showing areas of high dose(orange dose cloud) to determine
need for a wedge.
James 10
Which treatment plan covers the target the best? What is the hot spot for that plan?
Out of the 4 plans that were created during this project, Plan 4 had the best overall PTV
coverage and plan. Plan 2 was very close to the coverage that Plan 4 achieved however, Plan
4 was better overall. The hotspot for Plan 4 was 106.4% as opposed to 109% for Plan 2.
Did you achieve the OR constraints as listed above? List them in the table above.
None of the 4 plans achieved all of the dose constraints. The only plan to meet the spinal cord
constraint was Plan 4. The trade-off was higher lung, heart, and esophagus dose due to the
third beams entrance and exit locations.
James 11
One last possibility of improving the plan is using a mixed energy beam arrangement. My
center only has 6MV and 23 MV on the machine that I planned on, but an energy somewhere
in between may be more appropriate. So using a combination of 6 MV of 23MV can give a
dose distribution of that is more suitable.
References
1. Kirkpatrick JP, van der Kogel AJ, Schultheiss TE. Radiation dose-volume effects in the
spinal cord. In J Radiat Oncol Biol Phys. 2010; 76 (3 Suppl): S42-9.
Http://10.1016/j.ijrobp.2009.04.095.
2. Videtic GMM, Woody NM. Handbook of Treatment Planning in Radiation Oncology. 2nd
ed. New York, NY: Demos Medical Publishing, LLC; 2015: 85-100.
3. Song CH, Pyo H, Moon SH, Kim TH, Kim DW, Cho KH. Treatment-related pneumonitis
and acute esophagitis in non-small-cell lung cancer patients treated with chemotherapy
and helical tomotherapy. Int J of Radiat Oncol Biol Phys. 2010; 78(3):651-8.