April Hardman 4/1/2021 URMC

Plan 1:

What shape does the dose distribution resemble? The dose distribution resembles an hourglass
shape. The shape occurs due to the 50% contributions of each opposing field meeting at the centered
isodose point to deliver 100% prescription dose to this point.

How much of the PTV is covered entirely by the 100% isodose line? 36.3% of the PTV volume is being
covered by the 100% isodose line.

In your own words, summarize two advantages of using parallel opposed plan? (Khan 11.5A)
Reproducibility and total PTV coverage in appropriate field size.

For simple volumes, a parallel opposed plan can have advantages to multibeam arrangements with
three or more fields. One major advantage is the simplicity and ease of reproducibility at set up.
Generally, for all plans, simplifying the treatment parameters as much as possible without sacrificing
target coverage, is in good practice. Errors in patient set up result in errors of treatment. Simplifying the
plan helps to eliminate the possibility of potential errors for the therapists providing treatment. An
added advantage of parallel opposed planning is the homogenous dose to the target volume. The
contribution of dose from each beam results in uniform coverage of the target as the 100% isodose lines
meet where the beams converge. If the tumor volume is not laterally larger than the field size, gross
coverage of the target volume should be obtained with a parallel opposed plan using isocentric setup.
Plan 2:

How did this field addition change the isodose distribution? The isodose distribution is conformed to
the PTV volume. There is a new addition of low dose exiting through the right side of the chest as a
result of the added lateral beam.

How much of the PTV is covered entirely by the 100% isodose line? 52.9% of the PTV volume is being
covered by 100% of the prescription dose.
Plan 3:

What angles did you choose and why? Choosing beam angles that are equidistant from one another
results in better conformity to the PTV volume. Although we see a fair amount of the 50% isodose line
spilling outside of the PTV, the distribution is relatively uniform throughout for all beams. I was able to
find an angle arrangement that varies slightly from the one chosen that encompassed 48.8% of the PTV
volume. However, I chose not to select those angles as a larger percentage of low dose was seen
throughout the patient. The PTV coverage for the angles I chose is comparable at 47.3% coverage. I felt
the 1.5% difference in PTV coverage I felt was not significant enough to add dose to these normal
volumes and I know we will be building upon this plan. The angles chosen are as follows: AP-0, PA-180,
LT LAT-90, LAO-45, LPO-135.

In your own words, summarize why beam energy is an important consideration for lung treatment?
(Khan 12.5.B3) Lung tissue is of significantly lower density than that of soft tissue or bone. The amount
of a beam’s attenuation is dependent on the density of the material it traverses. The decreased density
of lung tissue due to the large pneumatic properties of lung tissue, results in less beam attenuation as it
traverses to depth within the patient and contributes to lateral disequilibrium. This lack of electronic
equilibrium reduces the dose at the beam’s axis and increases the scatter contribution in the penumbra
region. This effect is increased with higher energy photon beams and causes a reduction in PTV coverage
when the dose reaches the tumor volume from the pneumatic lung field. The vast inhomogeneity of this
region lends itself more favorably to lower energy photon beams, which have depreciated less at the
tumor surface than a higher energy beam would.
Plan 4:

How does field weight adjustment impact a plan? Field weighting allows you to manipulate
the dose so that it is portioned as needed across the beams. In areas that are either too hot or
too cold, altering the beam weighting of surrounding beams can draw that dose to the other
fields and result in a more conformal dose distribution with an overall improvement of PTV
coverage. Field weighting is one of the simplest methods to manipulate the beam before the
introduction of accessories.

List your final choice for field weighting on each field. Field weighting was adjusted to AP
41.6%, PA 24.3%, LT LAT 9.1%, LAO 12.5%, and LPO 12.5%. This lowered the hot spot slightly to
106.1%. With PTV coverage at 50.07%. It also lowered the spinal canal and lung doses in
comparison to the equally weighted plan. There was an overall reduction in low dose spillage
throughout the entire left side of the body and across the midline structures.
Plan 5

List the wedge(s) used and the orientation in relation to the patient and describe its purpose.
The wedges used for this plan are a 30-degree dynamic wedge on the AP beam, with the toe of
the wedge pointing superiorly to the patient and the heel inferior. This orientation was chosen
to increase coverage in the superior part of the PTV which was lacking coverage. A 25-degree
wedge was placed on the PA beam. The PTV was cold in the medial aspect, so a 90degree
collimator rotation allowed me to change the orientation of the wedge so that the toe was
facing the patient’s midline and the heel was to the left lateral margin. This increase dose
coverage to the medial borders of the PTV volume. The final wedge was a 15-degree wedge
angle placed on the LPO beam with a collimator rotation of 90 degrees. The toe of the wedge
points to the posterior margins of the patient and the heel follows the oblique angle toward the
lateral margin of the body. This increased the coverage to the posterior regions of the PTV that
were slightly lacking and moved the hotspot to an anterior-lateral location within the PTV as
opposed to nearer the mediastinum. Weighting of the beams was also adjusted and are as
follows: AP 32.3%, PA 31.3%, LT LAT 18.3%, LAO 11.1%, LPO 7.0%. The hotspot was reduced to
104.8%.

Describe how your PTV coverage changed (relating to the 100% isodose line) with your final
wedge choice(s). The addition of wedges and readjustment of the field weighting has increased
the PTV coverage to 54.7% coverage to the 100% isodose line. The PTV coverage improved by
12.3% in comparison to plan four, which utilized beam weighting alone. The addition of the
wedges did contribute to added low dose spillage of the 20% isodose line across the midline but
the 20% was eliminated completely from the LPO view sparring the scapula. Although there is
more spillage to midline of low dose, it does not intersect the opposing healthy lung. My focus
of this plan was to optimize PTV coverage and spare the opposing lung and spinal cord.
Plan 6:

What impact did normalization have on your final plan? Normalization increased the coverage
to the PTV substantially, from 54.7% in the previous plan to 95% after normalization. There are,
however, areas of 105% and 110% found throughout the PTV that was not present prior to
normalization. Small areas of 80% and 30% have arisen in the AP and LT LAT fields. Otherwise,
the dose distribution of all other isodose lines remained similar.
What is your final hotspot and where is it? The final hotspot is located within the PTV and is at
113.0%. The location of the hotspot did not change with normalization, but it did increase in
value.
Are you satisfied with the location of the hotspot? I am satisfied with the location of the
hotspot. If a plan must have a hotspot of 113.0%, I would always prefer that the intensity is
within the PTV volume and not within normal healthy structures.
Plan 7:

What energy(ies) did you use and why? I chose to leave all beams at 6x energies due to the
amount of dose loss caused by lateral disequilibrium at the tumor edge with higher energy
beams and the recommendations from the literature. Increasing the beam energy would also
result in an increased dose to normal structures which is unnecessary if adequate PTV coverage
could be achieved in this otherwise entirely pneumatic lung field. I added a new calculation
point and placed it in an area that was cold in the PTV. Then, I added a 25-degree wedge to the
Lt Lat beam to push the dose to the posterior-inferior margin that needed coverage. The
collimator for the Lt Lat beam was rotated 90-degrees and the heel of the wedge was facing the
anterior portion of the patient with the toe pointing in the posterior direction. I then readjusted
the weighting as listed below and renormalized the plan to 100% isodose to 95% of the target
volume. After multiple attempts of field in field, and the addition of a full and partial DCA, I
determined that in relation to normal structure dose and overall PTV coverage, this
arrangement was the most satisfactory in this case. Minor adjustments between other
techniques peaked to a point of diminished return and the preceptor and I agreed upon this
arrangement as the best.

What is the final weighting of each field in the plan? The final beam weighting of the plan is as
follows: AP beam 23.9%, PA beam 20.8%, Lt Lat beam 18.6%, LAO beam 7.0%, and LPO beam
29.7%.
Where is the region of maximum dose (“hot spot”), what is it, and is this outcome clinically
acceptable? The hotspot is 109.6%, which is below the preference tolerance of 110% by our
physicians. It is clinically acceptable and found within the mid PTV at the inferior aspect.
 Organ at Risk (OAR) Planning Objective Objective Objective Met?
Outcome (Y/N)
Heart RTOG V33 <60Gy 108cGy Y
0623
Heart RTOG V67 <45Gy 59cGy Y
0623
Heart RTOG V100 < 40Gy 14cGy Y
0623
Esophagus RTOG Mean < 35Gy 370cGy Y
0920
Esophagus RTOG V15 <54Gy 1287cGy Y
0920
Esophagus RTOG V33 <45Gy 138cGy Y
0920
RT Lung RTOG V37 <20Gy 286cGy Y
0623
RT Lung RTOG Mean < 20Gy 288cGy Y
0623
LT Lung RTOG V37 <20Gy 1885cGy Y
0623
LT Lung RTOG Mean < 20Gy 1683cGy Y
0623
Total Lung RTOG Mean < 20Gy 1099cGy Y
0623
Spinal Canal RTOG Max Dose <45Gy 480cGy Y
0623