PLAN 1: Create a field directly opposed to the original field (PA).

Assign equal (50/50)

weighting to each field.
The shape of the dose distribution is what one would expect from parallel opposed fields.
The low dose lines, from 20% to 80% form a rectangle and are relatively straight. From 90% to
100% the lines start to bow in toward the target. This is due to the fact that there is less lateral
scatter because the density in the lungs is low. Only 37.2% of the PTV is receiving 100% of the
dose, this is most likely because we calculated the dose to a point instead of the PTV volume and
we have not normalized yet. According to Khan1, parallel opposed fields are simple and
reproducible, provide homogenous dose distribution to the tumor and there is less chance for a
geometric miss because the field size has to be large enough to provide lateral coverage of the
tumor.

Figure 1.0. Plan 1 axial isodose distribution, including dose distribution key.
Figure 1.1. Plan 1 DVH, displaying 37.2% PTV coverage.
PLAN 2: Add a direct left lateral field to the plan and assign equal weighting to all fields.
How did this field addition change the isodose distribution?

With the addition of a lateral field, the dose distribution starts to get more conformal. The
80% isodose line surrounds the PTV, while most of the 70% isodose line is starting to cover as
well. With only 50% and lower isodose lines reaching out through the lung to the chestwall. The
addition of the lateral field brings the PTV coverage up to 54% of the volume receiving 100% of
the dose.

Figure 2.0. Plan 2 axial isodose distribution.

Figure 2.1. Plan 2 DVH, displaying 54% PTV coverage.
PLAN 3: Add 2 oblique fields on the affected side—1 on the anterior portion and 1 on the
posterior portion of the patient. Assign equal weighting to all fields.

Since I already had parallel opposed fields with a direct lateral, I initially added oblique
beams at 45 degrees between the AP and lateral fields and the lateral and PA fields. However,
once I calculated the dose, I was getting 80% isodose lines spilling in to the chestwall where the
anterior oblique field and the AP field intersected. I then angled the anterior oblique angle down
to 60 degrees which took the 80% dose out of the chestwall and made the dose distribution more
conformal overall. The tumor volume is a little more anterior, so I did not have the same problem
with the PA and the posterior oblique fields. I ultimately ended up with an anterior oblique at 60
degrees and a posterior oblique at 135 degrees.
Beam energy is important in lung tissue because of the density of lung, which mostly
comprises air. With 6 MV, the Dmax is shallower, and the build-up region is smaller making it
more appropriate for lung tumors, because the density of lung tissue is low. Because of the lower
density in lung tissue, there is more loss of lateral scatter in electrons, which reduces the dose
along the central axis.1 This can cause underdosing in the peripheral tissue of the tumor and the
effect is greater for fields smaller than 6 x 6 cm2 and for energies greater than 6 MV.1
Figure 3.0. Plan 3 axial isodose distribution.

Figure 3.1. Plan 3 DVH, displaying 51.8% PTV coverage.

PLAN 4: Alter the weights of the fields to achieve the best PTV coverage.

Changing the field weighting allowed me to increase PTV coverage 3% from the previous plan. I
ended up giving 86% to the AP, PA and left lateral fields, this pushed the 70% isodose line
completely in to cover around the PTV. This pushed the low dose lines from those beams out to
the chestwall, which helps spare the health lung tissue around the treatment volume. With only
14% of the dose coming from the oblique beams they contributed less dose to the chestwall and
heart. The final weighting of each beam is a follows AP/PA 28.5% each, left lateral 29% and the
LAO/LPO 7% each.

Figure 4.0. Plan 4 axial dose distribution.

Figure 4.1. Plan 4 DVH, displaying, 54.3% PTV coverage.
PLAN 5: Try inserting wedges for at least one or more fields to improve PTV coverage.
You may also adjust field weighting if you feel it’s necessary.

Because all the beams are located on the left side of the patient and we are calculating
dose to a point within the PTV, I was having a hard time getting coverage to the medial aspect of
the PTV. I used an 18-degree universal wedge on the AP and PA fields, with the heel laterally on
the patient. The purpose of these wedges was to reduce the hot spot in the lateral aspect of the
PTV and to help push dose toward the medial aspect of the PTV. I also used a 5-degree
universal wedge on the left lateral field with the heel to the anterior of the patient. The heel was
in the direction of the hot spot as well. In addition, this wedge was to help with the tissue deficit
towards the anterior aspect of the patient. The final plan with wedges still only covered the PTV
with 54% receiving 100% of the dose but it was 1.5% cooler. To me this is still an improvement
over the previous plan because when comparing dose to surrounding OAR, the wedged plan
contributes similar dose to the spinal canal and heart, but 366 cGy less to the esophagus than
plan 4 did.

Figure 5.0. BEV Field 1 AP.

Figure 5.1. BEV Field 2 PA.

Figure 5.2. BEV Field 3 Lt Lat.

Figure 5.2. Plan 5 axial dose distribution.
Figure 5.3. Plan 5 DVH, displaying 54.1% PTV coverage.
PLAN 6: Normalize your plan so that 95% of the PTV is receiving 100% of the
prescription dose.

Normalization was needed to allow 95% of the PTV to get 100% of the prescription,
however it dramatically increased the hot spot. The dose was still relatively conformal, with 70%
and higher surrounding the PTV. The final hot spot was 6740 cGy, which is 112%. While I
would have liked the hot spot to be below 110%, I am happy with the location because it is
located within the ITV. With the hot spot in the ITV, you know most of the dose is getting to the
tumor which is the goal of treatment.

Figure 6.0. Plan 6 axial isodose distribution.

Figure 6.1. Plan 6 DVH, displaying 95.8% PTV coverage.
PLAN 7: There are many ways to approach a treatment plan and what you just designed
was just one idea. Using the tools of your TPS, your current knowledge of planning, and
the help of your preceptor, adjust or design your own ideal 3D lung treatment plan. Get
creative! You may adjust the beam energy, beam weighting, wedges, add field-in-field, etc.
Normalize your final plan so that 95% of the PTV is receiving 100% of the dose.

For the final plan I chose to keep 6 MV for the beam energy for the same reasons
discussed under plan 3, lung tissue having a low density and small field size. For this plan, a
field-in-field technique was used. The AP, PA, LAO and left lateral fields all had subfields to
control the hot spot. Final weighting for each field is as follows: AP 21%, PA 24%, left lateral
17%, LAO 15% and LPO 23%. The AP/PA beams were weighted heavily to make sure the
medial aspect of the target was covered adequately. The second reason they were weighted more
heavily is due to the fact that there are three beams coming in laterally to contribute dose to the
target. The LPO was also heavily weighted because it did not have any subfields; the LAO and
left lateral fields were contributing to the hot spot so they have subfields and a lower weighting.
The final hot spot is 6461 cGy or 107.6% and located in the ITV. While I would have liked it a
little lower, this would be a clinically acceptable plan given that it is a 3D conformal technique,
and the hot spot is located in the target. Traditionally, a hot spot of 110% percent would be
acceptable.

Figure 7.0. Final plan, axial isodose distribution.

Figure 7.1. Final plan, sagittal isodose distribution.

Figure 7.2. Final plan, coronal isodose distribution.

Figure 7.3. Final DVH and clinical goals.
Table 1. Planning Objectives
Organ at Risk (OAR) Planning Objective2 Objective Outcome Objective Met (Y/N)
Esophagus Max dose 6300 2061 cGy Y
Heart Avg dose 2000 180 cGy Y
Spinal Canal Max dose 4500 1182 cGy Y
Body Max dose 7200 6460 cGy Y
Lungs-ITV Avg dose 2000 1046 cGy Y
Ipsilateral Lung-ITV V50 <2000 446 cGy Y

References
1. Gibbons JP. Khan’s the Physics of Radiation Therapy. Sixth. Wolters Kluwer; 2020.
2. NCCN guidelines