Lung Clinical Lab Assignment

Use the Lung CT data set provided to complete the following assignment:

Prescription: 60 Gy in 30 fractions to the PTV

Planning Directions: Place the isocenter in the center of the designated PTV—make sure it isn’t in air. Note:
calculation point will be at isocenter. Create a single AP field using the lowest photon energy in your clinic.
Create an MLC block on the AP beam with a uniform 1 cm margin around the PTV. Apply the following
changes (one at a time) as listed in each plan exercise below. Each plan will build in complexity off of the
previous one. After adjusting each plan, answer the provided questions. Include an axial screen shot for each
plan to show the isodose distribution along with a DVH clearly displaying your PTV coverage.
 Important: Please do not normalize your plan when making these adjustments until instructed to do so
in the final plan.
 Tip: Copy and paste each plan after making the requested changes so you can compare all of them as
needed.

Plan 1: Create a field directly opposed to the original field (PA). Assign equal (50/50) weighting to each field.
 What shape does the dose distribution resemble?
-After weighting the fields each to have equal distribution of a .50 field weight, the dose distribution
resembles an hourglass shape. There is an 100% and 105% isodose line at the entrance of the AP beam
and the entrance of the PA beam. There is also a 110% isodose hot spot coming from both beam
angles. The 110% isodose line on the posterior side of the patient is larger than the anterior 110%
isodose line. The 110 % isodose line is larger on the posterior side of the patient because the tissue is
thicker than on the entrance on the anterior side.
 How much of the PTV is covered entirely by the 100% isodose line?
-By looking at the DVH, it shows that only 6.537 % of the volume of the PTV is being covered by 100%
of the dose.
 In your own words, summarize two advantages of using a parallel opposed plan? (Review Khan, 5 th ed.,
11.5.A, Parallel Opposed Fields)
-Using the beam arrangement of parallel opposed fields, it can advance the plan in many ways. One
advantage of using parallel opposed fields is that it provides a more homogenous dose distribution to
the area that needs to be covered, essentially the PTV. The weight for both beams that are parallel
opposed from each other are usually equal in weight which is the cause for the prescription dose to be
displayed in a homogenous distribution. Another advantage is that a plan with this field arrangement
has a simple setup which allows the reproducibility of the plan to be easily achieved. 1
Plan 1 Isodose Lines:

Plan 1 DVH:
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?
-Adding a direct left lateral field to the plan and assigning equal weight to all the fields changed the
isodose distribution drastically. At the entrance of the PA and AP beams there is no longer dose
exceeding the 50% isodose line. The isodose lines that include the 80%-103% are now surrounding
and/or inside of the PTV. There is a small hot spot of 103% within the PTV. Adding another field caused
the hot spot to decrease due to dose being spread out between three fields instead of two. The 10 %,
20%, and the 50 % isodose line are now being pulled to the left of the patient due to dose coming from
the left lateral beam.
 How much of the PTV is covered entirely by the 100% isodose line?
-According to the DHV, 15.4075 % of the PTV is now being covered by 100% of the dose.

Plan 2 Isodose Lines:

Plan 2 DVH:
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.
 What angles did you choose and why?
-Before adding oblique angles to this plan, I needed to take into consideration the organs at risk that
could be affected by these added fields. Thinking about the organs at risk, it helped me determine
which angles that these fields should be placed at. I added a LAO field on the anterior portion of the
patient’s left side with the gantry angle being set at 70 degrees. I chose this angle because I wanted to
avoid dose to the spinal canal if possible. I then added an LPO field and set the gantry angle to 140
degrees. I decided to set this specific gantry angle because I wanted to avoid dose to the trachea
while attempting to limit the dose that the heart would be receiving. Even though we are
treating a tumor in the left lung, I took into consideration the healthy lung tissue that I wanted to try
to spare as much as I could. By adding two oblique fields to this plan, 16.8205 % of the PTV is now
being covered by 100% of the dose.
 In your own words, summarize why beam energy is an important consideration for lung treatments?
(Review Khan, 5th ed., 12.5.B3, Lung Tissue)
-It is important to consider the beam energy when creating a plan for lung treatments due to the lung
being low in density. If a higher energy beam is selected for a lung plan, there is a loss of lateral
electronic equilibrium as the beam travels through the lung. The electrons that travel outside of the
geometrical limits cause the dose profile to be less sharp. Another issue is that the electrons that are
laterally scattered can cause less dose to be on the beam axis.1

Plan 3 Isodose Lines:

Plan 3 DVH:

Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
 How does field weight adjustment impact a plan?
-Adjusting the weight of a field impacts a plan because it allows you to adjust how much dose you want
to be coming in from each field. If you weigh a field higher than others, then that field will have more
of an impact. If you weigh a field at a lower number than others, then it will not affect the dose and the
plan as much as the higher weighted fields. Adjusting the weight of the fields is another way to attempt
to control the isodose distribution within the plan. 22.231 % of the volume of the PTV is now being
covered by 100% of the dose.
 List your final choice for field weighting on each field.
-After adjusting the weights of each field, I ended up with the AP being weighted at 23.3 %, PA at
22.6%, LLAT at 38.9 %, LAO at 5.5 %, and the LPO at 9.7 %.
Plan 4 Isodose Lines:

Plan 4 DVH:
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.
 Embed a screen capture of the beams-eye view (BEV) for each field that you used a wedge.
 List the wedge(s) used and the orientation in relation to the patient and describe its purpose. (ie. Did it
push dose where it was lacking or move a hotspot?)
-I placed two wedges in my plan to adjust the isodose distribution. I added a 30-degree wedge on my
PA field with the heel towards the patient’s feet and the toe towards the patient’s head. I also placed a
wedge on my AP field that is in the same orientation as the wedge in the PA field. I decided to orient
the wedge with the thin edge of the wedge being at the superior portion of the PTV to push dose to
the superior portion of the PTV. Doing this will allow the dose distribution to be more equal
throughout the PTV.
 Describe how your PTV coverage changed (relating to the 100% isodose line) with your final wedge
choice(s).
-Before I added on the wedges, 100% of the dose was only covering 22.2 % of the volume and 95%
of the prescription dose was covering 68.4 % of the volume. Once I added the wedges onto the two
fields and adjusted the beam weight, my coverage changed as expected. 100% of the dose is now only
covering 20.3 % of the volume. Although the 100% line is now covering less of the volume, the 95%
isodose line is now covering more at 72.08 % of the volume.

AP Beam’s Eye View

PA Beam’s Eye View

Plan 5 Isodose Lines:

Plan 5 DVH:

Plan 6: Normalize your plan so that 95% of the PTV is receiving 100% of the prescription dose.
 What impact did normalization have on your final plan?
- Normalizing my plan so that 95% of the PTV is receiving 100% of the prescription dose made my plan
hotter. The 105% isodose line is covering a large portion of the PTV and there is now a 110%
isodose line inside of the PTV. The 20% isodose line does not extend as far to the right side of the
patient anymore, the dose line has shifted more medially. The 50 % isodose line is no longer entering
into the tissue on the left side of the patient, it is just going from the anterior to posterior direction.
The 80% isodose line did become larger after normalizing the plan and is now extending posterior
of the PTV.
 What is your final hotspot and where is it?
-Before normalizing the plan, the hot spot was at 104.3% and after normalization the plan went to a
hot spot of 112.6 %. The hot spot is now more medially within the PTV.
 Are you satisfied with the location of the hotspot?
-I am satisfied with the location of the hot spot because it is within the PTV.
Plan 6 Isodose Lines:

Plan 6 DVH:

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.
 What energy(ies) did you use and why?
 -I decided to keep my beam energies at 6X for all the fields. Due to the lung being low in density, and
the tumor being a different density than the lung tissue 6X seemed more appropriate than a higher
energy.1
 What is the final weighting of each field in the plan?
-The final weighting for each field includes AP at 27.4%, PA at 21.2 %, LLAT at 5.3 %, LAO at 22.4 %,
LAO.1 at 2.3 %, LPO at 18.8 %, and LPO.1 at 3.3 %.
 Where is the region of maximum dose (“hot spot”), what is it, and is this outcome clinically
acceptable?-The region of maximum dose is inside of the PTV. In respect to the isocenter, the hot spot
is anterior and towards the left. This outcome is clinically acceptable because it is within the PTV. In my
clinic, the goal for 3D plans is to have the hot spot lower than 110%. For the plan that I have created,
the maximum dose is 109.9 %.
 Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and coronal views.
 Include a final screen capture of your DVH and embed it within this assignment. Make it big enough to
see (use a full page if needed). Be sure to provide clear labels on the DVH of each structure versus
including a legend. *Tip: Import the screen capture into the Paint program and add labels. See
example in Canvas.
 Use the table below to list typical OAR, critical planning objectives, and the achieved outcome. Please
provide a reference for your planning objectives.

Final Isodose Distribution-Axial View

 Final Isodose Distribution- Frontal View

Final Isodose Distribution- Sagittal View

Organ at Risk (OAR) Desired Planning Planning Objective Outcome

Objective2
Heart Mean Dose < 26 Gy 1.337 Gy
Lungs V20 less than or equal to 30% 26.0 %
(Bilateral)
Spinal Cord Max Dose= 50 Gy 10.1 Gy

Esophagus Mean Dose < 34 Gy 4.49 Gy

Primary Bronchus x 23.78 Gy (mean)
Trachea x 3.85 Gy (mean)
X= planning objectives not included due to them not being a typical OAR in a standard fractionated case, only
considered OAR in SBRT fractionation according to RTOG constraints and Mobius3D.
References

1. Gibbons, JP. Kahn’s the Physics of Radiation Therapy. 5th Ed. Wolters Kluwer Health. 2014.
2. Chao K.S.C., Perez C.A., Wang T.J.C. Radiation Oncology: Management Decisions. 4th Ed. Philadelphia, PA:
Wolters Kluwer Health. 2018.