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? The shape of the dose distribution
resembles a rectangle. The 90% isodose line curves in slightly, almost resembling an
hourglass.
  How much of the PTV is covered entirely by the 100% isodose line? Only about 6% of
the PTV is covered entirely by the 100% isodose line. I have included a screenshot of
how I found this on the DVH.

 In your own words, summarize two advantages of using a parallel opposed plan?
(Review Khan, 5th ed., 11.5.A, Parallel Opposed Fields) One advantage of parallel plans
is how simple they are to treat. This simplicity may aid in reproducibility and may also
decrease the amount of time the patient is on the treatment table. This can be
especially important when treating patients in emergent situations. Additionally,
treating two fields on the same axis may help ensure accurate treatment because
there is a lower risk of missing the target geometrically when compared to fields with
angled beams.

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? The addition of the lateral beam
improved the isodose distribution by making the higher isodose lines (like the 100%, 95%,
90%, and 70% lines) more conformal to the PTV. The shape of the isodose distribution is
beginning to resemble a square now
 How much of the PTV is covered entirely by the 100% isodose line? 17.7% of the PTV is
being covered entirely be the 100% isodose line. I have included a screenshot of this
on the dose volume histogram below.
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? I chose an angle of 45° for the LAO and an angle
of 135° for the LPO. I chose these angles because they provided the best conformality
to the PTV while maintaining the dose delivered to surrounding normal tissue.
 In your own words, summarize why beam energy is an important consideration for lung
treatments? (Review Khan, 5th ed., 12.5.B3, Lung Tissue) The chance of underdosing the
outer portion of a lung tumor is higher when treating a small field with a high energy
beam. This is because the low density of lung tissue causes a loss in electrons
scattered laterally. This decreases the dose along the axis of the beam.
Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
 How does field weight adjustment impact a plan? Adjusting the field weight will adjust
the amount of the prescribed dose contributed by each field within a treatment plan.
For example, consider a 3D conformal AP/PA plan that prescribed to deliver 200cGy
per fraction. If the weighting on the AP field is 40% and the weighting on the PA field
is 60%, the AP field will contribute 80cGy/fraction while the PA field will contribute
120cGy/fraction. This will affect the isodose lines within the plan by shifting the dose
distribution more towards the heavily weighted field.
 List your final choice for field weighting on each field. For this plan, I used a beam
weighting of 9% on the AP, 8% on the PA, 63.5% on the L Lat, 9.8% on the LPO, and
9.8% on the LAO. This weighting gave me the best 100% isodose line coverage on the
PTV, while maintaining a “hotspot” less than 110%. With this weighting, 38% of the
PTV was covered by 100% of the dose, but I would never show a plan like this. Some of
the prescribed dose was spilling into the normal tissue regions. Also, at my clinical site,
we would not treat this way because our physicians prefer 95% of the PTV covered by
95% of the prescribed dose. This particular coverage was more appropriate (and gave a
lower high dose region of about 103%) with equally weighted beams.
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?)
AP: EDW 30 IN (heel to patient’s L, toe R)
PA: EDW 30 OUT (heel to patient’s L, toe R)
L Lat: EDW 20 OUT (heel to patient’s anterior, toe posterior)
LPO: EDW 15 OUT ( Heel anterior, toe posterior
LAO: EDW 30 IN (inferior to superior)
 Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s). The 100% isodose coverage is still fairly poor with this plan (18%),
but the hot spot is 102.6% and is in an appropriate location within the PTV. I
experimented with many wedges and beam weighting options, which resulted in little
improvement with respect to PTV coverage. I would definitely normalize the plan at
this point.
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? Normalization by a factor of
91.69% of this plan resulted in 95% of the PTV receiving 100% of the prescription dose.
It is significantly hotter than the previous plan.
 What is your final hotspot and where is it? The final hot spot is 111.9%. I have included
a screenshot of the crosshairs marking the location of this spot. It is within the PTV.

 Are you satisfied with the location of the hotspot? I think the location of this hot spot is
appropriate because it is located in the center of the PTV for this particular CT slice. It
is slightly inferior to the isocenter/calculation point.
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 used 6X for all beams in this plan because of
the tumor location within the lung. This is standard for lung treatments at my clinical
site.
 What is the final weighting of each field in the plan? I was advised by multiple
dosimetrists at my clinical site to delete the lateral beam. I used just AP, PA, LPO, and
LAO beams. The weighting for each field is AP: 29.3% PA: 18.7% LPO: 25% LAO: 27%
 Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable? I have included a screenshot of the global maximum dose. The
crosshair marks the location of the hot spot. It is 110.9% of the prescribed dose, or
6653cGy. This would not be acceptable at my clinical site. For 3D conformal plans, the
physicians at my clinical site prefer hotspots of less than 110% of prescribed dose.
 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.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Heart V40<80%, V45<60%, V40=0% V45=0% V60=0%

V60<30%, Mean<26Gy Mean=1.2Gy
Lungs V20<35%; V5<65%; Mean<20 V20=18.8% V5=32%
Gy Mean=9.5Gy
Spine Max<45Gy Max=15.3Gy
Trachea Max < 107% Max=26%
Esophagus Mean<34Gy, Max <105% Mean=3.5Gy Max=27%

Reference: Attending Physicians and Physicists at University of Virginia. The guidance values
are based on RTOG reports, journal articles, and research.