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.
Axial, coronal, and sagittal view of 6x AP/PA with 50/50 weighting with 1cm margins at isocenter.
DVH displaying PTV Lung
• What shape does the dose distribution resemble?
This isodose distribution resembles an hourglass shape. The 100% isodose line
appears about 0.5-0.6cm after entering the body for both the anterior and
posterior. It breaks up about 5cm into the body, inside of the lung. There is 100%
dose within the PTV but it does not fully cover the PTV. The 95% isodose line
begins about 0.4cm from the surface on both sides and stretches throughout the
entirety of the body besides the superior and inferior regions of the PTV. The
95% isodose line does not fully cover the PTV but covers a significantly larger
portion of the PTV than the 100% isodose line.
• How much of the PTV is covered entirely by the 100% isodose line?
The 100% isodose line (6000cGy) covers 30.98% of the PTV.
• 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 a parallel opposed field plan is that we can stay off critical
structures including the right lung and spinal cord with our beams, which keeps
dose to a minimum. Another advantage is the simplicity of this plan. There are
only 2 treatment beams so the treatment will be quicker to set up, image and
treat so the patient will not have to be on the table as long compared to a plan
with more fields.
Plan 2: Add a direct left lateral field to the plan and assign equal weighting to all fields.
Axial, coronal, and sagittal view of 6x AP/PA with a lateral with equal weighting with 1cm margins at
isocenter.
DVH displaying PTV Lung
• How did this field addition change the isodose distribution?
The addition of a lateral field helped increase the coverage of the PTV and
allowed the plan to be more conformal. In turn, the contralateral lung is
receiving exit dose. The 100% and 95% isodose lines are now confined mostly
around the PTV rather than the entire beam path in the axial plane.
• How much of the PTV is covered entirely by the 100% isodose line?
The 100% isodose line (6000cGy) covers 49.8 of the PTV.

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.
Axial, coronal, and sagittal view of 6x 5 field plan with equal weighting and 1cm margins at isocenter.
DVH displaying PTV Lung
• What angles did you choose and why?
While deciding which angles to use for my 2 oblique fields, I used the BEV and
turned on surrounding critical structures including the lungs, spinal cord, heart
and esophagus. These are all structures that we want to keep dose as minimal as
possible. For the anterior oblique field, we are most concerned with dose to the
spinal cord, which can receive a max dose of 50Gy. Ideally, I would like to use an
angle of 45 because being between 0 and 90, it could allow me the highest PTV
coverage. However, this angle would include the spinal cord and the right lung. I
selected an angle of 15 degrees because it allowed me to avoid treating the right
lung and it was the most I could stay off the spinal cord PRV5, which is the spinal
cord with a 5mm margin. An angle of 10 degrees allowed me to fully stay off the
spinal cord, however, 10 degrees is very close to the AP field (0 degrees) and we
have been taught that beams that are more spread out will improve conformity
to the target volume. I will likely weight this field lightly to limit dose to the
spinal cord.

BEV G15, outer pink structure is the spinal cord PRV and the inner pink structure is the
spinal cord.
 BEV G10, outer pink structure is the spinal cord PRV and the inner pink structure is the
spinal cord.

When selecting the posterior oblique angle, I was most concerned with selecting an
angle that helped me limit dose to the contralateral lung. An angle of 160 allowed me to
fully avoid treating through the right lung while also avoiding other structures including
the spinal cord and esophagus. With 1.00 margins, the superior aspect of the heart is
not covered by MLCs so it receives a bit of dose.

BEV G160, light purple structure is the right lung and the dark red structure is the
superior aspect of the heart.
• In your own words, summarize why beam energy is an important consideration for lung
treatments? (Review Khan, 5th ed., 12.5.B3, Lung Tissue)
Beam energy is an important consideration in lung treatment planning because
the lung is made of very low-density material compared to normal tissue.
Radiation beams interact with this low-density material differently than they do
with normal tissue. High energy beams result in greater lateral scatter and exit
dose compared to low energy beams. We aim to plan with the lowest energy
possible to keep our exit dose and lateral scatter to a minimum.

Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
• How does field weight adjustment impact a plan?
Field weighting is beneficial when a target is not midline and when you are trying
to limit dose to critical structures. Adjusting weighting can alter your target
coverage and dose to critical structures. In this case, the target is midline in the
ant/post direction, so I kept the AP and PA field weighted the same. G15 treats
 through the spinal cord so I want this to be the field with the least weight. G90
and G160 treat through the right lung so I also want to keep the weight of these
beams to a minimum.
• List your final choice for field weighting on each field.
G0: 0.24
G15: 0.10
G90: 0.23
G160: 0.19
G180: 0.24

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 first added a wedge on the PA beam. When looking a the PA BEV, I turned on
my 103% dose. I saw that it was falling inferolateral as seen in the image below.

I turned the collimator to 330 degrees to match this angle. The heel was located
inferolateral with the goal of pushing the dose superomedial within the patient. With a
30 degree wedge and without adjusting the weighting, the dmax decreased from 106%
to 104.9%, but the location of the 103% was not greatly affected as seen in the above
photo. The hotspot also remained in about the same spot. I would have increased the
weight of the PA beam so this wedge would have a greater impact but knowing that this
weighting distribution was giving me the best PTV coverage for this plan, I decided to
leave the weighting for now and add a wedge to the anterior field

Above is the BEV of the Ap field. I want this wedge to focus on pushing dose medially. I
rotated the collimator to 90 and added a 30 degree wedge with the heel facing laterally.
This only decreased the hotspot to 104.8% but pushed the 103% dose medially, as
intended. I decided 30 degree was a bit aggressive and switched the wedge to a 20
degree wedge with the same orientation. The hot spot decreased to 104.7% and the
103% was pretty equally distributed. The hotspot was in about the same location.

• Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s).
Prior to adding wedges to the plan, 100% of the dose was covering 46.571% of
the PTV. After the addition of wedges, 100% of the dose covered 56.415% of the
volume. Looking at the 100% isodose line, it is visible that the addition of wedges
helped it cover more medically within the patient.
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 the plan to 100% dose covering 95% volume increased the plan from
104.7% hot to 112.2% hot. At the same time, the yellow 100% isodose line now
covered the PTV much better than prior to plan normalization.
• What is your final hotspot and where is it?
The hotspot is now 112.2% and is located interior within the PTV. It is located
slightly posterior and lateral to midplane on the PTV.
 • Are you satisfied with the location of the hotspot?
Yes, this hotspot falls withing this PTV and it not near any of the critical
structures that we are concerned about.
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 treatment beams because increasing the energy made the plan
less conformal due to increased lateral scatter and resulted in greater exit dose
through the contralateral lung.
• What is the final weighting of each field in the plan?
G0: 0.22
G15: 0.149
G90: 0.215
G160: 0.183
G180: 0.234
• Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable?
This plan's hot spot is 111.3% and is within the PTV. It is at the superior, medial
aspect of the volume. Anterior to posterior, it is located roughly midline. Though
this hot spot is not located in the center of the PTV, it is still an acceptable
hotspot for the plan because it is under 115% and it is within the PTV.
• 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

Spinal Cord D0.03cc ≤ 4500-5000cGy D0.03cc = 721.1cGy
Esophagus D0.03cc ≤ 105% D0.03cc = 21.82%
321.9cGy
Mean ≤ 3400cGy

Heart V3000cGy ≤ 50% V3000cGy = 0.044%

D0.03cc = 4115.2cGy
D0.03cc ≤ 7000cGy Mean = 124.6cGy
Mean ≤ 2000-35000cGy
Spinal Cord PRV05 D0.03cc ≤ 5000cGy 809.5cGy

Dose constraints from The James Cancer Hospital department of Radiation Oncology clear
check standard lung template of 60Gy in 30fx.