Planning Assignment (Lung)

Lisa Spanovich
Target organ(s) or tissue being treated:

Prescription: 180 cGy x 37 fractions. Total Dose of 6660 cGy.

______________________________________________________________________________

Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below):

Organ at risk Desired objective(s) Achieved objective(s)

Heart 33% of the volume is < 60 Gy 12% is receiving < 60 Gy
67% of the volume is < 45 Gy 16% is receiving < 45 Gy
100% of the volume is < 40 Gy 17% is receiving < 40 Gy
Spinal cord Maximum dose is < 45 Gy Maximum dose is 38 Gy

Esophagus 15% of the volume is < 54 Gy 6% is receiving < 54 Gy

33% of the volume is < 45 Gy 8% is receiving < 45 Gy
Lungs 37 % of the volume is < 20 Gy 28% is receiving < 20 Gy

*Dose limits are referencing

the Mobius Chart
Mobius_DV_constrain
(at the end of the assignment, ts.pdf
I included a list of the critical
structures and their colors
relative to the DVH)

Contour all critical structures on the dataset. Place the isocenter in the center of the PTV (make
sure it isnt in air). Create a single AP field using the lowest photon energy in your clinic. Create
a block on the AP beam with a 1.5 cm margin around the PTV. From there, apply the following
changes (one at a time) to see how the changes affect the plan (copy and paste plans or create
separate trials for each change so you can look at all of them).

Plan 1: Create a beam directly opposed to the original beam (PA) (assign 50/50 weighting to
each beam)
a. What does the dose distribution look like?
 The dose distribution looks like an oddly shaped hourglass. The plan is most hot at the
anterior and posterior portions of the body, and it cools off as it reaches mid plane. The
reason for this is because the PTV is somewhat midplane. If the PTV was more anterior
or posterior, the isodose lines would look very different.
b. Is the PTV covered entirely by the 95% isodose line?
No, the PTV is not covered by the 95% isodose line. Only 91% of the PTV is covered.
c. Where is the region of maximum dose (hot spot)? What is it?
The hot spot is in the right breast/chest tissue (very anterior). The global maximum dose
is 114%.

Plan 2: Increase the beam energy for each field to the highest photon energy available.
a. What happened to the isodose lines when you increased the beam energy?
 The isodose lines were more penetrating. More of the PTV is covered with the 16x, as
opposed to 6x.
b. Where is the region of maximum dose (hot spot)? Is it near the surface of the
patient? Why?

The hot spot is still anterior, but it is now more in the anterior ribs, it moved deeper into
the patients body. This makes sense because the Dmax is 2.8 cm (for 16x) into the
patients body, as opposed to the Dmax of 1.5 cm for 6x photons. The maximum dose
dropped down to 106.7%.

Plan 3: Adjust the weighting of the beams to try and decrease your hot spot.
a. What ratio of beam weighting decreases the hot spot the most?
When adjusting the weighting, it is important to look at your isodose lines on all 3
planes, since we are planning in 3 dimensions. I focused on my sagittal view when
weighting my beam. After adjusting the beams, I determined that the most even
distribution is when the AP field receives 48.5%, and the PA field receives 51.5%. Even
though the PTV is slightly more posterior, I had to give more weighting to the PA field
because the beam was getting attenuated by the bone.

b. How is the PTV coverage affected when you adjust the beam weights?
It pulls the weight/isodose lines towards whichever field is receiving more percentage of
the dose. It is a tedious processes to slowly adjust the weighting so that you know you
have the most equal distribution.
Plan 4: Using the highest photon energy available, add in a 3rd beam to the plan (maybe a
lateral or oblique) and assign it a weight of 20%
a. When you add the third beam, try to avoid the cord (if it is being treated with the
other 2 beams). How can you do that?
i. Adjust the gantry angle?
ii. Tighter blocked margin along the cord
iii. Decrease the jaw along side of the cord
Any option would be OK, but I chose to adjust the gantry angle in order to avoid the
spinal cord. When you start to adjust the margin around the cord, it will help decrease
cord dose, but could also decrease PTV dose, depending on the location of the tumor.
Sometimes that technique is necessary, but it should be done with caution.
b. Alter the weights of the fields and see how the isodose lines change in response to
the weighting.
The isodose lines get pulled towards where most of the dose is coming from. I
received the lowest hot spot with the following weighting:
AP: 52%, PA: 28%, RPO: 20%
c. Would wedges help even out the dose distribution? If you think so, try inserting
one for at least one beam and watch how the isodose lines change.
Yes, wedges do help even out dose distribution because the body is not a perfectly
flat structure, and we need to compensate for thinner areas of the body. I added 30
degree paired wedges to the PA and RPO fields.
 Which treatment plan covers the target the best? What is the hot spot for that plan?
The treatment plan that covers the target the best is the Plan 4 with wedges. The hot spot
is 103.9%.

Did you achieve the OR constraints as listed above? List them in the table above.
I was able to achieve all OR constraints. I utilized the Mobius chart for dose limits.
*See attached PDF for Mobius chart.

What did you gain from this planning assignment?

I learned that the way the isodose lines fall are dependent on many things, such as having
multiple treatment angles, and wedges can help to even out the dose and get more
coverage. It also helps to decrease the hot spot, and the hot spot changes its location
depending on various factors such as weighting, energy, and amount of treatment fields. It
makes me appreciate the technology that we have today. When radiation therapy was very
new, there wasnt fancy treatment planning, so any of our lung labs could have potentially
been a plan for a patient, and it feels good to know that we now have much better options
than that.
 What will you do differently next time?
I now have a better idea of knowing that to cover the PTV, it is good to start with more than
one angle. More treatment fields gives a more conformal distribution. Also, when treating
a deeper tumor, it is necessary to use the highest photon energy the machine offers, to pull
the dose towards the inside of the patient. An exception to this comment would be lung
tumors because of its Hounsfield unit of -1000. Usually good coverage could be achieved by
using lower energies, or possibly mixed beam energies. It is difficult to get a great lung plan
with all high energy beams, mostly because the beams blow through the lung tissue.