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Planning Assignment (Lung)

Target organ(s) or tissue being treated: Left Lung Upper lobe

Prescription: 60 Gy @ 4 Gy/Fx in 15 fractions at Isocenter

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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)
Yes, by far.
Heart Absolute Dose @15 cc < 33
Gy
No, slightly exceeded.
Spinal Cord Abs. Dose at 0.1 cc < 35 Gy The dose was 38.76
Gy
Mean Absolute Dose < 30 Yes, Mean = 3.22 Gy
Esophagus Gy Yes, Max = 50.75 Gy
Max Abs. Dose < 63 Gy Yes, V50 ~ 0.04% !
Relative Volume @ 50 Gy < Yes, V60 = 0%
25%
Relative Volume @ 60 Gy <
10%
No, exceeded.
Brachial Plexus - Left Abs. Dose at 0.1 cc < 45 Gy 58.94 Gy

Skin Abs. Dose at 0.1 cc < 50 Gy Yes. 45.82 Gy

Mean Absolute Dose < 18 Yes, Mean = 2.67 Gy

Total Lung Gy Yes, V10 ~ 6%
Relative Volume @ 10 Gy < Yes, V20 ~ 4%
40%
Relative Volume @ 20 Gy <
30%

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
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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).
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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 is not very uniform, though it vaguely resembles an

hourglass. My patients tumor is more on the anterior side, so the PA beam

has to provide more MUs to achieve 50-50 split between each beam.

PA beam = 264 MUs

AP beam = 227 MUs

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b. Is the PTV covered entirely by the 95% isodose line?

No, only 92% of the PTV is covered by 95% isodose line.

Maximum dose to PTV = 62.22 Gy; Average dose to PTV = 59.02 Gy

Minimum Dose to PTV = 52.72 Gy

c. Where is the region of maximum dose (hot spot)? What is it?

The hotspot is near the back of the patient, about 3.2 cm inside from the

back. The maximum dose is 66.48 Gy, or 110.8% of the prescribed dose.

Plan 2: Increase the beam energy for each field to the highest photon

energy available (15X).

a. What happened to the isodose lines when you increased the beam
energy?
The isodose lines became flatter (i.e., more uniform), and the plan became

cooler. The coverage to the PTV is more homogenous, but the 95% isodose

line only covers 84% of the volume now.

Maximum dose to PTV = 61.09 Gy; Average dose to PTV = 58.59 Gy

Minimum Dose to PTV = 49.63 Gy.

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b. Where is the region of maximum dose (hot spot)? Is it near the

surface of the patient? Why?
The hotspot is still in the same general area as that for Plan 1 (6MV);

however, it has moved deeper (anteriorly) by about 1.1 cm. Now, the

maximum dose is 62.84 Gy, or 104.7% of the prescribed dose.

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The 15 MV beam has a Dmax ~ 3 cm compared to 1.5 cm for 6MV. This build-

up region pushes the dose deeper into the body.

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?
I increased the weighting for AP gradually and watched the maximum dose

value on the eval screen. The following table summarizes my observations.

The least hot plan was found to be with - AP : PA = 56.8 : 43.2%

AP Weight 50% 52% 54% 55% 56% 57% 58% 57.2 56.8
% %
Max Dose 62.8 62.2 61.6 61.5 61.1 61.0 61.0 61.0 61.0
(Gy)
4 9 9 0 8 2 8 4 1

b. How is the PTV coverage affected when you adjust the beam
weights?
As I increase the AP weight, the isodose lines get pushed posteriorly and

the hot spot gets pushed the same. Now, the plan is more uniform, but

slightly cooler overall.

Maximum dose to PTV = 60.82 Gy; Average dose to PTV = 58.34 Gy;

Minimum Dose to PTV = 48.82 Gy.

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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

Doing any of the above would allow us to avoid the cord. However, tighter

blocked margins may possibly reduce the coverage to the PTV. Then, if we

increase the MUs to increase the dose to PTV, we get larger hot spots. I

chose to adjust the gantry angle and decrease the jaw along side of the

cord.
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b. Alter the weights of the fields and see how the isodose lines
change in response to the weighting.
This was done and the best result is shown below.
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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, inserting a wedge in the correct orientation definitely helped even

out the dose. I played around with various wedge angles and found that

removing the PA beam completely gave me the best dose conformity. I

only kept the AP beam and the LPO beam. The AP beam had a 15 wedge.
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Which treatment plan covers the target the best? What is the hot spot
for that plan?

The last treatment plan covered the PTV the best. The hot spot = 61.80 Gy

Did you achieve the OR constraints as listed above? List them in the table
above.
The plan met the constraints for Heart, Esophagus, Skin and Lung. But, it did
not meet them for Brachial Plexus, Spinal cord.
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What did you gain from this planning assignment?

This assignment is a well-designed teaching tool. By varying one thing at a time,

I was able to see the effect of that one variable on the coverage and isodose

lines. We started by increasing the energy, then changing the beam weights,

then studying the impact of introducing the wedge, changing the gantry angle to

avoid the OAR (spinal cord), etc.

By the way, I also learned how to use a whole lot of tools in PINNACLE. Even

though contours for organs such as Heart, Brachial Plexus etc. normally would

be done by the physicians, for this exercise my preceptor asked me to practice

doing them. This was very helpful. For example, I learned how to use the

Boolean tools to contour the skin.

What will you do differently next time?

Hopefully, I will able to spot some of the things quicker and thus avoid

repeating some of these learning steps; but, I fear I have ways to go before I

reach that point!