Ian Zoller

Planning Assignment (Lung)

Target organ(s) or tissue being treated: Lt Lung

Prescription: 45 Gy in 30 fractions. Treated BID.

Setup: Patient supine using wingboard and vacbag for arms. Knee sponge under legs.

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)

Spinal Cord
(TD 5/5: 4700 cGy/20 cm)
Total Lung (Lt and Rt Lung
CTV)
(TD 5/5: 1750 cGy)
Esophagus
(TD 5/5: 5500 cGy)
Heart
(TD 5/5: 4000 cGy)
Max point dose: 50 Gy
Mean dose < 20 Gy; V30 <
25%; V20 <40%; V10 <50%, V5
<65%
Mean dose < 34 Gy; V50 <32%
Mean < 35 Gy; V30 <50%; V45
<35%; max dose: 70 Gy
Max dose: 37.76 Gy
Mean dose: 17.19 Gy
V30: 31.1%; V20: 37.7%;
V10:45.7%; V5: 67.3%
Mean dose: 13.47 Gy
V50: 0%
Mean dose: 15.58 Gy
V30: 29.8%; V45: 0.1%
Did not meet

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 takes on an hour glass appearance with the higher isodose lines
dipping in toward the center of the fields. The lines dip in farther in the medial aspect
of the field. The dose seems to be more concentrated toward the posterior of the
patient.
b. Is the PTV covered entirely by the 95% isodose line?
 No, the 95% isodose line is missing coverage of the PTV inferiorly and also medially
toward the heart.
c. Where is the region of maximum dose (hot spot)? What is it?
The max dose point is 123.2% of the tumor dose and is located posteriorly in the
patient.

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 higher isodose lines were constricted more laterally in the air of the lung, but less
constricted medially toward the heart. The PTV is getting better coverage with almost
the entire volume being encompassed by the 95% isodose line. The beams are also
more penetrating with the buildup region being deeper in the patient.
b. Where is the region of maximum dose (hot spot)? Is it near the surface of the
patient? Why?
The hot spot is still located posteriorly but it is deeper when compared to the lesser
energy. This is because of the greater depth of d max for higher energy photon beams.
The hot spot also decreased to 114%.
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 weighted the AP beam 51% and the PA beam 49%. This decreased the hot spot to
113.4%.
b. How is the PTV coverage affected when you adjust the beam weights?
The PTV coverage increased very slightly by changing the beam weighting. The
minimum dose to the PTV increased from 88.9% to 89.0%.
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
In order to avoid cord and to try and spare as much heart and lung as I could, I added an
LAO field with a gantry angle of 52. I also tightened my block margin along the cord side
to 0.5 cm and optimized the jaws.

b. Alter the weights of the fields and see how the isodose lines change in response to
the weighting.
 Weighting the AP and PA beams more in relationship to the oblique field causes the
isodose lines to become elongated in the anterior and posterior directions. Giving
more weight to the oblique field causes the isodose lines to become more
conformal to the target, but coverage is sacrificed medially.
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 they would. There is a hot spot at the intersection of the AP and LAO beams.
Orienting wedges with heels together at the intersection would help prevent this
hot spot and more evenly distribute dose. I inserted a 45 degree wedge in the AP
field and a 60 degree wedge in the LAO field and this gave me much better
coverage.
Which treatment plan covers the target the best? What is the hot spot for that plan?
The final plan using an oblique field and wedges covered the target the best while better
avoiding adjacent OARs. The hot spot for this plan is 106.8%. Without renormalizing,
95% of the dose is covering 98% of the PTV.
 Did you achieve the OR constraints as listed above? List them in the table above.
Following the steps for this lab, there were some constraints I did not meet. The V30
and V5 for the lungs failed to meet with 31.1% and 67.3% respectively.
What did you gain from this planning assignment?
I learned that there are multiple tools that we are able to use in order to manipulate the
beam and get the coverage that we want. These tools are using different energies,
adjusting field weighting, using wedges, adjusting field borders, and manipulating
gantry/collimator angles.
What will you do differently next time?
Next time I would try starting with something opposed that is slightly off cord using an
energy such as 10 MV. Then I would add an oblique field similar to the angle that I used
for this lab to stay off cord but instead use 6 MV. This would help me to get better
coverage while limiting dose to the opposite lung. If I was still struggling to get
coverage, I might try adding an LPO that avoids the opposite lung that is gently
weighted. In addition, I may try wedging my PA field in the sup/inf direction of the
patient to increase my coverage inferiorly.