Lung Clinical Lab 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). Create a single AP field using the lowest photon energy in your clinic. Create an MLC
block on the AP beam with a uniform 1.5 cm margin around the PTV. Apply the following
changes (one at a time) as listed in each plan exercise below. After making the adjustments
requested for each plan, answer the provided questions. Tip: Copy and paste each plan after
making the requested changes so you can compare all of them as needed.

Plan 1: Create a beam directly opposed to the original beam (PA). Assign equal (50/50)
weighting to each beam.
 What does the dose distribution look like?
The dose distribution is not ideal because the plan is hot anteriorly and posteriorly without
providing adequate PTV coverage.

 Is the PTV covered entirely by the 95% isodose line?

The PTV is not covered entirely by the 95% isodose line. 73.6% of the PTV volume is covered by
95% with the minimum dose to the PTV being 87.6% (12.75% of the PTV is covered by at least
100% of the prescription dose)

 Where is the region of maximum dose (“hot spot”) and what is it?
The Max dose in the plan is located posteriorly and is 115.9%

 What do you think caused the hot spot in this location?

The distance to the isocenter is slightly greater from the PA field than the AP and the beam must
pass through 4.2cm of solid tissue from the posterior field before reaching lung tissue and only
3.3cm of solid tissue anteriorly. Both of these things will contribute to the slight increase in
monitor units from the PA field, which is why the hotspot is located posteriorly and not
anteriorly.
Plan 2: Adjust the weighting of the beams to try and decrease your “hot spot.”
 What ratio of beam weighting decreases the “hot spot” the most?
The hot spot is decreased the most when the beam weighting is AP: 53% and PA: 47%. The
hotspot is decreased to 113.8% .

 How is the PTV coverage affected when you adjust the beam weights?
The minimum dose to the PTV remained the same at 87.6%; however, the overall coverage to
the PTV did increase slightly so that 74.9% of the PTV volume was covered by 95% and 13.1% of
the PTV is covered by 100%.

Plan 3: Add a 3rd beam to the plan (a lateral or oblique) and assign it a weight of 20%. Try to
avoid the spinal cord.
 How did you decide on the location of your 3rd beam?
I chose to place my third beam as a Lt Lateral because I felt it would offer the best coverage to
the PTV and was also away from the spinal cord.
  Did you do anything special to avoid the spinal cord? (ie. Adjust the gantry angle, tighter
blocked margin, decrease the jaw alongside of the cord)
By placing the third beam at an angle of 90 degrees I was able to avoid the spinal cord without
having to tighten the block margin or decrease the jaw alongside the cord.

 What does the dose distribution look like?

The dose distribution is much more uniform after adding the third beam and the plan is no
longer hot anteriorly and posteriorly like it was with only opposing beams.

 Is the PTV covered entirely by the 95% isodose line?

The PTV is not covered entirely by the 95% isodose line. 80.25% of the PTV volume is covered
by the 95% isodose line, which is an improvement from the AP/PA fields in Plan 2.

 Where is the region of maximum dose (“hot spot”) and what is it?
The region of maximum dose is located slightly superior and lateral within the PTV and is 103.6%

 What do you think caused the hot spot in this location?

I believe the hotspot moved to this location because of the addition of the third beam. All
beams are intersecting in the PTV causing the hotspot to move to this location. The superior
location is due to the AP beam having a heavier weighting than the PA.

Plan 4: Alter the weights of the fields and see how the isodose lines change in response to the
weighting.
 Describe the ideal beam weighting to achieve the best PTV coverage.
The best beam weighting with the angles is:
AP – 45.4%
PA – 30.6%
Lt Lat – 24%
 This beam arrangement allowed for a very small increase in PTV coverage (81% of the PTV being
covered by 95%), while still keeping the 90% isodose line from being in the anterior or posterior
skin of the patient.

 Where is the region of maximum dose (“hot spot”) and what is it?
The region of maximum dose is located within the PTV volume and is 104%

 What do you think caused the hot spot in this location?

The hot spot has only moved slightly from the last plan and I believe that is because of the small
change in beam weighting compared to Plan 3.

Plan 5: Try inserting wedges for at least one or more beams to improve PTV coverage.
 List the wedge(s) used and the orientation in relation to the patient.
I added a 30 degree wedge to both the AP and Lt Lat beams. For the AP beam I placed the
wedge with the heal inferior and for the lateral I placed the heal of the wedge anteriorly.

 Describe how the isodose lines changed.

The isodose lines shifted superiorly and posteriorly within the patient providing a better overall
dose distribution from the previous plan (increase from 81% to 85.8%).

 Where is the region of maximum dose (“hot spot”) and what is it?
The region of maximum dose is 102.7% and is located slightly superior and midline within the
PTV.

 What do you think caused the hot spot in this location?

I believe the hotspot shifted to this location because of the wedge I placed on the AP beam to
shift the dose more superiorly within the PTV.
Plan 6: At this point you may adjust the beam energy, beam weighting, and/or wedges to achieve the
best PTV coverage. Once you have obtained the best plan possible, 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 chose to use all 6x for the plan because I found when I used any 18x I was losing dose around
the periphery of the tumor volume due to the fact that 18x requires more distance to reach
electronic equilibrium (dmax) than 6x after traveling through the lung and reaching the tumor
volume.

 What is the final weighting of your plan?

AP 39%
PA 37.5%
Lt Lat 23.5%

 Where is the region of maximum dose (“hot spot”) and what is it?
The region of maximum dose is within the PTV volume (slightly anterior and lateral within the
volume) and is 109.7 after normalizing.

 What do you think caused the hot spot in this location?

The hotspot is located slightly superior within the PTV due to the wedge orientation that was
used to push dose superiorly and laterally.

 What impact did you see after normalization? Why?

After normalizing I saw an increase in the maximum dose of the plan as well as the PTV
coverage. This was due to normalizing so that 95% of the PTV would receive 100% of the dose.
By normalizing this way it made the plan “hotter” in order to provide the coverage requested.
The hotspot in the plan increased from 102.2 to 109.7 and the PTV coverage increased from 95%
 of the PTV being covered by 93.1% of the prescribed dose to being covered by 100% of the
prescribed dose. This increase in dose also caused the 90 and 95% isodose lines to once again
appear in the anterior and posterior skin of the patient.

 Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and
coronal views. Show the PTV and any OAR’s.

 If this patient is treated to 60 Gy, use the table below to list typical organs at risk, 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

Total Lung-ITV (RTOG) V20 <35-37% V20 = 21.7%
Mean dose <20Gy Mean dose = 12.7Gy
V5 < 65% V5 = 42.6%
Heart (RTOG) V30 < 50% V30 = 0.25%
V45 <35% V45 = 0.07%
Max dose< presc. dose (ideal) Max dose = 57Gy
Esophagus (RTOG) Mean dose < 34Gy Mean dose = 4.4Gy
Max 105% of presc. dose Max dose = 15.6Gy
Spinal Cord (RTOG) Max dose < 50Gy Max dose = 3.4Gy
Ideal <45Gy
 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.