LUNG CLINICAL LAB ASSIGNMENT

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?

There are hot spots on the AP beam, just anterior to the lung volume (along the chestwall), and hot
spots on the PA field, just posterior to the lung volume. The 95% isodose line has a slight hourglass
appearance. The 50% isodose line defines the field edge of the treatment field.

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

No. You can visually see that the 95% isodose line is not covering the entire PTV volume, and upon
further review looking at the DVH, the tumor volume at 95% is only receiving 5646.54 cGy instead of the
full 6000 cGy.

Where is the region of maximum dose (“hot spot”) and what is it?
The maximum dose is 6936.2 cGy and is located on the PA field in the muscle, just medial to the left
scapula (on a transverse image).

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

There is a lot of different densities that the radiation is penetrating through. On the AP field the beam is
traveling through fat, muscle, bone, and air before reaching the tumor – same goes for the PA field.
However, the tissue separation along the CAX is different between the AP (~2.53 cm) and PA (~3.76 cm)
field. The PA field must go through more tissue before being able to deposit its’ dose to the PTV – I
believe this is one main aspect why the hot spot is located on the PA field.
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 ratio of beam weighting that decreased the “hot spot” the most, is with a ratio of 53/47. Although
this ratio didn’t take away the “hot spot,” it did lessen the “hot spot” some and make the “hot spot”
more uniformly distributed between the AP and PA field.

How is the PTV coverage affected when you adjust the beam weights?
As you adjust a heavier beam weighting on the AP field it pulls the dose away from the posterior aspect
of the PTV and a lot of the dose is shifted towards the chest wall (I used a ratio of 71/29 to really
accentuate what was going on). As you adjust a heavier beam weighting on the PA field, it does just as
the AP field did, but the dose is pulled away from the AP field and the dose is mainly shifted into the
patients back (I used a ratio of 19/81).
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 decided to do a left lateral for the 3rd beam after trying to use an oblique and didn’t have good dose
distribution – I was getting too large of hot spots and not tight isodose lines.

Did you do anything special to avoid the spinal cord?

By angling the gantry to a left lateral beam with a margin of 1.5 cm around the PTV, that ensured that
the spinal cord was being avoided.

What does the dose distribution look like?

The dose distribution looks like a soft edged square (on a transverse view) until you start getting past
the 90% isodose line, then the isodose lines start spreading out anteriorly and posteriorly. On the AP
and PA fields, the isodose lines are right along the chestwall (for the AP) and the skin surface (for the PA)
once you get to the 70% or below, isodose line. The posterior aspect of the PTV is still not getting full
coverage from the 95% isodose line due to heterogeneity to lung.

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

No. A small portion of the most superior aspect of the PTV is outside the 95% isodose line, as well as a
portion of the posterior aspect of the PTV.

Where is the region of maximum dose (“hot spot”) and what is it?
The maximum dose is 6297.8 cGy and is located inside the PTV volume.

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

The hot spot looks near the center of the CAX and where all three beams intersect. One should expect
the dose to be deposited into the soft tissue and not in the surrounding air volume because of the dose
buildup.
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 ideal beam weight for this plan, I believe, was with a weighing of 32 (AP), 42 (PA), and 26 (Lt lat).
Essentially you want to see an even distribution of hot spots. I started with equal weighting and then
would lock one field at a time to see if the hot spots got better or worse by adjusting the weighting. I
also kept an eye on the max dose for the hot spot to make sure that number didn’t go up (which means
that I needed to bring the weighting back).

Where is the region of maximum dose (“hot spot”) and what is it?
The region of maximum dose is inside the PTV volume, and is 6311.8 cGy.

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

Just like plan #3, the hot spot looks near the center of the CAX and where all three beams intersect. One
should expect the dose to be deposited into the soft tissue and not in the surrounding air volume
because of the dose buildup.
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.
For the AP field, I used a 15-degree wedge, heel towards the lateral aspect of patient to account for the
slope in tissue. For the PA field, I used a 15-degree wedge, (same orientation as the AP) heel towards
the lateral aspect of the of the patient, toe towards the medial aspect. For the left lateral field, I used a
15-degree wedge, with the heel anterior to the patient, toe points posterior to the patient.

Describe how the isodose lines changed.

The isodose lines look like a soft edged square, until you get to the 70% isodose line and then the lines
spread anterior to posterior. The isodose lines (specifically the 95% and 98%) look slightly tigher around
the PTV volume.

Where is the region of maximum dose (“hot spot”) and what is it?
The “hot spot” is located inside the PTV and the maximum dose is 6260.7 cGy.

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

Just like plan #4, the hot spot looks near the center of the CAX and where all three beams intersect. One
should expect the dose to be deposited into the soft tissue and not in the surrounding air volume
because of the dose buildup. The location of the hot spot hasn’t really changed between these plans so
far, but the dose has gotten better with the addition of beam weighting and wedges.
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 used 6 MV because of the dose build up. When the beam first travels and hits tissue (skin
surface/tissue) there is a dose build up, then when the beam travels through the air and hits more
tissue, this creates a second dose building up. If you use 15 MV it would actually cause there to be some
margin around the tumor volume (due to the dose build up) and would spare dose to the tumor volume,
which is not the outcome we want to achieve.

What is the final weighting of your plan?

I used equal weighting on my two conformal arcs.

Where is the region of maximum dose (“hot spot”) and what is it?
The region of maximum dose is located inside the PTV, towards the inferior aspect and the maximum
dose is 6655 cGy.

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

The hot spot looks relatively near the center of the CAX and where all three beams intersect. One
should expect the dose to be deposited into the soft tissue and not in the surrounding air volume
because of the dose buildup. The location of the hot spot hasn’t really changed between these plans.

What impact did you see after normalization? Why?

I tried making a plan with 100% normalization but there wasn’t enough coverage to the inferior aspect
of the PTV so I had to normalize down to 94.5%. When I normalized down, the isodose curves expanded
out slightly to where I could achieve 95% of the PTV receiving the total 6000 cGy (100% of the dose). By
normalizing down, it did increase the dose of the maximum spot (or “hot spot”). When you normalize
down it is like when a teacher sets a grade curve. As an example, say a math test was given and a 90
was the highest grade in the class, and everyone else scored a 70 or lower, if the teacher says they’re
going to set a curve, the 90 becomes a 100 and everyone else’s grade gets increased by 10% - this is
essentially what is going on in normalization.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Heart V45 < 67%; V60 < 33%1 V45 dose 100.33 cGy
Left Lung Mean 20 Gy2 Mean dose 1733.5 cGy
Total Lung Mean < 20-23 Gy; V20 < 30- Mean dose 1189.9 cGy
35%1
Spinal cord < 50 Gy2 Max dose 1702.3 cGy
Esophagus Mean < 34 Gy2 Mean dose 641.6 cGy
Skin 10 cc < 70 Gy3 10 cc dose 6529 cGy
 Sources

1. University of Wisconsin – La Crosse

Normal Tissue Constraint Guidelines
https://uwlmedicaldosimetry2013.wikispaces.com/file/view/Constraints.pdf
Accessed January 31, 2018

2. Wiki Books
Radiation Oncology/Toxicity/QUANTEC
Wiki Books website
https://en.wikibooks.org/wiki/Radiation_Oncology/Toxicity/QUANTEC
Updated September 23, 2015
Accessed January 31, 2018

3. T.S. Kehwar, Ph. D., D. Sc. & S. C. Sharma, M. D.

Use of normal tissue tolerance doses into linear quadratic equation to estimate normal tissue
complication probability.
http://www.rooj.com/Radiation%20Tissue%20Tolerance.htm
Accessed January 31, 2018