Evgenia Nigay
Planning Assignment (Lung)
Target organ(s) or tissue being treated:
Prescription: 5,940 cGy 33 fx, 180 cGy/fx
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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)
Heart 33% 60 Gy 33% - 34 Gy
Spinal cord Max 45 Gy Max - 46 Gy
Esophagus Mean 34 Gy Mean - 28 Gy
Max 47 Gy Max - 60 Gy
Lung Sum 37% 20 Gy 37% - 13 Gy
Figure 1. Final DVH
Evgenia Nigay
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?
At the areas where the beams pass through the lung the dose distribution is uniform;
isodose lines dip where the beams pass through the tissue and bone due to higher density
and increased absorption when compared to lung.
b. Is the PTV covered entirely by the 95% isodose line?
95% isodose line covers only 80% of the PTV volume.
c. Where is the region of maximum dose (hot spot)? What is it?
Region of maximum dose is 113.5% and is at the posterior side, where the beam passes
through the rib.
Figure 2. Plan 1 screenshot showing isodose lines, the hot spot and PTV coverage
Evgenia Nigay
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?
Energy was increased from 6x to 15x. With increased energy, the isodose lines became
more uniform; PTV coverage improved and the hot spot decreased.
b. Where is the region of maximum dose (hot spot)? Is it near the surface of the
patient? Why?
Region of maximum dose remained at the same area but decreased to 108.8%. The hot
spot is near the surface of the patient where the beam passed through the rib; this hot spot
is most likely due to increased density of the bone, which leads to increased absorption of
the beam when it passes through.
Figure 3. Plan 2 screenshot showing isodose lines, the hot spot and PTV coverage
Evgenia Nigay
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?
AP:PA weighting of 0.555:0.445 reduces the hot spot the most (106.7%); this weighting
also reduces the area of the hot spot and shifts it to the anterior side.
b. How is the PTV coverage affected when you adjust the beam weights?
PTV coverage remained the same when adjusting the beam weighting.
Figure 4. Plan 3 screenshot showing adjusted beam weighting, PTV coverage and the hot spot
Evgenia Nigay
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?
To avoid the spinal cord, a posterior oblique field was used (110) and a collimation of 5
was added. Tighter margin around the PTV was created by adjusting the MLCs along the
side of the cord and closing in the X2 jaw.
a. Alter the weights of the fields and see how the isodose lines change in response
to the weighting.
Adjusting the beam weighting resulted in more uniform isodose lines, providing a more
conformal coverage and a lesser hot spot (104.1%).
Figure 5. Plan 4 screenshot showing isodose lines for a 3-field beam arrangement with adjusted weighting
Evgenia Nigay
b. 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.
Wedges helped slightly to improve the PTV coverage and decrease the hot spot and the
dose to the OARs. I used two 45 wedges, for PA and LPO fields.
Figure 6. Comparative DVH of PTV coverage for plan 4 and plan 4 w/ wedges
Figure 7. Plan 4W screenshot showing isodose lines for fields with wedges
Evgenia Nigay
Which treatment plan covers the target the best? What is the hot spot for that plan?
Plan 4 with wedges provided the best target coverage with a more conformal isodose
distribution and a lesser hot spot. Hot spot for this plan was 103.6%.
Did you achieve the OR constraints as listed above? List them in the table above.
OAR constraints for the heart and total lung volume were met; mean dose constraint for
esophagus was also met. However, maximum dose for spinal cord and esophagus were
higher than allowable.
What did you gain from this planning assignment?
This planning assignment helped me understand the effects of different energies and tissue
densities on the absorption/penetration of the beam. I observed the effects that beam
weighting and wedges have on isodose lines. I also learned that when creating a plan there
are many factors to consider: in addition to providing adequate PTV coverage, OAR
constraints must be met and kept as low as possible to spare normal tissue from unnecessary
radiation exposure.
What will you do differently next time?
To create a better plan, I would not use an AP/PA arrangement of beams because the spinal
cord and esophagus doses are too high. I would use an off-cord oblique beam arrangement to
avoid including the spinal cord in the treatment field. Also, the use of tighter margins all
around the PTV would help spare the surrounding normal tissue.
