Lung Clinical Lab Assignment

Use the Lung CT data set provided to complete the following 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. Note:
calculation point will be at isocenter. 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 cm margin around the PTV. Apply the following
changes (one at a time) as listed in each plan exercise below. Each plan will build in complexity off of the
previous one. After adjusting each plan, answer the provided questions. Include an axial screen shot for each
plan to show the isodose distribution along with a DVH clearly displaying your PTV coverage.
 Important: Please do not normalize your plan when making these adjustments until instructed to do so
in the final plan.
 Tip: Copy and paste each plan after making the requested changes so you can compare all of them as
needed.

Plan 1: Create a field directly opposed to the original field (PA). Assign equal (50/50) weighting to each field.
 What shape does the dose distribution resemble?
o The dose distribution almost resembles an hourglass shape. There are two high dose clouds at
the anterior and posterior part of the patient which fall off to a lower dose within the lung
portion before creating another high dose cloud close to the PTV. This is due to the
inhomogeneity within the patient and beams traveling through higher density tissue and lung
tissue.
  How much of the PTV is covered entirely by the 100% isodose line?
o Without making any changes to the current plan, the 100% isodose line is only covering 7.9% of
the PTV target.

 In your own words, summarize two advantages of using a parallel opposed plan? (Review Khan, 5th ed.,
11.5.A, Parallel Opposed Fields)
o According to Kahn, parallel opposed beam setups are one of the simplest field combinations.
Simple field arrangements allow for better reproducibility and little margin for any type of
geometric error while still allowing adequate dose to the treatment target. This is a quick
planning method that can be utilized for fast turnaround patients as well.

Plan 2: Add a direct left lateral field to the plan and assign equal weighting to all fields. How did this field
addition change the isodose distribution?
o With adding a third field, the isodose distribution has become more conformal around the PTV
target. It took away some of the high dose clouds anterior and posteriorly. This also helped
cool the plan down quite a bit because dose can spread out more between the 3 fields. My
“hot spot” went from 114.6% to 102.7% and has moved from the posterior high dose cloud to
the center of the PTV. A low dose cloud has also appeared laterally where the beam is
entering.
  How much of the PTV is covered entirely by the 100% isodose line?
o The 100% isodose line is now covering about 13.5% of the PTV volume.

Plan 3: Add 2 oblique fields on the affected side—1 on the anterior portion and 1 on the posterior portion of
the patient. Assign equal weighting to all fields.
 What angles did you choose and why?
o The angles I ended up choosing after some trial and error were G35 and G145. I utilized the
beams eye view to ensure I was using an angle that didn’t have any or the least amount of OAR
within the field. Below is an example of my LAO field. I had to angle it slightly higher to avoid
the esophagus as much as I could without coming in too close to the AP beam.
  In your own words, summarize why beam energy is an important consideration for lung treatments?
(Review Khan, 5th ed., 12.5.B3, Lung Tissue)
o Lung tissue has a much lower density than surrounding tissues which causes the beam to
interact much differently than it would with fat or muscle. Due to the lung density, an
increased number of electrons will travel outside the beam geometry limits causing loss of
sharpness and giving increased dose beyond the lung. These effects are exaggerated with
higher energies and can result in under dosing the peripheral edge of the tumor.

Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
 How does field weight adjustment impact a plan?
o Adjusting the field weights alters the contribution of a specific beam to a plan. By equalizing all
field weights each beam would contribute equally. Adjusting beam weight can help to minimize
exit dose and high dose clouds or maximize dose coverage. Beam weight is a balancing act to
achieve target coverage and minimize dose to tissue or OARs. Increasing a beam’s field weight,
pulls the isodose lines toward the beam origin while it decreases the weight of the other
beams.
 List your final choice for field weighting on each field.
Plan 5: Try inserting wedges for at least one or more fields to improve PTV coverage. You may also adjust field
weighting if you feel it’s necessary.
 Embed a screen capture of the beams-eye view (BEV) for each field that you used a wedge.

 List the wedge(s) used and the orientation in relation to the patient and describe its purpose. (ie. Did it
push dose where it was lacking or move a hotspot?)
o I ended up using a 30 wedge on the AP (gantry 0) and PA (gantry 180) fields. The heel for both
wedges was pointing towards the left lateral side of the patient. My high dose and 100% before
using a wedge was leaning towards the outer portion of the PTV and not covering as well
medially. So, I used wedges with the heel covering where the high dose and 100% was to try
and push more coverage for the PTV medially. Adding wedges slightly helped achieve better
coverage, but the plan still needs some help with either higher energy or normalization. The
hotspot did move medially but not by much and is still within the PTV.
 Describe how your PTV coverage changed (relating to the 100% isodose line) with your final wedge
choice(s).
o As I mentioned above, coverage improved minimally by adding the wedges. My 100% is still
only covering 14.2% of the PTV.

Plan 6: Normalize your plan so that 95% of the PTV is receiving 100% of the prescription dose.
 What impact did normalization have on your final plan?
o Normalizing the plan increased target coverage and raised my Dose MAX from 102.4% to
113.2%. There is a larger cloud of 105% expanding outside of the PTV, as well as a dose cloud
of 110%+ which is luckily remaining within the PTV target. Overall, normalizing made the plan
“hotter” by increasing isodose lines to achieve the 95% coverage.
  What is your final hotspot and where is it?
o The current hotspot is 113.2% and is at the inferior portion of the PTV, but still within the
target.

 Are you satisfied with the location of the hotspot?

o Yes, I am okay with the current hotspot location as it seems to be sitting within tumor (inside of
both the ITV and the PTV) and not normal tissue or an OAR.

Plan 7: There are many ways to approach a treatment plan and what you just designed was just one idea.
Using the tools of your TPS, your current knowledge of planning, and the help of your preceptor, adjust or
design your own ideal 3D lung treatment plan. Get creative! You may adjust the beam energy, beam
weighting, wedges, add field-in-field, etc. Normalize your final plan so that 95% of the PTV is receiving 100%
of the dose.
 What energy(ies) did you use and why?
o I kept all my field energies at 6X. I tried to adjust some of them to 10x to see if it would help
increase coverage before normalizing and noticed it hadn’t helped at all or even took some
coverage away.
 What is the final weighting of each field in the plan?

 Where is the region of maximum dose (“hot spot”), what is it, and is this outcome clinically acceptable?
o The hot spot falls within the ITV towards the inferior portion of the target. The hotspot for my
final plan is 105.7%. This is a very acceptable hot spot. At my clinical site, we try to achieve a hot
spot of 105% but that isn’t always possible. For 3D cases especially it can be upwards of 115%.
Also having it located within the target is what we strive for so it’s not falling in healthy tissue or
an OAR. Hot spot location is visible in all three screen cap views listed below.
 Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and coronal views.
o Below are the images for my final plan. I used the original plan I had done and then tried to play
with different angles and beam weightings to see if I could bring the OARs doses any lower.
Between the two plans, this is the one I ended up choosing because it actually had lower heart,
spinal canal and esophagus dose.
  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. See
example in Canvas.

 Use the table below to list typical OAR, critical planning objectives, and the achieved outcome. Please
provide a reference for your planning objectives.

Organ at Risk (OAR) Desired Planning Objective1 Planning Objective Outcome

Esophagus V5cc<51Gy V5cc= 13.9Gy
Heart V20<40Gy V20= 9.9Gy
Spinal Cord V5cc<47.4Gy V5cc= 7.6Gy
Total Lung V20Gy<37% V20Gy= 19.8%
Reference:

1. Timmerman, R. (2022). A story of hypofractionation and the table on the wall. International Journal of

Radiation Oncology Biology Physics, 112(1), 4–21. https://doi.org/10.1016/j.ijrobp.2021.09.027