Kelli Braith
DOS771: Clinical Internship I
Spring 2024
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 shape that is resembled is that of an hourglass due to the parallel opposed
beam arrangement. The distribution of the anterior posterior beam arrangement
improves dose distribution compared to one single field. The arrangement
deposits dose more superficially on the anterior and posterior portions of the
body, creating more dose to the superficial tissue. Parallel opposed fields are
homogeneous to the tumor and have less of a chance of geometric miss. One
disadvantage of parallel opposed fields is the unnecessary dose to normal tissue
and other critical organs.1
How much of the PTV is covered entirely by the 100% isodose line?
o The amount of the PTV entirely by 100% of the dose is 6.16%.
In your own words, summarize two advantages of using a parallel opposed plan?
(Review Khan, 5th ed., 11.5.A, Parallel Opposed Fields)
o Fields that are parallel opposed and equally weighted provide a uniform dose
distribution within the volume. Parallel opposed field are advantageous for
simplicity and reproducibility of set up.1 A simpler set up can assist with
efficiency if the patient is in pain or unable to lie on the table for an extended
period.
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 When adding a left lateral field, the isodose distribution is more conformal and is
less hot on the superficial portions of the patient. The 90% (blue) dose line is
almost encompassing the entire PTV. The global hot spot in the in the PTV, an
important part of treatment planning is ensuring that maximum dose is
delivered to the tumor while minimizing dose to the surrounding tissue. 1 Adding
a third field assists with conformal dose distribution.
How much of the PTV is covered entirely by the 100% isodose line?
o The 100% isodose line encompasses 14.5636% of the PTV.
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 that were chosen were 25 degrees from the anterior portion and 135
degrees from the posterior portion. These angles were chosen to try to limit
dose to OAR and get conformal dose distribution. The OAR are the esophagus,
heart, spinal cord, and contralateral lung. A gantry angle of 25 degrees from the
anterior portion assists with limiting dose to the esophagus, heart, and
contralateral lung. The gantry angle of 45 degrees from the posterior portion
assists with dose to the spinal cord, esophagus, and contralateral lung.
Plan 3 DVH:
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 It is important to consider lung tissue density for lung treatments. The lung has
lower lung density and gives rise to dose within and beyond the lung. 1 Higher
energy beams that are used may provide deeper penetration and dose
conformity, but the higher energies have a higher energy recoil electrons in low-
density material (lung), causing lateral electronic disequilibrium and degrades
the target coverage.4
Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
How does field weight adjustment impact a plan?
o When weighting the fields, the anterior and posterior beams are weighed the
same. This was done to assist with dose distribution to the anterior and posterior
portions of the target. The 90% isodose line covers more of the PTV and is also
more conformed to the target. This is vital to try to keep the lung dose as low as
possible outside of the treatment volume. An important value is the V20. The
pertains to the volume of the lung total. Pneumonitis increases with higher V20
percentages.2 Weighting on the lateral and oblique beams assisted with the
anterior/lateral superficial dose.
Plan 4 DVH:
List your final choice for field weighting on each field.
o ANTERIOR FIELD: 0.251
o POSTERIOR FIELD: 0.251
o LEFT LATERAL: 0.187
o A25L (GANTRY= 25 DEGREES): 0.131
o P45L (GANTRY= 135 DEGREES): 0.180
Plan 3: Dose on the superficial of the posterior beam aspect.
Plan 4:
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.
Left lateral beam: EDW25IN A25L (GANTRY= 25 DEGREES): EDW30IN
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 Left lateral beam: EDW25IN: the heel of the wedge is inferior. This was used to
shift the dose superior and more of the prescription towards the target and
decreased the higher dose inferiorly.
o A25L (GANTRY= 25 DEGREES): EDW30OUT: the wedge is positioned with the heel
lateral to assist with coverage medially. This also shifted the isodose lines to
better cover the target with 90% of the dose.
Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s).
o The PTV is covered 12.3812% by the 100% isodose line.
o The prescription was shifted superior and medial with the use of wedges. The
hot spot is in a more ideal location nearer the center of the PTV.
o I adjusted the weighting on the beams slightly after implementing the wedges.
This was done to shift the dose more into the PTV and to better conform the
dose to the target.
Plan 5: Dose distribution:
Plan 5 hot spot location:
Plan 4 hot spot location:
Plan 5 DVH:
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 Normalization made the plan hotter. The global hot spot went up from 102.2% to
111.9%. The plan needed a normalization value of 91.17% to achieve 100% PTV
coverage.
Plan 6 DVH:
What is your final hotspot and where is it?
o The hot spot is 6741.2 cGy (111.9%) and it is in the PTV and inside the ITV. The
ITV (internal target volume) is an internal margin that is added to the CTV to
consider internal physiologic movements and change in size, shape, and position
of the CTV during treatment.1
Are you satisfied with the location of the hotspot?
o The location of the hotspot is ideal. The hot spot is in the PTV and in the ITV. The
hot spot is in a location that is away from OAR. The hot spot is not close to the
esophagus, cord, or heart. This is achieved by trying to deposit the hot spot to
the lateral portion of the PTV to preserve OAR. According to QUANTEC, the
esophagus constraints are V35 < 50%, V50 < 40%, V70 < 20%, and V60 < 30%. A
fistula or stenosis could occur is these constraints are not met. Spinal cord max
dose 50 Gy, myelitis could occur if not met. The heart constraints are V30 < 46%
and V25 < 10% pericarditis and cardiac mortality are consequences of these
constraints.3
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 used 10x on all the fields. I chose 10x to decrease dose to the soft tissue. The
dose conforms more to the PTV. The tumor location also had an influence as to
why I chose 10x. The volume is more medial and more in the middle of the lung,
10x achieves a good distribution. The beam energies of 6x could have also been
used. The use of lower beams is preferred, to lower the beam penumbra due to
electron transport in low-density media.1
What is the final weighting of each field in the plan?
o The parent fields are weighted more and then the subfields are weighted less as
they will be delivering dose as the MLCs move to shape the beam.
Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable?
o Region of maximum dose is in the PTV and ITV. The hot spot measures 6521.5
cGy (108.7%). This dose is clinically acceptable as it is in the target and doses are
limited to OAR.
Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and
coronal views.
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.
o I referenced QUANTEC and the Mayo Clinic department standards as there is
room for clinical judgment by physicians and these standards will be reviewed in
the treatment decision-making process.3
Organ at Risk (OAR) Desired Planning Objective Planning Objective
Objective Met?
Outcome
Heart V30 Gy < 46% (QUANTEC) 0% Yes
V40Gy [%] < 33% (Department standard) 0% Yes
Mean < 20 Gy (Department standard) 1.075 Gy Yes
Max [Gy] < 62 Gy (Department standard) 40.533 Yes
Left Lung Mean [Gy] (Department standard) 16.42 Gy Yes
V10 Gy [%](Department standard) 40 %
V20 Gy [%] <= 30 % (Department 31.2 % No
standard)
Right lung Mean [Gy] (Department standard) 1.41 Gy
V10 Gy [%](Department standard) 0%
V20 Gy [%](Department standard) 0%
Lung total Mean < 20 Gy (Department standard) 10.13 Gy Yes
V10 Gy [%] < 42% (Department 23.26 % Yes
standard)
V20 Gy [%] < 35% (Department 18.14 % Yes
standard)
Spinal Canal Max < 50 Gy (QUANTEC) 7.67 Gy Yes
Esophagus Max [Gy] (Department standard) 11.40 Gy
Min [Gy] (Department standard) .069 Gy
Mean [Gy] < 34 Gy (Department 1.731 Gy Yes
standard)
V35 Gy [%] < 50% (Department 0% Yes
standard)
V50 Gy [%] < 45% (Department 0% Yes
standard)
V55 Gy [%] <= 40% (Department 0% Yes
standard)
V60 Gy [%] < 5% (Department standard) 0% Yes
PTV Lung Max[%](Department standard) 108.7 %
D99%[%] > 93% (Department standard) 98.94 % Yes
V95%[%] (Department standard) 100 %
V110%[%] < 1% (Department standard) 0% Yes
References:
1. Gibbons, JP. Khan’s The Physics of Radiation Therapy. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2020.
2. Washington CM., Leaver, D. Principles and Practice of Radiation Therapy. 3rd ed. St.
Louis, MO: Mosby; 2010.
3. Emami, B. Tolerance of normal tissue to therapeutic radiation. Rep of Radiot and Oncol.
2013; 1(1).
4. Wang, L., Yorke, E., Desobry, G., Chui, Chen-Shou. Dosimetric advantage of using 6 MV
over 15 MV photons in conformal therapy of lung cancer: Monte Carlo studies in patient
geometries. J Appl Clin Med Phys. 2002; 3(1). https://doi.org/10.1120/jacmp.v3i1.2592
