Ontida Apinorasethkul

DOS791
March 2, 2015
Clinical Lung Lab Assignment
In a lung case at my institution, dosimetrist would draw the normal structures, such as
spinal cord, lungs, heart and esophagus (Figure 1). Physician would draw brachial plexus and all
the treatment volumes (Figures 2 and 3). In this case, the physician did not draw the gross tumor
volume (GTV), however, the clinical target volume (CTV) was drawn. Four-dimensional
computed tomography (4DCT) was used to identify the internal clinical target volume (iCTV) to
account for tumor motion. There was a slight motion to the right of the CTV of 0.4cm.
Therefore, 0.4cm margin was added to the right to generate the iCTV. Then the physician
created a 0.5cm expansion to the planning target volume (PTV) from iCTV.
Volumetric Modulated Arc Therapy (VMAT) was chosen as a treatment planning
technique in this case. Because the patient had no left lung, VMAT was used. If both lungs were
presented, intensity modulated radiation therapy (IMRT) would be used for lower low dose to the
lungs. This plan was using 2 partial arcs of 180 counterclockwise to 350 and back clockwise
from 350 to 180. The concern of planning was placed to the right lung since the patient had
only one lung as well as the spinal cord. Therefore, the arcs were set to stop at 350. Isocenter
was set to be in the middle of the volume to cover the whole target. Jaw size was set to cover the
treatment volume during the 2 partial arcs. Collimator angles between the 2 arcs were
complimentary to each other; 20 and 340 to reduce the tongue and groove effects of the
multileaf collimator (MLC) leakage. 6MV was used for both arcs (Figures 4 and 5). According
to RTOG 0839, the dose prescription was 60Gy in 30 fractions (Figure 6).
The plan needed to be prescribed to 98.7% in order for the minimum dose requirement of
the PTV to meet 93% as well as getting 95% of the volume to meet 100% of the dose. Dose
prescription coverage is shown in Figure 7. Maximum dose of the plan was 112%, which was
well below 120% goal. Homogeneity correction was used for optimization and plan calculation.
All the organs at risk met and were well below the objectives (Table 1, Figures 8 and 9). There
was no compromise in the treatment volume to lower the right lung dose nor the cord. Dose
distribution showed a conformal plan without much streaks and spills (Figures 10 and 11). If

IMRT was chosen for this case, there might be a lot of dose streaks. However, in general, VMAT
plan spread out more low dose in the treatment region than IMRT plan.

Figures and Tables

Heart
Right Lung

Esophagus

Spinal
Cord

Figure 1: Organs at risk contours

Brachial Plexus

Figure 2: Organs at risk contours (contd)

CTV_6000

iCTV_6000

Figure 3: Treatment volume contours (CTV, iCTV and PTV)

Figure 4: Beam arrangements and jaw size

PTV_6000

Figure 5: Fields details

Figure 6: Dose prescription

Achieved
Organ at Risk
Spinal cord

Desired Objective
50.5Gy max
20Gy mean
Lungs
V20 < 37%
Esophagus
40Gy mean
Brachial plexus
66Gy max
V60 < 33%
Heart
V45 < 66%
V40 < 100%
Table 1: Organs at Risk Objectives

Objective
27.5Gy max
6.46Gy mean
V20 = 6.2%
25.3Gy mean
7.6Gy max
V60 = 0.08%
V45 = 0.42%
V40 = 0.67%

Figure 7: Dose prescription coverage to PTV in dose color wash

Figure 8: Dose Volume Histogram of treatment volumes and organs at risk

Figure 9: Dose information to the treatment volumes and organs at risk

Figure 10: Axial, coronal and sagittal planes showing isodose lines to the treatment volumes

Figure 11: Axial, coronal and sagittal planes showing dose color wash to the treatment volumes