Michelle Rocque

Clinical Practicum 1
Planning Assignment (Lung)
Target organ(s) or tissue being treated: Rt Lung Tumor
Prescription: 6000cGy

200cGy/fx 30Fx

Organs at risk (OR) in the treatment area (list organs and desired objectives
in the table below):
Organ at risk
Spinal cord

Desired objective(s)
Less than 50Gy with less than
0.2% complication
V20 <=30%

Achieved objective(s
157.2 cGy Max Dose
V20 = 26.12%

Lung
Esophagus

Heart

Mean <34Gy
V35 <50% V50 <40%
V70<20%
V30 <46% V25 <10%
Mean <26%

648.4 cGy Mean Dose

V30 = 11.9% V25 = 13%

Mean = 23.5%

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). Refer
to Bentel, pp. 370-376 for references:
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? Fairly evenly distributed
anteriorly/ posteriorly. The isodose lines collapse in laterally.

b. Is the PTV covered entirely by the 95% isodose line? Loses coverage
laterally around PTV
c. Where is the region of maximum dose (hot spot)? What is it?
Maximum dose region is in posterior chest wall and it is 110.4.
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? I lost most of the coverage of 95% isodose line around the
PTV. Dose is lost at the skin surface anteriorly and posteriorly.
b. Where is the region of maximum dose (hot spot)? Is it near the
surface of the patient? Why? Region of maximum dose is moved to
midline and medial aspect of field. This is due to the change of dmax.
The 23X beam has a higher dmax (about 3.2).
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? I
lowered energy to 6MV and weighting 53% AP; 47% PA which lowered
the hotspot to 108.8.
b. How is the PTV coverage affected when you adjust the beam
weights? PTV coverage is Ok until I start to overweight the AP then I
begin to lose coverage.
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? I turned the
contour of the spinal cord on and added the 3rd beam. Then I began
angling the gantry until I was able to avoid the structure. This patient
has a tumor that is close to midline so I made the field straight lateral
which totally is off cord.
i. Adjust the gantry angle?
ii. Tighter blocked margin along the cord

iii. Decrease the jaw along side of the cord

b. Alter the weights of the fields and see how the isodose lines
change in response to the weighting. At 20% weight on the lateral,
the coverage way not good medially so I increased the lateral
weight and then decreased to visualize if this would help skew the
isodose lines. By increasing the weighting on the lateral it helped
to even the 95% isodose around the PTV and lowered the hotspot.
c. 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. The hotspot was located anteriorly so I inserted a
dynamic 15degree wedge on the AP beam. This attenuated the
dose which was hotter on the anterior/lateral aspect and pushed it
medially. This lowered the hotspot and placed it in the PTV. I
normalized the plan to the 95% isodose line and this gave good
coverage with an acceptable hotspot.

Which treatment plan covers the target the best? What is the hot spot
for that plan? Plan 4 was the best with 3 beams. The hotspot was
107.6% normalized to the 95% isodose line.

Did you achieve the OR constraints as listed above? List them in the table
above.
All constraints were made except the V25 of the heart.
What did you gain from this planning assignment?
I could see real changes in how the target was covered with the
addition of the third beam. I gained knowledge of angling the gantry
to avoid organs at risk. I also saw how weighting drastically changed
the isodose lines.

What will you do differently next time?

Instead of AP/PA beams, I would try oblique fields to try and come off the
heart. This might increase the esophagus dose more. I saw by introducing more
beams the volume around the tumor became more conformal.