Michael May

Planning Assignment (Lung)

Target organ(s) or tissue being treated: Lung, Upper left lobe (Apical) lesion, 70.95 mL volume

Prescription:______1200 cGy x 5fx = 6000 cGy_______

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)

Spinal Cord <0.03cc = 28 Gy 308 cGy
<0.35cc = 22 Gy 225 cGy
<1.2 cc = 15.6 Gy 177 cGy
Esophagus <0.03cc = 35 Gy 994 cGy
<5.0cc = 27.5 Gy 911 cGy
Bilateral Lungs <37% volume = 13.5 Gy 177 cGy
<1500cc = 12.5 Gy 125 cGy
<1000cc = 13.5 Gy 442 cGy
<0.03cc = 53 Gy 1504 cGy
Great Vessels <10.0cc = 47 Gy 1195 cGy
*Objectives taken from Timmerman Constraints 2008 for 5 fraction SBRT

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?
The dose distribution resembles a traditional AP/PA hourglass except the air in the lung
has caused the medial portion of beam to pull more towards the medial field borders as
seen in the image below. This is because the beam travels through less tissue, or has a
shorter equivalent path, and therefore more dose gets through.
b. Is the PTV covered entirely by the 95% isodose line?
The PTV is entirely covered by the 85 % line, but not by the 95% line. The 95% isodose
line covers approx. 92% of the target volume per the DVH.
c. Where is the region of maximum dose (hot spot)? What is it?
There are hotspots at both the AP and PA surfaces but the absolute hotspot (120.4%) is
posterior at about the depth of Dmax for a 6x beam. This is because the isocenter is
slightly posterior of the ant/post midline and the anterior beam has to push more dose
to get to isocenter. The additive effect of the two beams places this hotspot posterior.
 The hotspot is in the medial portion of the beam due to differences in heterogeneity
including a larger portion of lung.
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?
The dose distribution with the higher energy beam more closely resembles the
traditional hourglass shape that we see in textbooks. The hot areas are pushed
slightly away from the surface due to an increased depth of Dmax. The posterior has the
larger portion of 100% dose due to isocenter position and differences in heterogeneity.
 b. Where is the region of maximum dose (hot spot)? Is it near the surface of the
patient? Why?
The regions of maximum dose are still both anterior and posterior in the tissue but the
absolute max is 113.0% in the posterior tissue. It is slightly deeper due to the increased
depth of Dmax. With a greater energy, the hotspot has decreased because less dose
needs to be pushed to reach 100% at the reference point.
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?
 Due to my isocenter being almost centered already, very little beam weighting was
needed. The AP beam is 51.2%, PA beam is 48.8%. The hot spot only decreased to
112.4%. Interestingly, the hot spot bounces from posterior to anterior surface
depending on slice now showing me that the weighting is pretty ideal. This bouncing
from one side to another could be caused by patient shape and differences in
heterogeneity.
b. How is the PTV coverage affected when you adjust the beam weights?
b. The 95% isodose line covers 95% of the target volume per the DVH.
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. Adjust the gantry angle?
A lateral beam was added and then adjusted to 105 degrees to help with
cord avoidance.
ii. Tighter blocked margin along the cord
The margin was decreased from 1.5cm to 1cm which assisted in cord
blocking.
iii. Decrease the jaw alongside of the cord
Jaw was slightly decreased due to jaw optimization feature when margin
was reduced. The cord is the blue structure contoured in the Beams Eye
view below.
b. Alter the weights of the fields and see how the isodose lines change in response to
the weighting.
With equal weighting, the 100% isodose line pulls to the postero-lateral corner of
where the 3 beams intersect. A 108.6% hotspot is present in this corner. Changing to a
20% weighting on the postero-lateral beam slightly shifts the isodose lines towards the
posterior. When weighting to lower the hotspot, it ends up moving to the anterior
surface due to the extreme weighting to achieve it. A 102.4% hotspot is achievable by
weighting AP 57.5, PA 22.5 and Lat 20. This does not create ideal volume coverage
though. The best coverage was with a beam weighting of AP 46.1, PA 43.9, Lat 10. This
resulted in a hotspot of 105.0% in the target volume.
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.
I then added a 45 left wedge to the PA beam and a 45 right to the lateral beam in order
to shift the hotspot and 100% dose to the center of the volume. By weighting my
beams as AP 44, PA 36, Lat 20 I was able to achieve my best results. This resulted in my
100% isodose line centering on the treatment volume my max point was only 101.0%.
After evaluating the DVH, 95% isodose was covering 97% of the volume. Normalizing
to 100% isodose covers 95% of the volume raised the hotspot to 105.8% but it
remained in the center of the target volume.
 Normalized as 100% to the reference point
Normalized as 100% dose to 95% volume

Which treatment plan covers the target the best? What is the hot spot for that plan?
The wedged 3 field treatment plan provided the best coverage and the lowest hotspot, only
101.0% and was in the center of the PTV. The third beam and wedges gives the planner
some flexibility in pushing the dose around to best suit the needs of the patient.
Normalized for volume coverage offered the most uniform coverage and only a 105.8%
hotspot.

Did you achieve the OR constraints as listed above? List them in the table above.
 I easily met the constraints of the OARs. A lot of this had to do with the position of the
target volume, being very superior and lateral in the left lung made it easy to avoid my
targets, even when using SBRT fractionation on a 3D conformal plan. Below is a DVH of the
volume normalized plan to support my values in the first table. Since it is not labeled, the
brown line is my bilateral lung dose.

What did you gain from this planning assignment?

A lab experience like this creates a great opportunity to experiment with various settings
and evaluate the changes that result. It prompted me to critically evaluate what was
happening and why things were happening with the changes I made. I learned a lot of
valuable fundamental concepts through this lab. It also helped to reinforce topics that my
clinical instructor and I have talked about. One of things I discussed with my clinical
instructor was different ways that I could have put in wedges. In this instance it worked
well but if I take what I learned and use it on other areas of the body, it may be more
beneficial to wedge the ant/post fields and then weight the later accordingly. This is
 because I can potentially get a more controlled/predictable effect. What I have now is
essentially a wedged pair with an anterior beam contributing.

What will you do differently next time?

Since doing this lab, I have been trying to predict what will happen prior to implementing a
change and then verifying my prediction or figuring out why it didnt work the way I thought
it would. This has been very helpful to my understanding of treatment planning. Next time
I would use a smaller margin, we use a 0.7cm margin on 3D conformal plans. I would also
try to evaluate my dose distribution better in order to determine what benefits a 3 rd or 4th
beam may provide me and where to add them. I would evaluate my available wedges and
collimator angles to improve the effect of wedging. As well as be able to determine the
ideal beams to add a wedge too.