Lung Clinical Lab 1

Lung Clinical Lab Assignment

DOS 771
William Deere

Plan 1
The dose distribution resembles a dumbbell, with higher dose buildup in both the chest and the
back. The maximum dose is in the back rather than in or near the PTV. The 100% isodose line
covers the PTV by about 34%. Two advantages of a parallel-opposed plan include lower risk of a
geometric miss and homogenous dose to the tumor.
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Plan 2
Adding a direct left lateral field with equal weighting to all fields improved the isodose
distribution considerably, with less dose buildup in normal tissue at beam entrance and the
maximum dose is now within the PTV. The 100% isodose line now covers approximately 56%
of the PTV. The 100%, 102%, 104%, and 106% isodose lines are more or less in a tight
triangular orientation due to dose build up where both beams intersect.
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Plan 3
I chose a 75-degree anterior oblique and a 165-degree posterior oblique. I picked 75 degrees for
the LAO since it more or less misses the spinal cord on beam exit and corresponds to 90 degrees
from the LPO set at 165. I felt it important to keep the posterior oblique field from angling too
close to the great vessels. Beam energy is an important consideration for lung treatments due to
the loss of lateral electronic equilibrium when a high-energy photon beam crosses through the
lung. Because lung density is lower, more electrons travel outside the geometric limits of the
beam. Considering this, it is preferable to use 10MV or lower energies for lung treatment. 1

Plan 4:
Field weight adjustment affects a plan in various ways, including coverage of the PTV, hot spot
location and intensity, and difference in dose to OAR or normal tissue. I weighted the plan
accordingly, AP Lung = 45%, LAO Lung = 20%, LPO Lung = 35%. Compared to the equally
weighted plan 3, this weighting improves coverage of the PTV. Nearly 50% of the PTV is
covered by the prescribed dose in this plan, vs 42.5% in plan 3.
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Plan 5
I used one 20-degree wedge on the AP field, heel towards the inferior of the patient. I used this
wedge to push dose towards the superior end of the PTV. I used a second 20 degree wedge on
the LAO field to help push dose towards the posterior portion of the PTV. Now the dose is more
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homogenous throughout the PTV and the region receiving 102% is more equally distributed
throughout the PTV. Before normalization, the plan only covered 46.69% of the PTV with the
prescribed dose. The 100% isodose line smoothed out a bit and looks to cover more of the PTV
especially in the axial view.
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Plan 6
Normalization is a method of improving target coverage by choosing an isodose level that
adequately covers the target per the prescription and normalizing the plan to that level. With
RayStation, the TPS I use in my clinic, I simply adjust the prescription percentage in order to
normalize. In this case, I had to normalize down to 94% of the prescription in order to cover 95%
of the PTV with the prescription dose of 6000cGy. By normalizing down, the overall plan is
hotter but that is to be expected. The final hotspot is at the lateral edge of the PTV, which is
preferable compared to outside of or distant from the PTV. However, I am not happy with the
high doses near beam entry on both my AP and LPO fields.
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Plan 7
For the final plan, I still used 6MV for each beam since lower energies are preferred for treating
tumors of the lung. As I mentioned in the discussion for plan 3, when higher energies are used to
treat the lung, they lose lateral electronic equilibrium. This has multiple effects but primarily it
decreases the dose at central axis of the beam as well as at the edge. The final weighting of the
beams is nearly equal:

The maximum dose is 6946 cGy or 115.7% of the prescription dose and it is inside of the PTV.
Having the maximum dose inside of the PTV is clinically preferable. Per the RTOG 0617
protocol, maximum dose can exceed 120% of the prescribed dose but it cannot go above 125%
of that dose. Therefore, the maximum dose in my plan is clinically acceptable.
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Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Spinal Cord Max Dose <45Gy 239 cGy Max Dose- RTOG
0623
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Total Lungs-ITV V20<37% of Rx Dose 16.38% - RTOG 0617

Esophagus Mean Dose <34Gy 502cGy - RTOG 0617
Heart 60Gy to <1/3 of Heart 94cGy - RTOG 0617

All planning objective outcomes were met per the RTOG 0617 recommended constraints.
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References
1. Khan FM, Gibbons JP. Khan's The Physics of Radiation Therapy. Lippincott
Williams & Wilkins; 2014.