Lung Clinical Lab Assignment

Erin Murdoch

Plan 1 – Create a field directly opposed to the original field (PA). Assign equal (50/50) weighting to
each field. Embed an axial screen capture of your isodose distribution.

1. What shape does the dose distribution resemble?

The isodose distribution is breaking up in the center of the patient. The dose is hot anteriorly
and posteriorly at the surface. The dose also connects at the center, around the PTV, although it
is still much hotter towards the skin. If I was only using AP/PA beams for this plan, my next step
would be to weight the anterior heavier, because the hot spot is located posteriorly.

2. How much of the PTV is covered entirely by the 100% isodose line?
9.5% of the PTV is being covered by the 100% isodose line.

3. What are two advantages of a parallel opposed plan?

Parallel opposed fields provide simple setup with reproducibility, less chance of geometric miss,
and homogenous dose distribution. (Kahn, 5th ed., 11.5.A) They can also be advantageous if you
are trying to spare healthy tissue in specific areas. AP/PA beams give a high dose within the
field, but they spare tissue if you have organs at risk laterally.
Plan 1
Plan 2 – Add a direct left lateral field to the plan and assign equal weighting to all fields. Embed an
axial screen capture of your isodose distribution.

1. How did this field addition change the isodose distribution?

The dose is concentrated more around the PTV with the addition of the lateral beam. The 95%
and 85% isodose lines are no longer reaching anteriorly and posteriorly. Instead of being
posterior, the hot spot is within the PTV. The dose is more conformal than in Plan 1.

2. How much of the PTV is covered entirely by the 100% isodose line?
17.8% of the PTV is being covered by the 100% isodose line.
Plan 2
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. Embed an axial screen capture of your
isodose distribution.

1. What angles did you choose and why?

I chose a left anterior oblique beam at 45 degrees and a left posterior oblique beam at 135
degrees. I selected these angles because they were exactly in the middle of the other three
beams and it made the dose more conformal. I considered angling the beams at steep angles, in
order to miss the spinal cord or esophagus. I tried this with the left anterior oblique beam,
placing it around 20 degrees. The angle was too close to the AP beam, and it made the chest
hotter anteriorly where the two beams overlapped. When the LAO beam is situated at 45
degrees, it does directly face the spinal cord and esophagus, but the dose is still pretty low in
this region because there are 4 other beams pulling the dose. The max dose to the spinal canal is
995 cGy in this plan.

2. Why is beam energy an important consideration for lung treatments? (Review Kahn, 5th ed.,
12.5.B3, Lung Tissue)

The low density of the lung causes an increased number of electrons that travel outside the
geometric beam limits. It also makes the dose profile less sharp. This can be seen easier in 3D
plans when the isodose lines bend inward while traveling through lung. This effect is more
dramatic with smaller field sizes and higher energies, which can make it possible to underdose
the periphery of the tumor volume. For this plan, I’m using 6X energy to lessen the likelihood of
this phenomenon.
Plan 3
Plan 4 – Alter the weights of the fields to achieve the best PTV coverage. Embed an axial screen
capture of your isodose distribution.

1. How does field weight adjustment impact a plan?

Changing the field weight allows dosimetrists to manipulate the dose by pulling it more or less
within the bounds of the field being altered. When the patient is being treated with fewer
beams, it is easier to see the change of dose distribution with different field weighting. When
we are utilizing several beams for one area, the change in distribution with weighting
adjustments is less dramatic.

2. List your final choice for field weighting on each field.

Initially, I tried selecting beam weights that made the dose more conformal. However, because
the plan instructions call for weighting that achieves the best PTV coverage, I altered the values
based on my DVH. The beam weighting that I found to give the highest PTV coverage is: 30% AP,
20% PA, 35% LtLat, 7.5% LPO, and 7.5% LAO.
Plan 4
Plan 5 – Try inserting wedges for at least one or more fields to improve PTV coverage. Embed a screen
capture of the beams-eye view (BEV) for each field that you used a wedge.

1. 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?)
I used a 60 degree wedge on both the AP and the LPO beams. Initially, I wanted to add wedges
to the AP with the heel facing the distal left side, and a wedge on the LtLat with the heel facing
anteriorly. This was my originally inclination because the heels would then be directed towards
the area with a deficit of tissue. However, because of the number of beams and the tissue
heterogeneity, the dose isn’t distributed very uniformly regardless of beam weighting. When
scrolling through the axial slices, the dose was concentrated anteriorly, and would move
posteriorly as I scrolled through. I decided the positioning of the wedges based on the dose
distribution and isodose cloud, rather than the patient’s anatomy. The heel of the wedge on the
AP beam is situated inferiorly, to adjust for the dose that was initially concentrated there. The
heel of the LPO beam is situated anteriorly to help concentrate the dose more posteriorly.

2. Describe how your PTV coverage changed (relating to the 100% isodose line) with your final
wedge choice(s).
For both wedges, I started with 15 degree wedges and watched my DVH while increasing the
wedge degree. I would only increase by one or two intervals, before I would switch to the other
wedged field and increase that beam wedge size as well. I was surprised that dose coverage was
best at such a large wedge for both fields. In Plan 4, I got the 100% dose a little higher, but the
shoulder of the DVH was pushed harder causing 95% of the volume to only be covered by the
90% line. A 45 degree wedge on each beam produced similar PTV coverage in the 100% line,
however, the 60 degree wedge pushed the shoulder of the beam even farther, which will allow
me to normalize to a higher isodose line. My initial plan covered 23% of the volume with 100%
dose, and the final plan covered 21% volume with 100% dose. My hot spot also decreased
significantly.
Plan 5
Plan 6 – Normalize your plan so that 95% of the PTV is receiving 100% of the prescription dose.
Embed an axial screen capture of your isodose distribution.

1. Define normalization.
Normalization is when you select an area that is receiving a specified percent of the dose, and
tell the treatment planning software to deliver 100% to this area rather than the previous
percent. The isodose line selected is typically under 100%. When an isodose line (X) is selected
to normalize to, the plan will get hotter overall by a percent of (100% - X).
2. What impact did normalization have on your final plan?
I normalized to the 92% line, which covered 96% of the PTV volume. This made my entire plan
hotter by 8%.
3. What is your final hotspot and where is it?
Unfortunately, my hot spot was also made hotter by 8%, which made the final hot spot 111.9%.
The hot spot is located inferiorly and posteriorly within the PTV.
4. Are you satisfied with the location of the hotspot?
I would have liked my hot spot to be more centrally located within the PTV. When the patient
breathes during treatment, the hot spot may treat marginal tissue around the PTV rather than
the PTV. With the selections I made for the location of my reference point and beam
weight/arrangement, this is the location for the hot spot while delivering maximum coverage to
the overall PTV. I thought the inferiority of the hot spot might indicate over-wedged fields, but
interestingly, the hot spot is under the heel side of the AP wedge.
Plan 6
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.

The directions for Lung Plans 1-6 required me to plan to a point within the beam. At my clinic site, we
utilize Body Maximum as the standard dose normalization. For Plan 7, I used the approach of planning to
Body Max. I used a similar beam orientation, except I replaced the 45 degree LAO beam with a 315
degree RAO beam. Because the dose distribution was difficult to make uniform with weighting alone, I
thought this plan would be easier with field-in-fields instead of wedges. This allowed me to make
smaller, more precise changes. My final beam arrangement is AP, PA, LtLat, LPO, and RAO, with a
segment (field-in-field) on all beams except for the left lateral. I prescribed to the 92% line. I used the
write-up process that is standard for my clinic site, so I could better compare my finalized plan to other
lung plans in our treatment planning system. This makes the screen caps for my plan more difficult to
compare to the write-ups for plans 1-6, so I included an image below that describes the percent dose
associated with each color.

1. What energy(ies) did you use and why?

The energy I used for all beams is 6X. It is the standard at my department to use low energy for
lung treatments because of the low density tissue within the field. Also, the separation between
the AP and PA beams is small enough to be treated adequately with 6X for these fields. I can
find this distance with the “Measure Distance” tool on Eclipse, or by subtracting my calculated
SSDs from 100cm and adding the values together (23 cm).
2. What is the final weighting of each field in the plan?
AP – 22.1%
AP FiF – 2.7%
PA – 32%
PA FiF – 2.8%
LtLat – 10.5%
LPO – 18%
LPO FiF – 1.8%
RAO – 8.9%
RAO FiF – 1.1%
3. Where is the region of maximum dose (“hot spot”), what is it, and is this outcome clinically
acceptable?
The hot spot is still located inferiorly within the visible tumor; however, it is central within the
contoured PTV. The hot spot is 6521.7 cGy, which is 108% of the prescribed 6000 cGy. This is as
expected, because I planned to body max, and I prescribed to 92% making the plan hotter by 8%
in all areas. This outcome is clinically acceptable and is lower than my hot spot for Plan 6.
4. Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and coronal
views.
5. 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.

6. Use the table below to list typical OAR, critical planning objectives, and the achieved outcome.
Please provide a reference for your planning objectives.

Organ at Risk Desired Planning Objective Planning Objective Outcome

Esophagus V50 < 32% (Maguire) V50 = 0, Dmax = 8.13 Gy
V60 < 33% (Emami) V60 = 0, Dmax = 8.13 Gy
Heart V45 < 67% (NCCN 2010) V45 = .0006
V60 < 33% (NCCN 2010) V60 = 0, Dmax = 47 Gy
Total Lung Mean < 20-23 Gy (QUANTEC) Mean = 10.3 Gy
V20 < 30-35% (QUANTEC) V20 = 19.7
Primary Bronchus Max 80 Gy (QUANTEC) Max = 64.1 Gy
Spinal Cord Max 45 Gy (RTOG 0623) Max = .5 Gy
PTV V100 > 95% V100% = 95.4%
(Volume getting 60Gy = 95.4%)