Asim Farooki

DOS 771: Clinical Practicum I

Clinical Lab Assignment

Planning Assignment (Lung)

Target organ(s) or tissue being treated: Left Lung
Prescription: 3471 cGy with 13 Fx = 267 cGy/Fx
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)

Lung - right

Max < 2000 cGy

740 cGy

Spinal Cord

Max < 4500 cGy

2034 cGy

Esophagus

Max < 5500 cGy

2340 cGy

Heart

Max < 4000 cGy

670 cGy

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?

For the first plan, 6X MV energy was used. The DVH displayed a uniform distribution
on both the anterior and posterior of the patients treatment site.
b. Is the PTV covered entirely by the 95% isodose line?
The PTV is not covered entirely by the 95% isodose line as a portion on the anterior
surface is outside of the line.
c. Where is the region of maximum dose (hot spot)? What is it?
The region of maximum dose is on the patients posterior aspect with a hotspot of
108.9%.
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?
For the second plan, 15X MV energy was used. This time the 95% isodose line had a
slightly better coverage, however the 100% isodose line tightened up sharply and only
crossed the middle of the PTV.
b. Where is the region of maximum dose (hot spot)? Is it near the surface of the
patient? Why?
The hotspot is still located posteriorly but has moved a bit higher from the previous
position and is decreased to 104.9% because of the increase in energy.
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?
After manipulating the beam weighting, I increased the weight on the AP over the PA
beam with a ratio of 0.56:0.44 in favor of the AP beam.
b. How is the PTV coverage affected when you adjust the beam weights?
After the weights manipulation, the 95% isodose line covers the PTV completely,
however the 100% isodose line still is not adequate.
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?
ii. Tighter blocked margin along the cord
iii. Decrease the jaw along side of the cord

All of the above mentioned options can be customized to deliver the required dose.
However in the patient I used for this assignment, the PTV was located on the anterior
aspect of the patient and was far from the cord. Hence, the cord was not of concern for
excess dosage. If it was the case, changing the gantry angle and tightening the margins
around the cord should help shave off some of the dose receiving there.

b. Alter the weights of the fields and see how the isodose lines change in response to
the weighting.
With the manipulation of the field weights, the isodose line changes significantly.
By increasing the weight of the lateral fields, we can try to achieve better coverage
for the PTV, however this led to a higher 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.
A wedge in this scenario can help with the delivery of a more uniform dose.

Which treatment plan covers the target the best? What is the hot spot for that plan?
After taking a look at all of the plans, I believe the 4th plan was most beneficial as it provided
the best coverage and kept the global hotspot to a minimum of all of the plans at 107%.

Did you achieve the OR constraints as listed above? List them in the table above.
Yes (see table on first page)

What did you gain from this planning assignment?

This assignment was a great example as it showed that we do not have to create complex
plans always to provide the best dosage to the PTV while trying to meet the constraints for
the organs at risk. A simple AP/PA plan is beneficial here as compared to at least two of the
other plans because it provided sufficient coverage, meanwhile providing an acceptable hot
spot.

What will you do differently next time?

In the future I hope to take this assignment as a learning tool and to remind myself that its not
always necessary to do more than what is required. A simple AP/PA treatment plan as seen
in this case is sufficient to create a simple plan, which would not increase treatment times by
incorporating the uses of wedges and our extra fields requiring addition time.