Kristine

Phillips
Clinical Practicum I
Lung Planning Assignment
4/9/2016


Planning a radiation therapy course for a lesion located within the lung can
present some challenges as the tissue density/heterogeneity factors play an
important part in how the beam interacts with lung tissue. For this particular lung
planning assignment, I created multiple treatment plans for a patient with a left lung
mass, centrally located within the lung, using a 3D conformal treatment technique.
The prescription for this lung lesion is 2.2Gy per fraction for 27 fractions to a total
dose of 59.4 Gy. All radiation therapy treatment techniques require the analysis of a
dose volume histogram (DVH) to track dose to organs at risk (OR) that are close to
the treatment volume. They also track the definitive dose received by the planning
target volume (PTV). When targeting a lesion in the lung especially, we will always
utilize a 3D conformal technique versus a complex isodose treatment technique due
to its location in the chest and its close proximity to surrounding healthy
structures. The organs at risk that were contoured for this patient included the
lungs, heart, and spinal cord. A combination of QUANTEC radiation dose values and
physician preference is used when designing the desired radiation dose objective to
these structures. For this particular patient, the V20 value, or the volume of the lung
receiving 20 Gy, should be below 30%. The heart radiation dose constraints consist
of a V60, V45, and V40 value; the volume of the heart receiving 60 Gy should be
below 33%, the volume of the heart receiving 45 Gy should be below 67 %, and the
volume of the heart receiving 40 Gy should be below 100%. Maximum dose to the
cord should not exceed 45 Gy 50 Gy and often times the physician will request that
a small portion of the cord, 1cc volume, can only get 50 Gy. Four radiation treatment
plans were created with different beam parameters to evaluate what is required
when designing a radiation therapy course to achieve these OR dose objectives as
well as deliver the prescription dose of 59.4 Gy in this case to the PTV volume.

The isocenter used for this particular radiation dose calculation was placed
in the center of the PTV, away from air and any air/tissue interface as much as
possible. An AP beam was placed as a start to all of the following plans with a block
created around the PTV that contained a 1.5cm margin; this block was created with
MLC leaves to conform around the PTV.

The first plan utilizes an AP/PA opposed beam arrangement, equal dose
weighting to each beam, and 6MV energy for both treatment fields. Figure 1 displays
the isodose distribution of this scenario. This isodose distribution hugs closely to
the skin surface and does not offer much skin sparing effects that can be witnessed
with higher energy radiation beams. The dose distribution with these two equaling
weighted beams displays hot spots or areas of maximum dose in both anterior and
posterior surfaces laterally as opposed to medially. This display can be common
when targeting a lung lesion due to the shape of the chest and lack of tissue in the
anterior surface as the chest rounds to the lateral side body. 100% isodose
distribution is cutting through the PTV volume and it bows in from the
mediastinum. Looking at the DVH, the prescription dose of 59.4Gy is only reaching

41.1% of the PTV volume with this beam arrangement. However, if we prescribe to
the 95% isodose line, the PTV coverage is 100%. The global maximum dose from
this plan is 108.5% or 64.4 Gy and this global max dose reflects 1 pixel detected in
the plan that is receiving this escalated dose. The location of this global maximum
dose is located within the 100% isodose line, on a posterior rib, not within the lung
tissue/air but instead posteriorly located on top of bone, close to the soft
tissue/bone interface.

Figure 1. Isodose distribution of AP/PA beam arrangements on a lung mass using
6MV energy, equal beam weighting, and prescribing to 100% isodose line.

The second plan involved the same AP/PA beam arrangement from plan 1,
equal dose weighting to both beams, and 18MV energy. Looking at Figure 2, one can
see that the 100% isodose distribution display got smaller and the 98% isodose line
is now bowing in from the field edges more. 18MV energy creates greater skin
sparing effects and instead of the isodose lines hugging the skin surface, they come
away from the surface and deliver a lower dose to the skin because of it. 100%
isodose line, as well as the 98% line, now falls within the air cavity of the lung and
these values extended into the soft tissue surrounding the lung cavity with 6MV
energy. When analyzing the DVH in Eclipse for this plan, only 25.6% of the PTV
volume is receiving the prescription dose of 59.4 Gy when prescribing to the 100%
isodose line. However, if we prescribe to the 95% isodose line, 100% of the PTV
volume is receiving full prescription dose. The global maximum dose in this plan is
102.2% which is a huge difference from the 108.5% seen in the first plan. The
location of this global maximum dose moved from the posterior rib/bone into the
posterior lung tissue (just in front of the soft tissue and lung interface). The reason
for the movement of the hot spot further away from the body surface is due to the
increase in energy. Higher energy photons have greater penetrating ability within
tissue and for this reason, the maximum dose is seen further away from the patient
surface within the patient.

Figure 2. Isodose distribution of AP/PA beam arrangements on a lung mass using

18MV energy, equal beam weighting, and prescribing to 100% isodose line.

The third plan created for this lung mass included the AP/PA beam
arrangement, 18MV photons, and unequal weighting of dose from each beam.
Increasing dose through the AP beam and taking dose from the PA beam, 1.1:0.9
ratio for example, increases the maximum dose value but the increase is less than if
we were to reverse it and increase dose to the PA beam by taking dose from the AP
beam. However, when I increase the dose delivered through the AP beam, the
isodose distribution shifts to the anterior surface and it appears hotter in this area;
the anterior portion of the PTV is covered by the 100% leaving the posterior portion
of the PTV not covered. The reverse is witnessed when I add more dose/MU to the
PA beam and take from the AP beam; isodose distribution shifts posterior, the
posterior surface appears hot, and the anterior coverage to the PTV is
compromised.

The final plan created for this patient included the initial AP/PA beam
arrangement, 18MV energy, and a third beam at an oblique angle to avoid the spinal
cord as much as possible. This third beam was weighted with 20% of the dose while
the AP/PA were equally weighted receiving 80% of the prescribed dose (AP=0.4,
PA=0.4, oblique=0.2). Figure 3 displays the isodose distribution from this beam
arrangement. 32% of the PTV is covered by the 100% isodose line when we
prescribe to 100% but it is 100% covered with prescription dose when we prescribe
to the 95% isodose line. There are three different ways to avoid the cord when
adding the third beam to target the lung mass. One can adjust the gantry so that the
beam is off the cord, the use of tighter blocked margins can be added along the cord,
and the jaw setting can be decreased to abut to the MLC block along side the cord
helping to eliminate any dose from leakage between the MLCs if the jaw was opened
along the cord. The third beam I added was with the gantry at 140 degrees and all
three beams in this plan avoided entrance and exit dose through the spinal cord. The
maximum dose value with this beam arrangement and dose weighting was 104.9%

and global maximum dose was located posterior at the soft tissue/air interspace
and area of overlap between the PA beam and oblique. By altering the dose
weighting between all three beams, and doing nothing else to modify the dose, one
can witness how the dose distribution is changed within and outside the PTV. When
I increase the MU to the AP beam, taking it from the PA beam, the hot spot travels
anterior, maximum dose decreases from what was seen in the first weighting
scenario, and PTV coverage with the 98% isodose line is better. When I increase
MU/dose weighting to the AP by taking MU from the oblique beam, maximum dose
is increased and the 100% and 98% isodose lines are broken up. Increasing dose to
the PA beam by taking it from the AP beam increases maximum dose a lot; this effect
is especially witnessed within the overlap area from the PA beam and oblique beam.
Even when I prescribe to the 95% isodose line with this arrangement, my PTV
coverage is only at 91.8%. Lastly, increasing weight to the AP beam by taking a little
from both the PA beam and oblique beam, decreases the maximum dose and the
isodose distribution travels to the anterior patient surface.

Figure 3. Isodose distribution of AP/PA beam arrangement with an olique beam at
gantry 140; 18MV energy, unequal beam weighting, and prescribing to 100%
isodose line.

The use of wedges would absolutely help this plan and dose distribution
display. When there is an AP/PA opposed beam arrangement alone, the shape of the
body is not being accounted for; the use of a wedge in this setting would make the
anterior body surface appear even. Adding a posterior oblique beam to this plan
only adds more dose coming from the posterior surface and without the use of a
wedge to push dose anterior in this case, the anatomy within the overlap of the PA
and oblique beam is hot and receives more than the prescription dose. I tried using a
single wedge on each beam in 3 separate plans to see how the dose distribution
changed within the treatment fields and how PTV coverage was altered. Placing a 30
degree dynamic wedge on the PA beam, with the toe placed towards midline of the
body, helps to push the high degree of lateral dose medially to better cover the PTV.

Maximum dose increases with the use of a wedge but weighting the fields differently
can help decrease the hot spot again and PTV coverage is better with the use of a
wedge pushing dose medially. When I placed a 45 degree dynamic wedge on the
posterior oblique beam, toe facing anterior, it helps to block dose that is being
delivered to the overlap area between the PA and oblique beam as well as push dose
anterior where we need more coverage. If I place a wedge on the AP beam, toe
medial/right, I am able to push the dose medially and it provides better coverage of
the PTV because of it. The hot spot remains posterior however in this case without
adjusting the weights of dose from each beam.

When asked to select the treatment plan that best covers the target volume, I
had a toss up between plan 2 and plan 4 to deliver a prescription dose of 59.4 Gy to
the lung lesion. To help me view both plans at the same time I went into plan
evaluation and compared them side by side. Figure 4 displays the isodose
distribution from both plans (AP/PA with a wedged oblique angle on the right and
AP/PA only with 18MV energy on the left) and figure 5 displays the combined DVH
for both plans (triangles represent the 3 field lung plan and squares represent the
AP/PA plan). Figure 4 displays a maximum dose of 102.2% for AP/PA beam and
103.5% for 3 field beam arrangement with a wedge on one field.
Plan 2 was the AP/PA beam arrangement with 18MV energy. Dose to the
organs at risk is as follows: V20 on the lung was 15% and V5 of the lung was 17%.
The maximum dose to the cord was 3.258 and 1cc volume was 2.1 Gy. 1 Gy was
delivered to 1.95% of the heart and the maximum dose detected for the heart was
2.369Gy. As you can see, all of the OR constraints in plan 2 was achieved and PTV
has 100% coverage when prescribing to 95% isodose line.
Plan 4 involved the use of equally weight AP/PA beam arrangements with an
additional posterior oblique beam that was weighted with 20% of the dose. This
plan also had a 30 degree wedge on the PA beam (toe placement right). Dose to the
organs at risk is as follows: V20 on the lung for this plan was 15% and V5 was 21%.
The maximum dose to the cord was 5.303 Gy and 1cc volume was receiving 2.4 Gy.
1Gy was delivered to 3.7% of the heart and the maximum dose recorded to the heart
was 2.507 Gy. 100% PTV coverage with the prescription dose is achieved when we
prescribe to the 95% isodose line. Again, you can see that all OR constraints and
desired dose objectives were achieved for this plan as well.
By analyzing figure 5, the DVH comparison of the two plans side by side, one
can see that they are almost identical in the prescription dose delivery to the PTV
volume and surrounding OR. I would pick plan 4 with the additional oblique beam at
140 degrees on the gantry and a 30 degree wedge on the PA beam to treat this
patient. Just by looking at Figure 4, you can see we are treating an unnecessary
amount of left lung with the AP/PA beam arrangement and dose is more conformal
to the PTV with the additional wedged, oblique beam. With the use of this
assignment, I gained knowledge surrounding the use of beam modifying devices and
how such devices change the display of the isodose distribution when placed in the
beams path. With this additional knowledge and skills surrounding wedge
placement and beam dose weighting, I would add at least one more wedge to this
plan, change the dose weighting from each beam, and add an additional oblique or
lateral beam to achieve prescription dose to the PTV.


Figure 4. Isodose distribution of the AP/PA beam arrangement with an oblique
angle at gantry 140; 18MV energy, unequal beam weighting, and a 30 degree wedge
on the PA beam on the right side of the screen and the left image displays the
isodose distribution for the AP/PA beam arrangement with 18MV.

Figure 5. DVH comparison between the AP/PA beam arrangement with an oblique
angle at gantry 140; 18MV energy, unequal beam weighting, and a 30 degree wedge
on the PA beam on the right side of the screen and the left side displays the isodose
distribution for the AP/PA beam arrangement with 18MV.