DOS Clinical Practicum I

Planning Assignment (Lung Lab)

Ashley Coffey
Target organ(s) or tissue being treated: Rt medial posterior tumor of the
lung
Prescription:__45Gy in 15fx (3Gy/fxn)
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Organs at risk (OR) in the treatment area (list organs and desired objectives
in the table below):
Organ at risk

Achieved objective(s)

Spinal Cord

Desired
objective(s)
Max dose 45Gy

Heart

V40Gy < 50%

V40 < 28%

Lung

V20 < 30%

Esophagus

V60 < 30%

Rt 63.5% (NOT met- PTV in right

lung)
Lt 0% (max 7Gy)
0% getting 60Gy (dose not that
high)

Max dose of 44.5Gy

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?

The isodose lines tend to streak and are not uniform. The
80% isodose line is the most uniform and covers the PTV
well but any isodose curve above that does not.
b. Is the PTV covered entirely by the 95% isodose line?
No, not at all. The 95% line does not touch the PTV. It is in
the anterior aspect of the patient, just below surface
level.
c. Where is the region of maximum dose (hot spot)? What is it?
The hot spot is in the anterior portion of the patient and
inferior corner of the field about 1.6cm from the surface
of the skin. The dose at this point is 4723cGy (105%).
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 isodose lines are starting to meet and form the hour
glass shape. The PTV is covered by the 88% and 90%
lines now. Increasing the energy increased the
penetration which is why the PTV is covered and the lines
are becoming more uniform.
b. Where is the region of maximum dose (hot spot)? Is it near the
surface of the patient? Why?
The hot spot is still in the anterior portion of the patient
but the superior area of the field. It is 3.7cm below the
surface, which is more than double the depth with 6MV. It
is still near the surface because with only two opposing
beams entering the patient, it is hard to obtain good
penetration and coverage. If more beams were
intersecting the patient, it would move the hotspot into
where a beams cross inside the patient.
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 adjusting the weight in many directions and in
many intervals, the lowest hot spot is achieved with
50/50 coverage. The 50/50 weighted hot spot is 4721 cGy
(105%). However, in order to move the hot spot (anterior
to posterior), that can be accomplished with 45/55
(AP/PA) weighting. The hot spot is also only 14cGy hotter
than with 50/50 which is insignificant.
b. How is the PTV coverage affected when you adjust the beam
weights?
The 45/55 weighting also receives the best PTV coverage
of any weighting adjustment with this plan. With 50/50,
the PTV only receives a maximum dose of 4489 cGy and a
mean of 4235 cGy, which is not acceptable. The 45/55
plan delivers a maximum dose of 4699 cGy and mean of
4389 cGy which at least provides the PTV with 16.6%
coverage (also not acceptable).
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 alongside of the cord

For the third beam, I made the gantry angle 230 in order
to avoid as much of the cord as possible while still
covering the PTV. It is not ideal at all to exit through the
heart but it was the only option to avoid the cord for this
exercise. However, the heart dose is still low and meets
constraints. I closed the margin on that beam to 0.5cm
around the PTV and kept the jaws to the edges of the
margin. The cord still received some dose from this beam
but the tumor is so close to the cord that is was
unavoidable. Adding the third beam did decrease the
overall dose to the cord since it took some weight away
from the AP/PA beams which encompass the entire cord

with both beams.

b. Alter the weights of the fields and see how the isodose lines
change in response to the weighting.
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.
Yes, wedges did help to even the dose distribution.
Adding a wedge to the PA and RPO beams as well as
adjusting the weighting did cover the PTV best overall.

Which treatment plan covers the target the best? What is the hot spot
for that plan?
The plan that covers the PTV best is three beams (AP/PA/RPO)
at the weighting of 36.5/48.5/15 with a 30 wedge in the PA
beam and a 15 wedge in the RPO. With 95% dose assigned to
maximum dose point, the PTV received 63.16% coverage. The
hot spot is at 4737cGy or 5% hot. With the prescription line

adjusted to the 93% line, the coverage increases to 85.11%

with a hot spot of 4842cGy or 7% hot. In both scenarios, the
hot spot is kept under the 10% allowable dose and all of the
constraints have been met.

Did you achieve the OR constraints as listed above? List them in the table
above.
No, not every constraint was met. The right lung received a
large amount of dose but the tumor also resides in the right
lung so it was unavoidable. The constraints were met on all of
the critical structures. Only 65% of the right lung received
1750cGy which is the TD 5/5 tolerance of the entire lung.
Looking at it from a different standpoint, one third of the lung
can receive a maximum of 4500 cGy, which I also did not come
close to with my average being 2700 cGy.

What did you gain from this planning assignment?

It was a great lab to show the effects of planning with limited

beams and segments. The use of different wedges was also
interesting to see the effects of each sized and used on
different angles. I learned many basic skills and critical
thinking in order to create the PTV coverage that is acceptable
(or close to acceptable) with limited resources. It was also
good to see the beam interaction with lung versus more dense
structures such as with the pelvis lab.

What will you do differently next time?

The lab will help to eliminate the process of starting
completely from nothing and working up in terms of 6MV
opposing fields. I can skip such basic steps to start from a
more solid foundation in developing a 3D treatment plan that
provides adequate coverage while still meeting dose
constraints. I would also try to avoid the exit dose through the
heart with a different three field arrangement. It was great to
see the process of slowing adjusting the plan and analyzing
the steps to understand the planning thought process. The
assignment as a whole will help to develop my treatment
planning skills.