You are on page 1of 10

Lung Clinical Lab Assignment

Kyle Garafolo

Use the Lung CT data set provided to complete the following assignment:

Prescription: 60 Gy in 30 fractions to the PTV

Planning Directions: Place the isocenter in the center of the designated PTV (make sure it isn’t in air). Create a
single AP field using the lowest photon energy in your clinic. Create an MLC block on the AP beam with a
uniform 1 cm margin around the PTV. Apply the following changes (one at a time) as listed in each plan
exercise below. After making the adjustments requested for each plan, answer the provided questions. Tip:
Copy and paste each plan after making the requested changes so you can compare all of them as needed.

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.
 What shape does the dose distribution resemble?
o Based on the equal weighting with 6MV parallel-opposed fields, the dose distribution slightly
resembles the shape of an hour glass. Dose uniformity varies throughout the beam path, with
higher isodose lines anteriorly and posteriorly near the skin surface and slight inward bowing
toward the PTV.
 How much of the PTV is covered entirely by the 100% isodose line?
o The 100% isodose line covers only 7.7% of the PTV
 What are two advantages of a parallel opposed plan? (Review Kahn, 5th ed., 11.5.A, Parallel Opposed
Fields)
o Parallel opposed fields present several advantages. These advantages include
simplicity/reproducibility of treatment setup, dose homogeneity to the tumor, and less
potential for geometric miss of the target (as compared to angled beams).
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.
 How did this field addition change the isodose distribution?
o The isodose distribution is much more conformal than in plan 1. In plan one, there were large
areas of 100% dose near the anterior and posterior skin surface. By adding a third field and
equalizing the field weights, the dose is more evenly distributed around the PTV and there are
no longer those large areas of 100% dose near the skin surface.
 How much of the PTV is covered entirely by the 100% isodose line?
o The 100% isodose line now covers 14.2% of the PTV

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.
 What angles did you choose and why?
o The two oblique fields I added had angles of 45 degrees (LAO) and 135 degrees (LPO). I chose
these angles because they were positioned equally between the AP/PA and left lateral fields.
After calculating the dose I found that the dose was slightly more conformal to the target;
lower isodose lines shifted from more of a square shape (from plan 2) to more circular in shape
with the addition of the oblique fields. In addition, I found these additional fields reduced dose
to the skin even more. The 100% isodose line now covers 15% of the PTV.
 Why is beam energy an important consideration for lung treatments? (Review Kahn, 5 th ed., 12.5.B3,
Lung Tissue)
o Higher energy beams will result in deeper penetration, better dose uniformity and skin sparing;
however, because lung is a low density material, it will create a longer range for the higher
energy recoil electrons. As a result, higher energy photons create a loss of lateral electronic
equilibrium, thus reducing coverage to the target. This occurs because the low density of the
lung causes more of the electrons to move outside beam limits, which makes the penumbra
less sharp. Additionally, the loss of electronic equilibrium results in a build-up region near the
outskirts of the target, giving rise to the chance of underdosing the target. The effects
mentioned above are more pronounced with higher energies and small fields, therefore making
it more optimal to use low energy beams with lung plans.

Plan 4: Alter the weights of the fields to achieve the best PTV coverage. Embed an axial screen capture of your
isodose distribution.
 How does field weight adjustment impact a plan?
o Adjusting field weighting impacts the relative percentage of dose reaching the target and
organs at risk (OAR). By making these adjustments to field weighting, isodose lines can be
shifted to achieve optimal coverage.
 List your final choice for field weighting on each field.
o After adding two oblique fields, I considered leaving the beams equally weighted (20% each),
but this resulted in only 15% coverage by the 100% isodose line. I then adjusted field weighting
to improve 100% coverage to the PTV. My field weights were: AP =15%; PA = 10%; LAO = 25%;
Lt Lat = 25%; and RPO = 25%. I found weighting each beam in this manner produced the most
optimal prescription coverage to the target at this point in planning. The 100% isodose line now
covers 18.5% of the PTV. Additionally, the mean PTV coverage increased by 0.3%, from 95.5%
to 95.8%. One factor I will continue to evaluate as I continue planning will be the potential
repercussions of weighting in this manner, such as increased superficial dose or dose to the
OAR on the higher weighted fields
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.
 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?)
o I opted to use three wedges for this plan: one from the AP, PA, and Lt Lat. Wedge orientations
included: AP – EDW45IN (toe pointing superiorly); PA - EDW25OUT (toe point to patient’s
right); Lt Lat - EDW60IN (toe pointing superiorly). Adding these wedges only produced a
marginal improvement to dose conformality to the target. While the target is still not
adequately covered, I found the wedges did help in modifying the placement of the dose.
 Describe how your PTV coverage changed (relating to the 100% isodose line) with your final wedge
choice(s).
o Adding the wedges partially sacrificed 100% prescription dose coverage to the PTV. As a result,
The 100% isodose line now covers 14.4% of the PTV
Field A – AP: EDW45IN
Field B – PA: EDW25OUT

Field C – Lt Lat Lung: EDW60IN

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.
 Define normalization.
o Plan normalization is an optimization method used to adjust the isodose lines to modify coverage to
target structures or organs at risk. While normalizing a radiation dose prescription can help to
achieve target coverage goals, it also affects the dose delivered to the surrounding healthy tissue.
 What impact did normalization have on your final plan?
o Normalization resulted in much better coverage to the target. However, the trade off from this
was that the plan got much hotter to not only the target but to other nearby organs at risk. The
overall hot spot increased to 116.6% and the 3D mean for the PTV increased to 107.9% from
95.8% from plan 5.
 What is your final hotspot and where is it?
o The final hotspot increased to 116.6% and is located mostly in the middle of the PTV,
occasionally favoring the patient’s anterolateral aspect in a few slices.
 Are you satisfied with the location of the hotspot?
o I am happy that the hot spot is located within the PTV. However, I would prefer to adjust the
beam weighting or wedges slightly at this point to even out the dose distribution (visualized on
a few slices – the screen capture below is at iso). In doing so, the hot spot would likely be
reduced slightly.

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.
 What energy(ies) did you use and why?
o I used all 6MV photon beams for my plan. Due to the fact that we are treating a low density
tumor in the lung, higher energy photon beams will have a larger build-up region and thus will
travel further in the lung. This results in a longer distance to reach electronic equilibrium
(dmax), so coverage to the edges of the target may suffer if higher energies are used.
 What is the final weighting of each field in the plan?
o I used a total of four fields. Field D is a dynamic conformal arc, which was used to help
distribute dose more evenly to the PTV.
 Field A AP L Lung: 19.4%
 Field B PA L Lung: 27.3%
 Field C LLat L Lung: 16.6%
 Field D CCW L Lung (dynamic conformal arc – 179 degrees to 305 degrees): 36.7%
 Where is the region of maximum dose (“hot spot”), what is it, and is this outcome clinically acceptable?
o The global maximum hot spot is 113% and is located a few slices inferior of the middle of the
PTV. At my clinical site, this would be considered a clinically acceptable hot spot, especially
given that it is located well within the PTV.
 Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and coronal views.
 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.
Primary Bronchus
PTV_Lung

Spinal Canal ITV

R Lung
Trachea

Total Lung - ITV

L Lung

Esophagus

Heart
 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 (OAR) Desired Planning Planning Objective Outcome Reference


Objective (with clinical outcome)
Total Lung (Lung minus ITV) Mean < 20 Gy 1028 cGy (clinical pneumonitis) RTOG 0623
Total Lung V20 ≤ 30% 31.8% (clinical pneumonitis) QUANTEC
(18.4% for Total lung - ITV)
Esophagus Mean < 35 Gy 420 cGy (Grade ≥ acute esophagitis) RTOG 0920
Heart V25 < 10% 0.06% (Long term cardiac mortality) QUANTEC
Spinal Cord (canal is Dmax < 45 Gy 568.1 cGy (Myelitis) RTOG 0623
contoured)

You might also like