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Karol Wynn
Clinical Lab 1
March 7, 2015

Clinical Stage IIIA Non-Small Cell Lung Carcinoma, T1bN2, RTOG-0839

Target Volumes: The patient data set used in this lab was from a 61-year-old Caucasian male,
diagnosed with Right Upper Lobe (RUL), Non-Small Cell Lung carcinoma, (NSCLC) large cell
subtype. The patient was immobilized for treatment using a vac-loc bag incorporating a wing
board and B-headrest. A 4D CT and a free breathing CT was obtained starting at the level of the
cricoid process superiorly and ending inferiorly below the liver. The free breathing CT scan was
fused to the 4DCT Bins 0 to 90. The dosimetrist fused the CT scan to a treatment planning
fluorodeoxyglucose (FDG)-PET/CT with capture of SUV >3. This volume was defined by the
physician as the gross tumor volume (GTV)_6000. The physician outlined the internal target
volume (ITV)_6000 on each 4DCT Bin and the composite ITV_6000 was created with the
Boolean operation on the Eclipse treatment planning system. The patient was to be treated with
daily Image Guided Radiation Therapy (IGRT) therefore a clinical target volume (CTV)_6000
was built by adding 3mm to the ITV_6000. The CTV_6000 was then expanded 3mm to form the
planning target volume (PTV)_6000. Daily IGRT was done with CBCT on the Varian
TrueBeam. The therapists were to align to the target volume and the bony anatomy as ordered by
the physician.
Organs at Risk (OR): The physician outlined the Brachial Plexus as required for upper lobe
lung target volumes. The dosimetrist contoured all other organs at risk (Figure 1). The
dosimetrist contoured the Lung_L and Lung_R and combined these volumes using the Boolean
operation to form the OR Lungs. The OR Lungs had the CTV_6000 subtracted from the volume.
The spinal cord was contoured on all images. The volume contoured included all tissue inside the
bony canal of the vertebral column. This structure had the highest priority in the dose constraint
metric with a maximum point dose of 50.5Gy. A point dose was defined as 0.03cc. The
Esophagus was outlined starting at the cricoid process and ending at the Gastro-Esophageal
(GE)-Junction. The heart was then contoured beginning at the level of the inferior pulmonary
artery to the heart base. The majority of the target volume was superior to the heart in this case.

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The External contour volume included the Body contour and internal volumes. The
NonPTV_6000 was the External or Body contour in Eclipse subtracting the PTV_6000.
Treatment Prescription and Planning Objectives: The treatment prescription for this trial was
60Gy in 30 fractions with 200cGy delivered per fraction. The patient was to be treated 5 days per
week starting on the first day of Chemotherapy. The PTV6000 should be normalized such that
100% receives 95% of the 60Gy. The protocol further required a minimum point dose of 95%
and a maximum dose not to exceed 120% of the prescription dose. In this case, the minimum
dose constraint was the most difficult to meet. The planning objectives were prioritized by the
above with the spinal cord constraint being the first priority. The OR dose constraints were met.
A detailed dose constraint table is provided (Table 1).
Planning Technique and Beam Arrangement: A 3D conformal (3DC) technique was utilized.
The plan included a six field oblique beam arrangement utilizing 6 MV photons. The beams were
arranged to optimize the dose distribution with the gantry angles of 150, 355, 230, 190 and
with two non-coplanar beams at 35 with table angles of 35 and 340 (Figure 2). Three fields
utilized enhanced dynamic wedges (EDW); field 230 had a 15EDW with the heel direction in
the superior plane, field 150 and 35/35table with 25EDW with the heels medial. The fields
were further defined with the multileaf collimator (MLC) fielded to the PTV_6000 plus 10
millimeters. Heterogeneity dose correction was applied with the Eclipse AAA_11031 algorithm.
Plan Outcome: The treatment plan met the dose conformality criteria and the OR constraints
(Figure 5). A 3DC technique was utilized because an evaluation of target location compared to
the critical structure proximity was deemed acceptable for 3DC. The dose inhomogeneity within
the planning volume was the most difficult aspect of this plan. The PTV_6000 included target
volumes in the soft tissue and island volumes in the right lung. The isocenter was first placed
centered in the target volume, but when normalized to the 95% coverage, the minimum dose
objective was not met. The cold volumes were located at the superior and inferior lung target
volumes. The isocenter was then placed in the soft tissue with a limit of 2 centimeters from the
isocenter to block edge respected. The beams were differentially weighted to achieve coverage
with the addition of enhanced dynamic wedges. The plan normalization value to achieve 95%
coverage and the minimum dose constraint was 94% (Figure 3&4). The maximum dose was
67Gy and minimum dose was 57.1Gy within the 57Gy limit. This technique was more difficult
to keep the hotspot within the PTV. IMRT or VMAT may have been a better solution in this

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case, but as a clinic we have found that insurance providers have denied these techniques for our
patients, unless we cannot meet lung dose or other critical structure constraints.

(Figure 1) Red is GTV_6000, Yellow is ITV_6000, Blue is PTV_6000. Lungs are Cyan, Heart
is Fuchsia, SpinalCord is Green, BrachialPlexus is Light Green and Esophagus is Royal Blue.

(Figure 1a) Larger GTV_6000 and PTV_6000 volumes with isodoses.

(Figure 2) Beam arrangement

(Figure 3) Isodose distribution in axial, sagittal and coronal planes.

(Figure 4) Dose color washes from 66Gy to 6Gy. DVH: Light Green is Right Lung, Dark Blue is
Left Lung and Cyan is Lungs.

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PTV_6000 Dose Specifications:
Dose: PTV_6000: 100% of target at 95%
Min Dose to PTV_6000: 57.1Gy
Max Dose to PTV_6000: 67Gy

Organs at Risk
SpinalCord
Lungs

Desired Objectives
Max point dose <50.5Gy
V20= <37%
Mean dose <20Gy
Mean Dose <40Gy
V60Gy volume recorded
Max point dose <66Gy
<1/3 is <60Gy
<2/3 is < 45Gy
100% is <40Gy

Esophagus
BrachialPlexus
Heart

Achieved Objectives
36.1Gy
28%
15.6Gy
10.5Gy
0cc at 60Gy
15.4Gy
<1% at 60Gy
1.7% at 45Gy
2% at 40Gy

(Table 1)

ITV_6000
GTV_6000
PTV_6000

Esophagus
Lungs

SpinalCord

Heart
BrachialPlexus

(Figure 5) Dose Volume Histogram