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Planning Assignment (Lung)

DOS 771: Clinical Practicum I


By: Doris Chen

Target organ(s) or tissue being treated: Palliative Right Lung


The tumor is located more posteriorly with a volume of 290.59 cm 3
and an equivalent sphere diameter of 8.2cm.
Prescription: 267 cGy/frac over 15 fractions = 4005 cGy
Organs at risk (OR) in the treatment area (list organs and desired objectives
in the table below):
Organ at risk
Spinal Cord

Desired objective(s)
Max < 4000 cGy

Achieved objective(s
Yes
Max = 1650.3 cGy
Mean = 77.2 cGy

Esophagus
Heart

Mean < 3400 cGy


V50 < 40%
V30 < 50%

Right Lung

None

None

Left Lung

None

None

Sum Lung

Mean < 2000 cGy


V20 < 30%
V5 < 45%

Mean = 758.6 cGy


V20 = 16.3%
V5 = 24%

V30 = 19%

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 plan was created using AP/PA beams and normalized to the isocenter.

a. What does the dose distribution look like? The PTV does not
have sufficient coverage when using 6X opposed beams with
equal weighing. The anterior part of the lesion is "colder" while
the posterior part of the lesion is "hotter." This suggests that
the isocenter favors posterior coverage; therefore, the AP
beam should be weighed more to improve anterior coverage
while lowering posterior hot regions.
b. Is the PTV covered entirely by the 95% isodose line? No.
c. Where is the region of maximum dose (hot spot)? What is it? The
hot spot is located on the posterior end on the rib with max of
125.6%.
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 AP/PA beams were increased from 6X to 15X. Since
15X is more penetrable, the isodose lines traveled deeper into
the patient. Unlike 6X, not a lot of dose accumulated near
surface.
b. Where is the region of maximum dose (hot spot)? Is it near the
surface of the patient? Why? Using the same normalization (to
isocenter) and same beam arrangement (AP/PA), the maximum
dose decreased from 125.6% to 111.9%. The hot spot is still
closer to the surface and on the posterior rib.
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?
I weighed the AP 60% and the PA 40%, which decreased my hot
spot from 111.9% to 106.9%.
b. How is the PTV coverage affected when you adjust the beam
weights?

The PTV coverage slightly increased by 1%, from 60.6% to


61.6%.
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?
Although a right lateral field would spare the cord, the field
would impact the heart and the left lung. Thus, I have decided
to create a right posterior oblique (RPO) that spared the cord,
heart, and left lung.
i. Adjust the gantry angle? The angle of my RPO is 220.
ii. Tighter blocked margin along the cord
iii. Decrease the jaw along side of the cord
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.
The PA and RPO beams abutted and the region of overlap is
where the dose is more concentrated. A 45 wedge on the
RPO would help improve dose distribution. The heel part
would help make the overlapping region less hot and push
the dose more superiorly.

Which treatment plan covers the target the best? What is the hot spot
for that plan?
Plan 4 that had 3 fields and a 45 wedge provided the most
optimal plan that met all of OR constraints with 95% PTV coverage.

Did you achieve the OR constraints as listed above? List them in the table
above.
Yes

What did you gain from this planning assignment?

I learned about the impact of different degrees wedges. I


evaluated a plan that used a 15 wedge versus a 45wedge and
noticed how the isodose lines changed. I learned about overwedging and under-wedging a plan. Also, I panned through the
PTV and looked at the shape of the PTV to determine which angle
to use for the third field, and where the heel of the wedge should
be placed.

What will you do differently next time?


Although AP/PA plans are attractive in the sense of lower integral
dose when compared with 3D plans using multiple fields,
coverage is sacrificed. When treating lung tumors, it is important
to derive a plan that provide adequate coverage for definitive
care. The goal is to control the disease, therefore, it is important
to come up with a 3D conformal plan that is fully covers the
planning treatment volume (PTV). This assignment has taught me
that simple AP/PA plans are not the best way of treating lung
tumors. Also, oblique fields are normally accompanied by a
wedge to compensate for tissue irregularity.