Planning Assignment (Lung)

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

Prescription: 30 fx @ 2.0 Gy to 60 Gy

Organs at risk (OR) in the treatment area (list organs and desired objectives
in the table below):

Organ at risk Desired objective(s) Achieved objective(s)

V20<35% V20=24.3%
Lungs V5<65% V5=53%

V40<80% V40=17.1%
Heart V45<60% V45=13.1%
V60<30% V60=5.2%

Spinal Cord Max<50 Gy Max=24.1 Gy

Mean<34 Gy Mean=2.26 Gy
Esophagus Max<105% of RX Max=93.1%

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).

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? It looks like an hourglass.
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 resides in skin near the surface posteriorly. The region of
maximum dose is 128.9%.
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? They pinched in a bit at the medial portion.
b. Where is the region of maximum dose (hot spot)? Is it near the
surface of the patient? Why? The maximum dose or hot spot is now
in the anterior surface of the patient. It decreased by almost 9% to
120.7%. The hot spot is near the surface of the patient since the beam
is being attenuated by the body.
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?
PA beam at 51% weighting and the AP beam weighted at 49%
decreases the hot spot the most. Not much difference between the
weighting of beams was necessary as the PTV was located virtually
midplane.
b. How is the PTV coverage affected when you adjust the beam
weights? None, due to tumor location.
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? I was able to avoid the cord by
simply adjusting the beam angle to an RPO, 245 degrees.
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. AP=35%, PA=32.5%,
RPO=32.5%
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. Wedges definitely helped even the dose distribution.
I used the following:
AP=30 OUT, PA=15 IN, RPO=30 OUT

Which treatment plan covers the target the best? What is the hot spot
for that plan?
Three beams covered the target best. The hot spot (107.9%) was
anterior and medial to the tumor, within the 100% isodose line, in contrast to
the other plans where the hot spot was near the skin surface.

Did you achieve the OR constraints as listed above? List them in the table
above.
YES, see above

What did you gain from this planning assignment?

I learned how to copy and paste the plan so I could have more than
one plan to compare as I made the changes to the plan. In this manner, I
could evaluate and appreciate each change as they were made. Sometimes
it is hard to actually see the changes in the isodose lines when changing
more than one parameter at a time.

What will you do differently next time?

Next time I will choose a plan where the tumor is not so midplane; this was so
much so that the changes in beam weighting were not obvious. I also got
somewhat lucky with this practice planning lab in that the tumor was situated in
such a way that staying off cord was fairly simple.