Seth Cox

DOS 771
02/17/2017
Professor Vann

Planning Assignment (Lung)

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

Prescription: 7.5 Gy x 8 fractions for 60 Gy total

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)

Spinal Cord Max 50 Gy 14.47 Gy

Esophagus V50 < 32% V50 = 3.05%

v60 < 33% V60 = 1.53%
Heart V45 < 67% V45 = 0.45%
V60 <33% V60 = 0.36%
Lungs V20 < 35% V20 = 33.7%

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?
There is a large dose distribution at the surface, through the anterior and posterior of
entrance of the beam. From there, you see the isodose line becoming concave within
the cavity, especially as it is approaching the PTV.
b. Is the PTV covered entirely by the 95% isodose line?
 No, the 95% isodose line cannot cover the entire PTV, it is close, but having the mass
in the right upper quadrant would mean likely needing to weight the beams
differently..
c. Where is the region of maximum dose (hot spot)? What is it?
The hot spot is on the patients right back, where the entrance to the treatment field, it
is 7626.9 cGy

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 line within the lung cavity became much more erratic, with larger holes
near the PTV, but lowering the overall hot spot.
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 right back area, where the entry point for the PA beam is
coming from. Because of the distance to the PTV, the 50/50 weighting causes more
MUs needed to be used from the PA beam. It then makes sense that the hotspot
would be located posteriorly as it enters the field.
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?
Changing the weighting moves the hot spot more anteriorly and reduces the hot spot
overall. Which is interesting. It makes sense to need to weight the beam more
anteriorly to get the hot spot to move, but it does not make sense that the posterior
beam would need to be so much lower, since it has a further distance to travel.
b. How is the PTV coverage affected when you adjust the beam weights?
When moving the beam weighting from 50/50 you begin to gain coverage of the PTV
and begin to get complete coverage of 95% of the PTV while lowering the overall hot
spot.
The weighting was 65 AP, 35 PA for the best coverage and reduction of the hot spot
for the patient 6782.4 cGy.
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?
ii- Right lateral beam placed. Moved block along the cord more.
i. Adjust the gantry angle?
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.
There is a large hole in the 100 isodose line, however the entire PTV of the right
upper lung is covered by a mean dose 6252.4 cGy, so it is getting over 100% of the
prescribed dose.
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 created a more uniform dose around the PTV, the hot spot went into the
rib and intercostal space, but was down to 112.8%, which in my understanding of lung
treatments, is not that high.

Which treatment plan covers the target the best? What is the hot spot for that plan?
 Plan four was the best in terms of hot spot at 112.8% and the entire PTV of the right
upper lung is covered by a mean dose 6252.4 cGy, so it is getting over 100% of the
prescribed dose.

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

What did you gain from this planning assignment?

This planning assignment gave me the ability to see what different types of planning must
be used in order to create the optimal treatment plan for a patient. Most of our lung
patients, if not all, are run through our TomoTherapy machine and planning system, so I
have not been privy to that yet. So getting to see the difficulty that comes with planning
a lung and how much goes into it was interesting.

This also gives me an understanding of how to plan lungs on a linac and with 18x beam
strength.

What will you do differently next time?

After going through this exercise, then talking with our planning team, they informed me
that nearly all of their lung treatments are done with 6x energy, then explained the
reasoning. This would allow me to understand moving forward why plans will always
have such an active hot spot, but also allow me to understand how planning for patients.

I will be able to utilize my understanding of how plans are made within one facility, but
also take with me the ability to make plans using other theories and methods at a new
facility when I am working as a medical dosimetrist.