Lung Clinical Lab Assignment

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?

The isodose lines resemble an hourglass, with the 90% isodose line connecting
through the center but bowing in while extending through the lung. At the superficial
entry points, the isodose lines expand over the width of the field.

● How much of the PTV is covered entirely by the 100% isodose line?
According to the DVH, only 10.6% of the PTV is receiving the full 100% of the
dose.

● What are two advantages of a parallel opposed plan? (Review Kahn, 5th ed., 11.5.A,
Parallel Opposed Fields)
One advantage of parallel-opposed beams would be the straightforward and
simple setup of the patient.1 In addition, particularly when comparing to a single
 field technique, the dose distribution of a parallel-opposed plan is much more
even and conformal in part due to the ability to weight each beam.

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?

With the addition of the lateral field, there is now a larger portion in the center
of the PTV being covered by the 100% isodose line, and the 90% line creates a box
surrounding the PTV where the three fields intersect. Only the 50 and 30% isodose lines
extend across the AP/PA length of the patient through the lung, and the 70% line ends
before extending into the lung at the superficial entry points.

● How much of the PTV is covered entirely by the 100% isodose line?
According to the DVH, 22.4% of the PTV is now receiving 100% of the dose.

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?
I chose to do a Left Anterior Oblique (LAO) at 45° and a Left Posterior Oblique
(LPO) at 135°. I chose these angles because they are at angles halfway between the
existing fields, which will increase uniformity and heterogeneity of the dose and prevent
from a larger percentage of the beam coming from a similar direction. It should be
noted that the LPO beam does travel through a greater amount of tissue and exits into
the greater vessels of the heart along with the lateral field. These will likely have a lesser
weighting in an actual plan.

● Why is beam energy an important consideration for lung treatments? (Review Kahn, 5th
ed., 12.5.B3, Lung Tissue)
When treating the lung it is important to take note of the energy used, because
the lower density of air (in comparison to soft tissue) causes electrons to scatter outside
of the normal trajectory of the beam and into the lung.1 This effect is more common in
higher energies above 6MV. However, at lower energies and greater depths, high doses
are often recorded within and just beyond the boundaries of the lung as a result of
significantly less attenuation of the beam in air.1 For these reasons, it is important to
look at where the PTV lies within the body and lung when choosing energies.

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?
By adjusting the weight of the fields in a plan, one is able to alter dose
homogeneity and PTV coverage. For example, if a PTV is closer to the source of the AP
beam rather than the PA, it would most likely improve the dose distribution and
coverage if the AP had a higher weighting. Dose to normal structures may also be
affected by adjusting field weighting. If a critical structure sits just behind the PTV,
similar to the great vessels and the heart in this case, a lower weighting of the beams
that would cause exit dose to these structures would improve their sparing.

● List your final choice for field weighting on each field.

AP = 38%
PA = 35%
LLAT = 5.5%
LAO = 15.5%
LPO = 6%

The majority of the dose will be coming from the AP/PA due to its lack of exit dose into
the heart and great vessels. I assigned the highest weight to the AP beam due to its slightly
greater proximity to the PTV than the PA. The LAO beam was weighted the highest of the
lateral and oblique beams due to its proximity as well, and the LPO and LAO were each
weighted very lightly because of their exit dose directly into the heart and great vessels.

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.
 AP

PA

● 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?)
I used 15° wedges on both the AP and PA fields. Both wedges had toes pointing
deeper into the patient where dose coverage was lacking. I used smaller wedges
because I did not want a drastic increase of dose being pushed deep and closer to the
heart. Placing them on the AP and PA beams, which were weighted the highest, had a
more profound effect than when I experimented with wedges on the other fields of
lower weighting.

● Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s).
 PTV coverage improved from approximately 12.8% to 17% after wedges were
introduced. The 100% isodose line extended further inferior to cover the PTV and Right
deeper towards midline. Farther superior where the 100% line broke apart in the
unwedged plan, it remained intact in the wedged plan. The far superior 100% PTV
coverage changed very little between plans and remained cold.

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.
Normalization is the prescription of a specific dose coverage to a point, volume,
or isodose line.

● What impact did normalization have on your final plan?

Normalization made the plan significantly hotter. The 90 and 95% isodose lines
cover a large portion of the lung and there are small volumes outside of the lung in the
soft tissue that are receiving up to 100% of the prescription. In the center of the PTV
there is a large volume of over 110% of the dose.

● What is your final hotspot and where is it?

The final hotspot is 113.4% of the prescribed dose. It is in the center axially, and
in approximately the inferior third of the PTV.

● Are you satisfied with the location of the hotspot?

Given its position inside the PTV and near the volumetric center, I am satisfied
with the location.
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?
I continued with 6MV because of the large amount of lung and air the beam
traveled through before reaching the PTV. I was concerned with the possibility of underdosing
the periphery of the PTV if I used a higher energy, because it would have penetrated deeper,
and there would be a greater chance of losing lateral electrons to scatter.1

● What is the final weighting of each field in the plan?

I used four fields equally spaced at 0°, 60°, 120°, and 180°.
AP=29.5%
LAO=18%
LPO=25.7%
PA=26.58%

● Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable?
The hot spot is 110.3% of the dose, or 66.18 Gy. It falls within the PTV in the
center sup/inf, slightly to the left axially, and in the center ant/post. At my clinical site this value
would be acceptable but we would most likely normalize slightly less to lower the hot spot
under 110%.

● 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.

● Use the table below to list typical OAR, critical planning objectives, and the achieved
outcome. Please provide a reference for your planning objectives.
 Dose objectives taken from RTOG Protocol 0623, A Phase II Trial of Combined Modality
Therapy with Growth Factor Support for Patients with Limited Stage Small Cell Lung
Cancer.2

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Esophagus Mean Dose < 34 Gy Mean = 2.94 Gy
V60 Gy < 10cc V60 Gy = 0 cc
Heart V60 Gy < 33% V60 Gy = 0%
V45 Gy < 67% V45 Gy = 0%
V40 Gy < 100% V40 Gy = 0.0%
Lung (minus GTV) V20 Gy < 37% V20 Gy = 18.5% (Lung minus ITV)
Mean Dose < 20 Gy Mean Dose = 9.84 Gy
Spinal Cord Dmax < 45 Gy Dmax = 10.67 Gy (Spinal Canal)
PTV 99% of PTV > 93% of 99% = 58.66 Gy
prescription (55.8 Gy)
References

1. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th Ed. Philadelphia, PA:
Lippincott Williams & Wilkins. 2014:179, 221-223.

2. Lilenbaum
R, Komaki R and Martel M K. RTOG 0623: A phase II trial of combined

modality therapy with growth factor support for patients with limited stage small
cell lung cancer.
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=062
3. Published 2007. Accessed April 23, 2019.